Background: To have an impact on population health outcomes, it is essential for pre-licensure nursing students to be educated on knowledge, skills, and attitudes required to effectively deliver primary care nursing across the care continuum. In response to these needs, the Health Resources & Services Administration (HRSA) called for integration of primary care competencies. Funded by the FY 2018 nurse education, practice, quality and retention – registered nurses in primary care (NEPQR - RNPC) program, a new post-baccalaureate curriculum focused on interprofessional community based primary care was developed emphasizing an integrated framework for healthcare delivery. Key features of the program incorporated aesthetic knowing and iPad device technology (See P37 - The Crossroads of Art and Technology in a Community-Based Primary Care Nursing Curriculum, AAACN 45th Annual Conference 2020 Poster).
Purpose: There is also a need in pre-licensure nursing education to incorporate service-learning which goes hand in hand with primary care education. According to Kuh (2008), service-learning is a high impact educational practice. Our local community has needs related to literacy and health promotion. Through collaboration with our community partners, it was our goal to improve the literacy and health promotion of the community.
Description: In the wellness and health promotion course, students in teams, drawing on their aesthetic knowledge and digital creativity, crafted health fair educational content digitally. During the COVID-19 pandemic, the content was pushed out via a virtual digital platform (Padlet) with QR code technology. In 2021, we were able to incorporate the project with clinical learning objectives while also collaborating with our community partners to deliver the educational content in a face-to-face format in tandem with pre-existing planned outdoor events, while also offering the digital content via QR code technology.
Projected outcomes: We anticipate these service-learning activities will propel community engagement in healthy living practices and have an impact on health self-efficacy. It is also anticipated that student participation in these events will enhance student learning and service in the context of primary care delivery across the lifespan while also building essential primary care competencies.
Participant learner outcomes: Upon completion, participants will be able to
• Describe how service-learning can intentionally be integrated with primary care competencies.
• Describe how technology can be leveraged in service-learning.
• Describe how service and community-based learning can be collaboratively and intentionally integrated with pre-existing community programing.
Topics: clinical pre-licensure primary care nursing education
Keywords: clinical, community health, digital innovation, primary care nursing education, service-learning
Student contribution: Students created the educational material delivered during the events.
Level of presentation: advanced beginner
Category: clinical
Purpose: The purpose of this project is to show improvement in clinical functions, i.e., staffing, provider availability, and safety over a four-year historical overview. The evidence shows that clinical function improved over this period (from 2017 to 2021) reducing patient safety reports by 30% as well as improving staffing ratios and provider availability with a 35% progression. The need for introduction of team huddle was indicated by the inclusion of TeamSTEPPS within military treatment facilities (MTF).
Introduction: The PICOT question is do daily team huddles increase communication and collaboration between clinical team members, as well as preventing safety events? Daily team huddles including providers, nurses, case management, technicians, as well as other invited clinical and non-clinical resources have shown to improve clinical experiences qualitatively and quantitatively to improve patient care and staff resiliency.
Implementation: Using the TeamSTEPPS toolkit, molding the huddle format to a smaller-sized MTF, with a six-week trial of modification, this process had almost immediate effect. Facility staff were committed to this implementation and developing positive change. They were further supported by MTF commanders and executive staff. Improvements as well as dilemmas were presented and discussed at staff meetings as well as the executive staff presentations. Twice daily huddles implemented for first four weeks, then decreased to once daily as huddle process had fewer procedural corrections.
Evaluation: Utilizing a look-back review, data was compiled using completed yearly patient safety reports (PSR) obtained for the years 2017 to 2021. These were further separated into clinical and non-clinical areas. The clinical PSRs were assessed for the following clinical topics: similar patient names, procedural timeouts, wrong site, medication error, patient documentation error, and specimen error inaccuracy. PSR showed a definite decrease by 30% while staffing ratios and availability improved by 35%.
Conclusions/recommendations: It is recommended that engaging in morning clinical huddles be incorporated into all clinical and non-clinical areas for a continued improvement in communication and patient safety. Further recommendations include an afternoon team huddle at the end of the week to review lessons learned and team successes.
Background: In 2012, the ambulatory care services division developed the patient care services (PCS) education team. This clinical education team provided all clinical education face to face between clinical educator and learner. While the PCS education team matrix changed over time, the core methods of direct observation and return demonstration remained the sole determinants of learning in the student. In 2020, because of the coronavirus pandemic, in-person learning became impossible. Historically, our patient care services educators in each of our four medical groups across two states operated independently of each other. This included having different clinical new-hire orientation programs and not all PCS educators maintained an annual skills program to support clinician (RN, LPN, and MA) continued education.
