A large academic healthcare system in the Southeastern United States answered the call from the Institute of Medicine (IOM) and the American Academy of Ambulatory Care Nursing (AAACN) to establish a transition to practice program for new graduate registered nurses (RN). This healthcare system had in place a multi-site nurse residency program (NRP) that received the “accredited with distinction” designation by the American Nurses Credentialing Center (ANCC) as part of their practice transition accreditation program (PTAP). In the summer of 2020, to better serve the healthcare needs of the community, this NRP expanded to include ambulatory care areas. This also aligned with the timing of the re-accreditation process of the ANCC PTAP, and the program was designed to meet all of the standards outlined in that program.
This healthcare system is also affiliated with a local university that offers a licensed practical nurse (LPN) to registered nurse (RN) degree program. Due to the high enrollment among the current LPN staff in the LPN-to-RN program, the leaders of the ambulatory care NRP recognized a need to modify the curriculum of the NRP to accommodate these staff members who wish to remain in their current clinic while transitioning to the RN role. Considerations for this population of nurse residents included work experience that could exempt them from some of the sessions offered to traditional bachelor of science in nursing (BSN) degree nurse residents, minimizing time away from the clinic since they are already established nurses who are essential to their clinic flow, and feedback from former LPN-to-RN nurse residents.
Extensive formal and informal evaluation was conducted with the LPN-to-RN nurse residents to determine the effectiveness of the program modifications for this population. These nurse residents offered insight regarding how the NRP has fostered their professional growth, offered needed support, and facilitated transition to their new RN role with ease. Moving forward, the ambulatory care NRP will offer multiple pathways to entry into the program to further ease the transition to practice and increase understanding among external and internal candidates. These pathways of entry include traditional BSN, LPN to RN, and existing staff (non-LPN) entry.
Background: During the COVID-19 epidemic, UW Health Northern Illinois, SwedishAmerican, saw a rise in hospitalizations. The organization mobilized an ambulatory care nurse-led discharge unit to improve bed capacity management. This innovative solution was able to serve over 200 patients. This unit exemplified transformative leadership and innovation during the height of the pandemic.
Purpose: The purpose of this unit was to provide respite to the inpatient units by creatively improving bed capacity at the organization. The goal was to use resources available to promote patient care and keep surgical procedures ongoing.
Methods: In November 2020, the discharge unit called 1 North was developed. The unit had an experienced team with over 100 years of ambulatory care experience including manager, supervisor, educator, nurses, and ancillary support. Ambulatory care staff volunteered to be trained and work for an 8-week period. The unit was open Monday through Friday from 7am to 7pm and located in a converted conference room. Admission criteria was developed with the goal to discharge patients to keep surgical volumes and inpatient bed capacity stable. Daily leadership evaluated surgical volumes along with inpatient census to collaborate, prioritize, and determine the best plan to meet the organizations needs. Post-implementation, a response plan has been developed if the unit is needed in the future.
Findings: Over 200 patients were seen in the discharge unit during the 8-week implementation. This unit improved hospital revenue by $320,000 from surgical procedures that were able to continue. The nursing staff felt empowered and appreciative to offer support to the inpatient staff while providing strategic collaboration. Overall this innovative response was a breath of fresh air and was an exemplar during our Magnet designation in 2021.
Purpose: Antepartum electronic fetal monitoring (EFM) is an essential skill for the outpatient OBGYN nurse to perform on pregnant women to help guide clinical care for the mother and fetus (ACOG, 2021). NICDH (National Institute of Child Health and Human Development) has developed guidelines and standard terminology for EFM to communicate fetal heart rate (FHR) patterns. It is critical for nurses to know this terminology so they can accurately communicate, escalate, respond, and intervene (Cypher, 2018). In our search for training materials, all education offered by nationally recognized OBGYN organizations were centered on inpatient EFM, which is outside of an ambulatory care nurse’s needs. Similarly, the inpatient fetal monitoring training at our organization was too extensive for ambulatory care nurses. This gap made it difficult to train new hires especially staff with limited to no fetal monitoring experience. The purpose of this project was to formalize the ambulatory care nurse training process for EFM to ensure staff are knowledgeable of NICDH terminology and utilize this terminology when interpreting and communicating results to help prevent adverse fetal outcomes.
