Emerging Technologies and Nursing Care: Microsoft HealthVault

 

What is Microsoft HealthVault?

Health information technology is where the future of the United States’ health care system is heading. Microsoft has been an innovative leader in the transition into patient controlled health information with the creation of the Microsoft HealthVault. Microsoft HealthVault is a place where a patient can store, record, and share their personal health information. The overarching goals of this health information technology includes: to organize a patient’s own health information and the personal health information of their family (with the family members’ consents), to better prepare a patient for a doctor’s visit or unexpected emergency, to create a complete picture of a patient’s health, and to help patients achieve his or her health and fitness goals (HealthVault, 2014). The HealthVault allows patients to keep all of their health records together and in one place including, but not limited to, medications/prescriptions, health history, allergies, lab results, and x-rays and other images.  This information is connected between websites, computer software, and mobile apps for quick and convenient access from any internet connection. A  list of devices including pedometers, blood pressure monitors, and blood glucose monitors connect with HealthVault that uploads directly to the consumer’s HealthVault (HealthVault, 2014). Microsoft is attempting to partner with hospital systems and other healthcare facilities, so that this information can be accessed at anytime, anywhere no matter if that patient has been to that healthcare facility in the past (HealthVault, 2014). This is a work in progress, but Microsoft is currently piloting programs with New York Presbyterian Hospital (Steinbrook, 2008). This connection with facilities would allow for lab results, prescription history, and visit records to be sent to the patient’s HealthVault record on request by the patient (HealthVault, 2014). The expected outcomes for an online repository like Microsoft HealthVault include improvement of  health, physician – patient communications, coordination, quality of care, and an increased inversion to medical errors, which would then ideally reduce the cost of care (Steinbrook, 2008). Microsoft HealthVault strives to empower patients and offer increased convenience for managing their health (Hampton, 2008).

Development at a Systems Level

The driving force behind the development of this technology is the external environment. Since the HITECH Act of 2009, there has been increased interest in moving health records into the electronic field due to its ability to connect and show trends in information(Steege, 2014). Microsoft HealthVault connects patients to healthcare systems and their providers. It also can show a patient and/or provider trends in certain labs (blood glucose) and vital signs (blood pressure) (HealthVault, 2014).  Another external environment factor is the Agency for Healthcare Research and Quality (AHRQ). AHRQ funds healthcare organizations for a variety of reasons and one reason, related to Microsoft HealthVault, is the goal of supporting patient centered care (Steege, 2014). Microsoft HealthVault advertises that it wishes “to create a more complete picture of your health, with you at the center,” thus it is a patient centered technology to enhance patient care (HealthVault, 2014). There are numerous barriers to care that exist in the healthcare system and the Microsoft HealthVault is helpful in rectifying these barriers. For example, if a patient is traveling from a different state and has an emergent event, the patient using HealthVault would be able to show the emergency care providers their past medical history and that hospital could have access to this patient’s records with their permission. In this way, HealthVault helps providers offer individualistic and thorough patient care. There is concern that Microsoft is seeking to expand their role in the United States’ $2 trillion health care system. Uncertainty exists concerning if the long term result will be improved health and decreased cost or if this is simply a new business opportunity (Steinbrook, 2008). HealthVault may not be applicable to every patient population because it requires access to Internet and it requires a certain amount of technology literacy. To overcome the technology literacy barrier, they could offer free training sessions to anyone that signs up for this service.

Examples of Efficacy of Personal Health Records (PHR)

A pilot project was conducted in 2008- 2009 at Madigan Army Medical Center in Tacoma, Washington. The project included 250 users, of which 169 were selected to use Microsoft HealthVault  and the other users were selected to use Google Health as their Personal Health Record (PHR). Sample evaluation of the 169 Microsoft HealthVault users reflected 100% satisfaction with convenience of record access and 91.7% satisfaction with overall functionality of PHR (Do, 2011). Microsoft HealthVault allowed the study subjects to initiate or stop the transfer of electronic health information including, but not limited to, lab results, medications, appointments, inpatient notes, medical procedures, and medical problems list. HealthVault study subjects  were able to determine who, how long, and what information. Those involved with Microsoft HealthVault were impressed by how easy it was to access and store information (Do, 2011).