Objectives: Transition new-hire clinical orientation to a virtual platform while maintaining effective learning utilizing multiple modalities of student engagement.
Standardize new-hire clinical orientation and an annual skills program across all regions.
Methods: The PCS educators worked to evaluate current programs to identify core objectives and determine changes needed for creating a standard program and adapting to the new virtual delivery method. The virtual clinical new-hire orientation program includes multiple delivery methods to meet unique learner needs such as core content presentations, case studies, group discussions, verbal feedback, teachback in the form of a medication safety Jeopardy® game, and guided self-directed learning.
Results: Transitioning to a virtual platform for the clinical new=hire orientation and annual skills programs across all medical groups has allowed the patient care services educators to work together to support a larger number of new hires, as hiring moved from bi-weekly to weekly due to the pandemic’s effect on staffing in the practices. In collaboration with practice leadership and clinical preceptors, mid-year 2020, 41.18% of participants reported “strongly agreed” that the virtual clinical new-hire orientation program prepared them for their new role as an ambulatory care clinician. This is compared to 42.86% in 2018. The standardized virtual clinical new-hire orientation program facilitated inviting those is non-tradition clinical roles to participate. Having these non-traditional clinical roles trained to perform duties within the practice allowed for continued safe patient care during the pandemic when staffing shortages were the most prevalent.
Conclusion: Creating a standardized program and moving to a virtual platform facilitated the ability to continue to support the onboarding of new hire and transfers into the role of ambulatory care clinicians. PCS educators committed to sharing the responsibility of providing virtual clinical new-hire orientation each week for ambulatory care new hires across all regions. This new program helped to address staffing shortages in a small way while also maintaining high-level learning.
Every year, over 20 MILLION people use drugs. Opioids, in particular (but not exclusively), took the lives of over 100,000 people in the USA in 2020, up from 70,000 people in 2019. Additionally, healthcare dollars are spent every year on emergency room care for cellulitis, cardiovascular disease, hepatitis C, and HIV care linked to drug use. As nurses, we care for people daily who use drugs, sometimes knowingly, and other times unknowingly. People use drugs recreationally, and others suffer from substance use disorder or addiction. People who use drugs may not seek care, and if they do, they rarely admit use to their healthcare providers due to fear of judgment and stigma, so there are lost opportunities for health promotion and education.
Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. They are in alignment with the Future of Nursing 2020-2030 report, calling for nurses to assist individuals and communities through clinical care, political advocacy, thorough assessment, and awareness and use of community resources. Registered nurses are well positioned to assist with educating and caring for people who use drugs and, in doing so in a compassionate and respectful way, changing the fate of individuals and communities, and potentially reducing the suffering and death that the opioid epidemic is causing. This can and must be done, in alignment with the ANAs code of ethics for nurses, provision 1, which states that nurses practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person. We can meet all people where they are and build from there.
Myths to dispel: All people who use drugs are addicts. All drugs are bad. Heroin is the most addictive substance. All people who use drugs have a moral failure. People who use drugs choose to do so and can stop at any time. All people who use drugs are liars and commit crimes.
Foundations to lay: A nurse’s language must be person-centered, objective, and take into consideration life circumstances, health, and adverse childhood experiences. The language used in communicating with patients, providers, and colleagues shape the care provided, and that power cannot be underestimated. One’s actions must be collaborative and not punitive, and the patient and provider must be able to find common ground to build upon. Recovery is a return to physical health, financial stability, and meaningful social and familial connections. This is the end game, not necessarily abstinence.
This poster presentation will provide information on these basic principles of harm reduction and also outline the specific evidence-based tactics employed by harm reductionists that improve the lives of people who use drugs, namely: narcan, needle exchange programs, fentanyl test strips, safer injection practices, low-threshold bupenorphine prescribing, and overdose prevention sites.
Participants will be able to articulate the effect of person-centered language on the care of people who use drugs and evaluate/share with others a variety of harm reduction interventions that can be considered for people who use drugs.
Compliance with colon cancer screening continues to be a challenge for many primary care practices. The American Cancer Society (2021) found that colorectal cancers are the second most common cause of cancer death in the United States. Preventative screening can help with the early detection and treatment of colorectal cancers.
Literature shows using fecal immunochemical testing or fecal occult blood testing has historically had an overall low return rate when suggested as part of the office visit (Chido-Amajuoyi, Sharma, Talluri, et al., 2019). Finding innovative ways to offer patients additional options for colorectal cancer screening can be useful in increasing compliance. Nurses play a key role in increasing compliance with disease prevention by providing education, outreach, and practice-based techniques to increase compliance with preventative health measures such as colorectal cancer screening.