Description: Over the last year, we have developed an online module and an in-person class for interpreting EFM for the ambulatory care nurse. Our online module was designed as a refresher for the experienced nurse and as an initial introduction of terms and content for the novice. Our current training plan consists of all new hires taking the online module and completing the quiz, then depending on experience level and quiz score, they may be required to attend an in-person fetal monitoring class prior to demonstrating competency.
The online module consists of a one-hour lesson plan that breaks down each component of EFM. Participants get practice interpreting fetal heart rate patterns with different clinical scenarios commonly seen in the outpatient setting. There is an EFM interpretation quiz at the end of the module to ensure understanding of the content. If the nurse is a novice, or did not score a 100% on the quiz, they would be required to attend the in-person fetal monitoring class.
The in-person class shares similar content to the module but breaks down the topics further and has more of a focus on interpretation. This class is designed to be interactive and allow the learners to ask questions and be more involved in the lesson. We created clinical scenarios to accompany fetal heart rate patterns. The learners use all the information to properly interpret the fetal heart rate pattern and to discuss appropriate interventions.
Evaluation/outcome: The learners are required to complete a quiz at the end of the online module and in person class, as well as a fetal monitoring competency we developed which they must be signed off by their preceptor with the outcome of increasing competence in EFM.
Purpose: Interdepartmental collaboration in a pediatric healthcare system has been limited between the pediatric emergency departments (EDs), urgent care centers (UCs) that provide immediate fracture care, and outpatient clinics that manage patient follow-up care. A review of internally reported adverse events showed an upward trend of incidences related to preventable casting and splinting-related injuries. A literature review was performed for evidence-based recommendations on safe cast removal and a series of interventions were implemented. An evidence-based practice (EBP) project was initiated July 2020 to improve staff education and collaboration between departments and reduce fracture care related complications while improving transparency of event reporting.
Description: Data was collected via an internal occurrence notification system (ONS) on incidences of pressure injuries related to splint application, and cast saw burns secondary to cast removal or bivalving/univalving of casts. An initial incidence rate per year was established. Interventions that were implemented included creation of a best practice instruction for safe cast removal, and creation of an orthopedic clinic shadowing program for ED orthopedic technicians. Evidence-based practice found during the literature review suggested proper saw technique, adequate cast padding, use of protective barriers, safe patient positioning, and attention to blade temperature were all contributing factors for safe cast removal and reduction in injuries. These EBP guidelines were included in the best practice instruction. Quarterly instruction and new hire skill validation sessions were developed for ED and UC nurses, techs, and medics. Regular communication of departmental policies and education with leaders in the EDs, UCs, and orthopedic practice was encouraged.
Evaluation/outcomes: ONS data showed a total of 17 reported incidents of fracture care-related injuries from October 2019 to September 2020. Rates after full implementation of improvement efforts decreased to 7 total incidents the following 12-month period from October 2020 to September 2021. Ongoing education for new hires will be continued as well as trending of incident reporting. Additionally, anonymous staff survey data demonstrated a reported increase in both knowledge and confidence with skills for performing ordered splinting secondary to education and skills validation sessions. The above described collaboration and educational efforts contributed to a 59% decrease in fracture care related injuries, as well as a reported increase of 16% in staff knowledge and 23% in staff confidence.
Background: The need for registered nurses (RNs) in primary care settings has never been greater. Despite the growing body of evidence on the importance of the role of RNs in primary care, educational programs for RNs at the ADN and BSN level have not integrated in curriculum enhanced and expanded roles in primary care. It is imperative that RNs practice to the full scope of their license in community-based primary care teams to increase access to care, with an emphasis on chronic disease management, including mental health and substance use conditions.
In 2018, our college of nursing (CON) responded to a call, and was awarded funds, from the Health Resources and Services Administration (HRSA) to educate a sustainable primary care nursing workforce equipped with the competencies to address pressing national public health issues, improve access to care, and improve population health outcomes by strengthening the capacity for registered nursing education and practice. Furthermore, addressing national nursing needs under three priority areas: education, practice, and retention. Through an academic-clinical partnership with a rural federally qualified health center (FQHC) in southern Ohio, primary care registered nurses were enrolled in our CON certificate and residency programs over the course of 2 years (2020-2022). This poster presentation will explore our academic-clinical partnership through the RN residency and how the 2020 cohort developed and implemented an evidence-based quality improvement RN-led Medicare annual wellness visit (AWV) program.