In a study by Steinbrook, an online survey done in November 2007 showed that 91% respondents agreed that patients should have access to their own electronic health record and 60% agreed “benefits of electronic medical records outweigh the privacy risks” (Steinbrook, 2008). There is no substantial collective impact that has been measured yet because the Microsoft HealthVault went public fairly recently in October 2007 (Steinbrook, 2008).

Material Needs 

There are no start up costs for Microsoft HealthVault and anyone can sign up on the Microsoft HealthVault website. The only thing needed to use HealthVault is a connection to the internet and a device (PC, tablet, or smart phone) (HealthVault, 2014). Staff (nurses, physicians, medical assistants etc.) would need to have training to be able to help patient’s navigate through their information (Steinbrook, 2008). Patient controlled electronic health data may be incomplete, inaccurate, or difficult to verify and thus there are liability concerns for physicians if they rely on them (Steinbrook, 2008). Patients using this technology will only get out of it what they put in to it. For example, if they are not compliant with accurately documenting their blood pressures or blood sugars, this will be of no benefit to them. Consumer education will be required to ensure they are correctly using this technology to receive the most benefit. Currently, HealthVault is not offering education to their consumers and the individuals answering consumer questions are information technology (IT) individuals, not necessarily individuals with medical backgrounds. I believe in the future (if this technology gains popularity) Microsoft should be hiring physicians and nurses to help patients with health related questions. In another survey performed by Steinbrook (2008), 60% of the participants agreed that the benefits of patient controlled electronic medical records outweigh privacy risks. This statistic is from only one study of patient controlled health records and could contain biases related to demographic characteristics of the study population (i.e. race, ethnicity, or gender) and possible health disparities (i.e. socioeconomic status). Cost outweighing benefit of this technology would be dependent on each individual patient. If a patient does not have access to Internet, for this patient to purchase Internet, a compatible electronic device, and possibly wired devices that connect with the program would be unreasonable, unless there was financial assistance. I believe this technology serves a better-off patient population due to its requirement of Internet and the convenient devices that connect to HealthVault. For the patient that is able to afford Internet and devices, I believe that cost outweighs benefit, because it has no start-up cost or cost for the service. If every patient was able to afford this service, it would be an innovative technology for promoting primary and secondary prevention.

Ethical Issues

With any personal health information, privacy is a key concern. This concern comes even more to the forefront with an online repository (i.e. Mircosoft HealthVault) due to the patient’s data being stored outside of the healthcare system and not being covered by a single entity subject to HIPAA regulations (Steinbrook, 2008). Microsoft HealthVault considers the use of their service to be private, but they may “access, disclose, or preserve information” including personal information and content. HealthVault enables participating providers to get reports about whether the information the provider sent to the patient was used. Microsoft intended this to support the U.S. “meaningful use” initiative of the HITECH Act (2009), which provides incentives for health care providers to send patients their medical information electronically (Microsoft, 2014). The Microsoft HealthVault has a detailed privacy policy that can be accessed by consumers at the following wed address: https://account.healthvault.com/help.aspx?topicid=PrivacyPolicy&culture=en-US.

As stated previously, patient compliance and engagement in the technology could be a liability issue, specifically for the physicians that rely on the personal health information (Steinbrook, 2008). The patient may enter incorrect data or not enter data at all. There are devices that connect to HealthVault that would ensure compliance, but cost would be an issue for patients. For example, an automatic blood pressure cuff that automatically transmits data to HealthVault costs approximately $150.00 (HealthVault, 2014).

Another ethical issue involves possible discrimination due to accessibility of this service and health literacy (Brennan, 2014). HealthVault prides itself in being accessible, but not everyone has connection to the internet and may even need to use public transportation access the internet at the local library. In rural settings, they may not have an internet connection or it may be unreliable, so this is not inclusive of all individuals. Microsoft HealthVault should also look to make sure their service is at an appropriate health literacy level to ensure patients are able to understand the information.