This study measured colorectal cancer screening rates in a safety net primary care practice and included patients who are 45 years of age or older and who have not completed a screening colonoscopy. Registered nurses provided education on the use of the fecal immunochemical test (FIT) to patients who were due for a colorectal cancer screening. Education included collection process, mailing instructions, and follow-up steps. According to Houge et al. (2019), obtaining fecal specimens at the time of the visit is impractical; therefore, creating a path for patients to perform and send in the FIT kits from home may increase compliance.
This shared decision-making process allowed patients alternative options for colorectal cancer screening and promoted patient empowerment and satisfaction (Yeh et al., 2018). The method used in this study is a retrospective chart review of the target population to measure the response rate of those patients who were provided with a mail-in home FIT kit and findings in the chart review. The results of this study include demographic information, language, race/ethnicity, level of education, and insurance status. Additionally, the study reviewed the number of participants who had a positive screening, using the at-home FIT kit and subsequently completed or scheduled for a screening colonoscopy.
Learning outcomes
1) Define the benefits of early colorectal cancer detection for primary care patients.
2) Identify target population for home colorectal cancer screening.
3) Describe process for home FIT testing and the role of the nurse.
References
1) American Cancer Society. (2021). When should you start getting screened for colorectal cancer? https://www.cancer.org/latest-...
2) Chido‐Amajuoyi, O. G., Sharma, A., Talluri, R., Tami‐Maury, I., & Shete, S. (2019). Physician‐office vs home uptake of colorectal cancer screening using FOBT/FIT among screening‐eligible US adults. Cancer medicine, 8(17), 7408-7418.
3) Hogue, S. R., Gomez, M. F., da Silva, W. V., & Pierce, C. M. (2019). A customized at-home stool collection protocol for use in microbiome studies conducted in cancer patient populations. Microbial ecology, 78(4), 1030-1034.
4) Yeh, M. Y., Wu, S. C., & Tung, T. H. (2018). The relation between patient education, patient empowerment and patient satisfaction: A cross-sectional-comparison study. Applied Nursing Research, 39, 11-17
As part of our organization’s Magnet journey to achieve nursing excellence, our ambulatory care education department had an opportunity to centralize and standardize new employee orientation (NEO) for clinical staff. Aligning with our professional practice model which embraces caring relationships as a central focus, our ambulatory care education team re-designed the NEO curriculum with the following goals in mind:
• Provide the new hire with an overview of the organization’s mission, vision and values and integration of these into ambulatory care services.
• Provide the new hire with the resources, skills, and support necessary to be successful in their new job or role with an emphasis on standard work to improve quality metrics.
• Connect with the new hire to foster a supportive and caring relationship and welcome them into the organization.
Previously, new clinical staff received 1-5 days of NEO depending on role. Ambulatory care practice managers, some non-clinical, were required to oversee orientation and training of new hires. This resulted in variances and inconsistencies in the new-hire orientation process and reported decreased satisfaction by staff and leaders. Also, the needs assessment showed that only 40% of the assigned inpatient-focused learning management system (LMS) modules were relevant to the ambulatory care new hire.
To address the areas for improvement, principles of adult learning theory including a learner-centered approach were applied to the curriculum re-design. This approach incorporated a blended-learning model involving didactic lecture, facilitated case studies, hands-on skills, and interactive self-directed learning modules. The self-directed LMS modules were revised to include specific content relevant to ambulatory care.
During the onboarding process, the new hire is automatically assigned the ambulatory care LMS curriculum appropriate for their role (RN/LVN or MA). In addition, the new hire is registered in the LMS for an 8-hour instructor-led training (ILT) that is offered bi-weekly. Course content is based on the clinical education matrix from the Association for Nursing Professional Development (ANPD) as well as additional education needs identified in collaboration with ambulatory care stakeholders.
Learner engagement methods include case studies with facilitated group discussion, gamification, simulated patient care activities using the electronic medical record (EMR), videos with group debriefing, hands-on skill practice (ex., manual blood pressure measurement), and interactive, self-directed learning modules.
Utilizing Kirkpatrick’s levels of evaluation, the post-activity evaluation process includes a questionnaire to evaluate the learner’s satisfaction with the program (level 1: reaction). A formative assessment is conducted by providing feedback following the return demonstration of hands-on skills as well as asking the learner to identify one takeaway from the program to apply to their clinical practice (level 2: learning). Each new hire is provided a standardized core competency-based orientation (CBO) tool to have validated in the clinical practice area (level 3: behavior). Anticipated outcome measures include a decrease in first-year turnover, decrease in average length of orientation, decrease incidence of errors, improved quality metrics, and improved perceived patient safety culture (level 4: results).