Program purpose: Developed using the ambulatory care registered nurse residency program (2017) from the American Academy of Ambulatory Care Nursing (AAACN), the RN residency program at the CON was designed to meet the program aims of HRSA as outlined above. Additionally, the residency builds confidence and competence of the primary care nurse through a structured, professional transition-into-practice experience that creates and enhances professional networks while sharpening leadership and change agent proficiencies.
Description: This HRSA-funded program provided salary support to hire and train RNs to work in a rural FQHC providing chronic disease management, care coordination and transition in care, and population health management. The nine-month residency program is comprised of 4 modules (foundations, communication, professional practice, and systems). At the end of the residency, each resident is required to complete an evidence-based quality improvement capstone project that will offer a substantial change of practice in their organization. The 2020 residency cohort used an evidence-based practice (EBP) model to develop and implement a plan for a RN-led AWV program.
Program outcomes: As a result of the RN residency and academic-clinical partnership, the RNs were able to successfully implement the practice of RNs conducting AWVs beginning July 2021. This practice change has led to increased value-based quality visits by delivering health education and promoting health screenings with Medicare beneficiaries. This academic-clinical partnership successfully met the aims of the program by expanding the role of the RN and increasing access to care.
Purpose: The demand for healthcare delivered in ambulatory care settings has increased. With value-based care programs, ambulatory care nurses increasingly work as care managers providing holistic, person-centered care that is integrated across settings. Specific electronig health record (EHR) tools, comprehensive training, and standard processes support care managers in coordinating care and transferring knowledge across the health system. However, at an academic medical center in the Pacific Northwest, there has historically been a lack of education, standardization, and training for ambulatory care nurses.
Description: An environmental scan of current care management processes was conducted through RN survey, contextual inquiry, and information technology discovery sessions.
100 ambulatory care nurses across primary and specialty care completed a survey about their practice. The majority (87%) stated their work involved care management. Most (69%) reported documenting care coordination activities within telephone encounters; however, participants also reported documenting in at least eight other areas of the EHR. Approximately half (53%) relied on tools within the EHR to describe patients’ progress and organize outreach; others relied on tools such as Excel, Outlook, or a notebook for these purposes.
These survey results were supplemented by an 8-hour contextual inquiry in one primary care and one oncology clinic. Notable observations included: 1) variation in management of incoming patient communication, 2) simple patient questions requiring 25 minutes of chart review and care coordination to reach resolution, and 3) nurses’ reliance on non-EHR tools to track complex patient populations.
Information technology discovery sessions with 33 primary care staff (including nurses, behaviorists, pharmacists, and medical assistants) revealed: 1) lack of a standardized method for referral into care management, 2) lack of consistency in tracking care managed patients, 3) inconsistent documentation of care plans (53%) and patient goals (63%) in inconsistent locations of the chart, and 5) lack of standard work for patient outreach.
Taken together, these data highlight variability of nursing practice, workflows, and EHR use in ambulatory care. These conditions negatively impact transfer of knowledge across settings, time needed to review charts in preparation for care management and patient experience and safety. This information was instrumental in bringing enhanced EHR care management tools and education to clinics in a phased approach, first in primary care and then in specialties.
Evaluation/outcomes: The ambulatory care informatics team recommended enhanced EHR tools for care managers including: 1) an order for enrollment into care management; 2) episodes of care, care planning/goal activities, and standardized patient assessments; 3) tools for planning and tracking outreach; and 4) expanded “at a glance” information.
Next steps include: 1) creating comprehensive education on these tools to enable standard processes; 2) designing reports to assess tool use, provide feedback to users, and enable data extraction; 3) improving visibility of ambulatory care managers’ work in acute, critical care, and emergency department settings; and 4) expanding use to care managers in specialty clinics.
Initial outcome data will focus on process metrics concerning consistency of standard EHR tool use in primary care.
The goal of this project is to allow women veterans to collect their own vaginal swabs, when medically prudent, in order to reduce repeated trauma in a population of women with a high incidence of past sexual abuse and violence. Self-collection eliminates the need for an intrusive pelvic examination with speculum insertion. Self-collection occurring during nursing triage or a scheduled nurse visit can also reduce the wait time for women veterans to obtain a proper diagnosis and treatment.
Women veterans have high rates of adverse childhood experiences, sexual assault, and intimate partner violence. Providers often represent military officers and are seen as having power in the relationship. Pelvic examinations can be painful and cause loss of privacy and control, physical touch in intimate areas, and vulnerable physical positioning. Some women veterans are waiting up to two weeks for a provider visit to assess complaints of vaginal discharge or requests for STI (sexually transmitted infection) testing.
Synthesis of evidence: What does the evidence tell you (us)?
Patients prefer self-collected vaginal swabs, rather than provider collected endocervical swabs. There is no statistically significant difference in sensitivity and specificity between the two collection methods. Urine samples are sometimes used in lieu of provider collected swabs but may detect 10% fewer cases of GC and CT compared with vaginal samples. The CDC recommends self-collection for the latter. Patient-collected samples reduce physical contact and eliminate the need for a speculum examination.
Practice change and implementation strategies: What was the practice change? How was it implemented?
We conducted a plan do study act (PDSA) to address patient-generated requests for STI testing. Patients without exclusion criteria collected a vaginal swab in the clinic after receiving instruction by the nurse. There was no change in how the swabs were processed by the labs.
Evaluation: What did you measure? How was it analyzed?
We measured ER or return visits for same or worsening symptoms within 30 days. Inadequate samples reported by the lab. Number of self-swabs performed. Spontaneous patient comments. No technical analysis was required.
Conclusions and implications for practice: We completed 57 self-swabs between August 2020 and March 2021. There was a 100% viable specimen collection success rate. Improved resource utilization and patient access and promotion of trauma-informed care were noted. No reported 30-day return visits or inadequate samples. All patient comments were positive. 58% cost reduction per patient encounter. Nursing clinical skill was designed for sustainment. This process can be expanded to primary care clinics and ER. Self-swab for HPV and STI testing.
Lessons learned: Patients would greatly benefit if the process was expanded throughout the primary care clinics and the ER (one patient took a $50 Uber to WHC to swab herself; vaginal specimen collected from ER provider was insufficient, the patient performed a self-swab at the women’s health clinic). Visual aids are helpful to the patients.
Learning objective for audience (1): Describe how self-collected vaginal swabs produced equal results in women veterans as provider collected swabs.
Purpose: The most recent biannual report of vaccination errors from The Institute for Safe Medication Practices (ISMP), released on December 4, 2019, revealed that of the 1,143 events submitted, most errors reached the patient and occurred in medical clinics, physician practices, hospital (ambulatory care) and public health immunization clinics. The most common types of errors included wrong vaccine administered, wrong timing, extra dose given, and expired vaccine administered. About one-third of the extra doses given involved failure to check a patient’s vaccine history. More than one-half of the errors involving a wrong vaccine administered were due to similarities in product names, abbreviations, or packaging. The purpose of this quality improvement project was to reduce patient harm caused by vaccine administration errors in the ambulatory care setting.
Methods: Using our hospital’s event reporting system, MIDAS®, an increase in medication errors related to vaccines in ambulatory care physician practices was observed in late 2019. A vaccine checklist tool was created by the medication safety officer in collaboration with the ambulatory care practice council, consisting of registered nurses and medical assistants, to encourage an independent double check of the five rights of medication administration in addition to vaccine-related requirements. The checklist was piloted in July 2020 in five practices to obtain feedback regarding effectiveness and content. The final version was distributed to all primary care practices in the community health system with instructions for use in December 2020. Data was collected pre-checklist implementation from December 2019 to November 2020 and for post-implementation December 2020 to November 2021. This study is exempt from Institutional Board Review.
Results: N/A
Conclusions: N/A
Nurse leaders recognize that fundamental changes within nursing education curriculum are needed to support the quadruple aim and respond to the dynamic changes in healthcare (Bodenheimer & Sinskey, 2014; Palumbo, Rambur, & Hart, 2017). If the nation is to meet the increasingly complex healthcare needs and provide care that is truly patient-centered, collaboration between education and practice is imperative to prepare the healthcare workforce and positively impact the way care is delivered (Cuff, 2013). The purpose of this project was the development of ambulatory care clinical experiences for pre-licensure BSN students.