Over the past year and a half, the healthcare workforce has transformed the care delivery system design and functionality. At the conception of COVID-19, ambulatory care services across the nation were essentially shut down as we learned how to work with a new set of safety measures, staffing allocations, and complexities of a pandemic. We continue to move toward stabilizing and rebuilding our ambulatory care delivery process and realize that many things have changed. We are faced with a staffing crisis, fear, anxiety, variants, vaccines, and an undefined "new normal." This poster will describe the operational variations in standard work created to address the pandemic response, including safety measures and clinical staffing allocations and how they are different as we build back up the care delivered in the ambulatory care setting. We will discuss the successes and struggles faced at different points in the process and the difficulties with staffing and safety we are facing as leaders in today’s transforming ambulatory care setting.
Purpose: This work compared the utilization of the newly developed and implemented COVID-19 immunization standardized procedures for registered nurses (RNs) and pharmacists (PharmDs) and standardized protocols for licensed vocational nurses (LVNs) and determined potential impact at two ambulatory care health centers in a large, municipal healthcare system. Participants will be able to describe the impact COVID-19 immunization SPs have on patients, staff, and organization.
Description: In response to the U.S. Food & Drug Administration’s COVID-19 vaccine emergency use authorizations, the CDC COVID-19 vaccination recommendations, and in accordance with the California Board of Registered Nursing standardized procedure guidelines (2011), the interdisciplinary practice committee (IDPC) developed COVID-19 immunization standardized procedures/standardized protocols (SPSPs) for RNs, PharmDs, and LVNs. These SPSPSs enable trained RNs, PharmDs, and LVNs to safely, efficiently, and appropriately order COVID-19 vaccines for a large diverse and vulnerable patient population.
The IDPC, consisting of RNs, physicians, and administrators, developed and implemented the SPSPs and corresponding workflows, order sets, forms, and training. While ordering immunizations is a provider function, SPSPs enable RNs to function at a higher complexity level in defined situations, allowing RNs to perform functions not usually within their scope of practice (Perris, 2020). Under the COVID-19 immunization SPSPs, designated staff screen patients, using fixed eligibility inclusion and exclusion criteria to determine if patients are eligible to receive the COVID-19 vaccine by SPSP. The SPSPs then provide staff with clear instructions and algorithm to use in determining the appropriate COVID-19 vaccine to order for eligible patients and steps to take for patients ineligible to receive the COVID-19 vaccine by SPSP.
Comparison and analysis of the following were performed: number of staff trained, number of COVID-19 vaccines administered, and proportion of COVID-19 vaccines ordered by SPSP at two health centers. A chi-square test was used to conduct statistical analysis.
Outcome: From January 1, 2021, to February 28, 2021, 78 staff (29 [37.2%] center “A”; 49 [62.8%] center “B”) were trained on the COVID-19 immunization SPSPs: 42 (53.8%) RNs, 6 (7.7%) pharmDs, and 30 (38.5%) LVNs. There was no difference in the number of RNs and LVNs trained at each site (X2 (1, N=72) = 0.2788, p= 0.597). A total 1,585 (.904) of the 1,754 COVID-19 vaccines at center “A” were ordered by SPSP and 169 (.096) by provider. In comparison, 1,298 (.77) of 1,685 COVID-19 vaccines at center “B,” were ordered by SPSP; 387 (.23) by provider. Combined, 2,883 (.838) of the 3,439 vaccines were ordered by SPSP and 556 (.162) by provider, demonstrating high SPSP utilization to order the vaccine. COVID-19 immunization SPSPs allow trained staff to function at the top of their scope, allow scarce provider resources to focus on managing the most complex patients, and decrease potential delay in patients receiving their COVID-19 vaccine by enabling trained staff to order the vaccine rather than waiting for the provider.
References
1) California Board of Registered Nursing. (2011). Standardized procedure guidelines. https://www.rn.ca.gov/pdfs/reg...
2) Perris, K. (2020). Optimizing the RN role in ambulatory care with standardized procedures. AAACN Viewpoint, 40(4)3-7.
Objectives
• Identify methods to enhance medical assistant top of education practice, using a phased orientation pathway.
• Discuss the benefits of a medical assistant orientation pathway on staff engagement, clinic satisfaction, and MA retention.