The registered nurse education for a nurse-led enhanced workforce (RENEW) grant project was created to utilize an academic-practice partnership model to recruit and educate undergraduate registered nurse (BSN) students and licensed registered nurses (RN) in the skills needed to practice at the full scope of their license in community-based primary care teams. The RENEW project was implemented by enhancing the existing BSN curriculum for all students in the BSN program to receive primary care content. Additionally, students selected (n= 48) for the RENEW program had 150 clinical hours replaced from the acute care setting with clinical hours in primary care in the rural and underserved settings. These 150 hours were completed over 2 years (4 semesters) to allow a longitudinal clinical experience with the same preceptor. Lastly, RNs currently working in primary care were provided preceptor training as well as a summer course utilizing the AAACN care coordination and transition management core curriculum.
The RENEW project has actualized academic-practice partnerships, furthering the relationship between education and practice (Bodenheimer & Mason, 2017), fulfilled the goals of the quadruple aim, and will be the mainspring for creating and sustaining a culture of health in the rural and underserved communities. Ongoing evaluation suggests the primary care/ambulatory care settings are a viable option for clinical experiences for the pre-licensure BSN student.
The poster will visually display the integration of ambulatory (primary) care content into the pre-licensure BSN curriculum and the creation of ambulatory care clinical experiences for the students. The project was evaluated using surveys and skill development tracking using Typhon software. Survey results were tabulated, analyzed and used in rapid cycle quality improvement processes.
Learning outcomes
1) Describe the development of primary care curriculum and clinical experiences for BSN students.
2) Identify the role of the RN in team-based primary care.
3) Discuss the establishment of academic-practice partnerships.
4) Articulate the impact and value of RNs working at the full scope of licensure in nurse-led primary care.
Background: COVID-19 presents many challenges for nursing educators due to rapidly evolving research and best practices as well as the highly contagious nature of the virus. The biggest challenge is educating pre-licensure and licensed registered nurses about the COVID-19 disease process and the provision of patient care while simultaneously avoiding the risk of unnecessary exposure to the virus that comes with hands-on learning opportunities.
Purpose: The purpose of this study was to determine the impact that immersive virtual reality (VR) patient simulation has on the perceived clinical competency of pre-licensure and licensed registered nurses learning to care for patients with COVID-19. Immersive VR simulation goes beyond the traditional lab experience to immerse learners in an environment with a realistic holographic patient (D'Errico, 2021).
Method: Learners were presented with an asynchronous, computer-based education module introducing the COVID-19 disease process and patient care information. Learners then viewed a series of video clips depicting a holographic patient with COVID-19. Learners were also provided with basic patient information, a case scenario, an SBAR report, vital signs, a description of evolving symptoms/behaviors as the virus progressed, and guiding questions. Objectives of the simulation were to equip learners to: 1) identify signs and symptoms typical of COVID-19, 2) discuss the assessment and risk stratification of patients with suspected or confirmed COVID-19, and 3) correlate the signs and symptoms indicating deterioration and need for escalation of care.
Results: This study utilized a quasi-experimental research design with pre- and post-questionnaires to measure learners’ perceived clinical competency. Learners were asked to rate their level of confidence with various nursing skill competencies and nursing professional behaviors related to the care of patients with COVID-19. From a sample of 509 pre-licensure and licensed registered nurses, learners expressed the most significant gains in their level of confidence with the following nursing skills: developing care plans for patients (+11.2%), answering questions for patients or families (+14.8%), administering oxygen therapy (+17.6%), and educating patients or families with disease-related care knowledge (+18.5%). Learners also expressed gains in their level of confidence with the following nursing professional behaviors: communicating verbally with precise and appropriate terminology in a timely manner with patients and families (+5.8%) and with healthcare professionals (+4.4%).
Conclusions: Learners’ perceived clinical competency related to the care of patients with COVID-19 increased as a result of immersive VR patient simulation, despite the absence of hands-on clinical training. The simulation allowed learners to visualize a declining patient with COVID-19 and to think critically about the nursing interventions related to the patient’s care. Using virtual reality (VR) simulation to improve COVID-19 perceived clinical competency is not only applicable in a collegiate setting but also in ambulatory care settings for staff education, orientation, and annual competencies.
Reference
1) D’Errico, M. (2021, January 7). Virtual simulation versus immersive virtual reality: What’s the difference? UbiSim Inc. https://www.ubisimvr.com/virtu...