Background: In 2019, our organization started the journey to ensure all clinical team members were working at the top of their education and skill set. Utilizing our ambulatory care shared governance platform, an assessment of registered nurse (RN) tasks was completed and categorized. Each task fell into three categories: 1) RN-only task (cannot be delegated), 2) RN or medical assistant (MA) task (depending on setting and skill set), and 3) non-RN task (does not require RN skill set). We also assessed current MA staff to determine appropriate skill sets and competencies.
Based on our assessment, it was determined that certain tasks could be removed from the RN workflow and added to clinic MA practice to support top of practice work in both roles. However, a gap was noted in MA confidence, critical thinking, and skill set to successfully complete certain tasks.
Description of project: To meet the goal of increasing MA confidence, skills, and critical thinking, a new phased orientation pathway was developed. The pathway includes orientation to clinic workflow and point of care testing, education on specific clinic diagnoses, opportunities to enhance provider interaction and support, and activities promoting care coordination. Each phase of the pathway consists of shadow opportunities, critical-thinking worksheets, and provider interactions to assist the MA in understanding the complex needs of their patient populations and support interdisciplinary communication. In the final phase, MAs utilize the learned knowledge from worksheets, clinical experiences and practice, and observation/shadow experiences to complete a diagnosis concept map for each identified diagnosis, bringing together the full patient picture. The orientation pathway and tools are integrated into our shared electronic platform (electronic orientation binder) to increase ease of use and monitor ongoing progress. Utilizing change management strategies, our program has been met with minimal resistance.
Results: Preliminary post-implementation results show increased MA and provider satisfaction, decreased MA turnover, improved clinic workflows and productivity, and improved interdisciplinary communication. Additionally, a significant percent of MA turnover was due to career and professional growth within the organization, as a result of enhanced critical thinking and role changes related to this program.
Conclusion/future needs: The orientation pathway is currently integrated into 50% of our specialty clinics, so we plan continued integration for remaining clinics due to the pathway’s success. There is a continuing need to address RN reluctance to change through RN education regarding MA scope of responsibility. Future needs for dedicated MA educator for targeted support.
Purpose: Our organization sought to expand the RN transition-to-practice (nurse residency) program, and ambulatory care services was identified as an area of interest for proposed growth. Our team was tasked with building a residency for ambulatory care float pool nurses using AAACN and current organization standards.
Several gaps arose when evaluating current state versus our desired future state for the ambulatory care residency program: experience and education gap for new graduate nurses in the ambulatory care setting, lack of ambulatory care-specific education in our current inpatient specific residency program, ambulatory care leadership awareness and support, and preceptor preparedness for new graduate nurses.
Description of project: A tiered plan to address identified gaps was created, first addressing preceptor preparedness and leadership support, and next focusing on the creation of ambulatory care-specific orientation plans, education, and support infrastructure to address the new nurse experience gap.
Preceptor preparedness focused on increasing standardization of preceptor practices and preparing preceptors for supporting new graduate nurses. This was implemented through a series of educational opportunities, including a preceptor retreat, computer-based training, resource toolkits, and informal rounding.
Leadership support was addressed through "kick-off" informational sessions during leadership meetings and micro-learning opportunities at each leadership session thereafter.
To bridge the new graduate nurse experience and knowledge gap, a phased orientation was built in with the support of our inpatient team. This includes an initial inpatient rotation to build critical-thinking, clinical judgement, and assessment skills with a gradual transition to clinic orientation. Clinic orientation consists of rotation through each specialty clinic, with emphasis placed on those clinics requiring specialized skills and competencies. Lectures were also developed in the areas of telenursing and triage, common diagnoses, and general ambulatory care information. Shadow opportunities with the care coordination team and other ancillary roles are also offered. Simulations were explicitly built for emergencies in the ambulatory care setting.
Nurse residents are also integrated into ambulatory care culture through a formal mentoring progra, and participation in our ambulatory care-shared governance structure.
Evaluation/outcome: Data gathered post-implementation assessed retention at various intervals, resident nurse self-reported satisfaction and preparedness for practice, hiring manager satisfaction, receiving managers/clinical staff satisfaction with resident engagement and performance in clinic, and preceptor satisfaction with resident performance.
Preliminary data shows retention rate at 100% at all time intervals; high satisfaction amongst preceptors, manager, and clinic staff with resident performance and engagement; and high engagement and job satisfaction in our new graduate nurses.
Future implications: Future efficiencies revolve around solidifying telenursing practice through telenursing simulations, integrating social determinants of health focus into orientation lecture, and leveraging academic partnerships to begin early transition to practice during the final year of nursing school.