Nursing has a substantial role in ensuring ethical practice of this service. In relation to the ANA Nursing Code of Ethics Provision 1, the nurse is to practice in a way that engages a person in their strengths and meets the patient where they are at in regards to health literacy and style of preferred learning. Nurses should practice in this way to empower their patients and encourage them to take ownership of their health (Brennan, 2014).

Implications for Nursing and Interdisciplinary Practice – A Systems Approach

Nursing has an evolving role in incorporation of technology and systems theory into practice specifically nursing informatics. Nurses that work in nursing informatics will likely be taking on a larger role in integrating patient controlled personal health records into patient care as PHRs continue to gain popularity.  This role would include being effective in knowledge and information gathering, management, and distribution of information regarding patient controlled personal health records (Steege, 2014). These nurses may become the go-to person for trouble shooting patient issues with the technology. Education/training would be required for nurses working with this system, so that they may educate the patients on how to use the technology (Steege, 2014). There may be a requirement for nurses and other health care professionals to interpret data the patient receives. For example, if a patient has lab results sent automatically to their HealthVault and they do not know what the results mean, there should be a physician’s or nurse’s note sent with the lab results explaining their significance to the patient.

This new role of the nurse would fall under Provision 3 of the ANA Nursing Code of Ethics, which encourages nurses to advocate for their patients’ health, including services available (i.e. HealthVault). Nurses would help their patients by using technology to connect with them and provide guidance (i.e. lab results interpretation) (Brennan, 2014). Nursing in the future (and in the present as this technology becomes more prevalent) will require the nurse to use technology to facilitate communication between the patient and their physicians regarding personal health information, thus building a trusting relationship through technology (Brennan, 2014). In the future, nurses and other health care professionals could be considered “super-users” of personal health records. These health care providers with PHRs knowledge would be the leaders in their unit/department to assist other staff and patients trouble shoot issues with the technology.

More information

Project Health Design

Click to access Standard-Model-For-Collecting-And-Reporting-PGHI_Sujansky_Assoc_2013-07-18.pdf

Health IT

http://www.healthit.gov/patients-families/video/health-it-you-giving-you-access-your-medical-records

 

Resources

 Brennan, P.F. (2014). Legal, ethical, and social implications of technology [Powerpoint presentation]. Retrieved from the Learn@UW website, https://uwmad.courses.wisconsin.edu/d2l/le/content/2363203/viewContent/14537427/View?ou=2363203.

Do, N.V., Barnhill, R., Heermann-Do, K.A., Salzman, K.L., & Gimbel R.W. (2011). The military health system’s personal health record pilot with Microsoft HealthVault and Google Health. Journal of health informatics and biomedicine 18 p 118-124  doi:10.1136/jamia.2010.004671.

Hampton, T. (2008). JAMA. 2008;299(5):507-509. doi:10.1001/jama.299.5.507.

HealthVault. (2014). Retrieved April 1st, 2014, from Microsoft HealthVault website, https://www.healthvault.com/us/en/overview.

Microsoft healthvault account privacy statement. (2014). Retrieved April 3rd, 2014, from Microsoft HealthVault website, https://account.healthvault.com/help.aspx?topicid=ServiceAgreement.

Steege, L. (2014). Technology enhanced healthcare [Powerpoint presentation]. Retrieved from the Learn@UW site: https://uwmad.courses.wisconsin.edu/d2l/le/content/2359431/viewContent/14572084/View

Steinbrook, R. (2008). Personally controlled online health data – The next big thing?. New England Journal of Medicine. 358;16: 1653-1656. Retrieved from www.nejm.org.

 

 

 

 

 

Novice to Expert- Seeking and Finding your Voice

Transition to Practice for New Nurses

The transition from new graduate to professional nurse can be a time of both excitement and fear. The idea of beginning a career as a professional nurse may seem daunting as many novice nurses question whether or not they are ready for this new step in their chosen path as a nurse. Bowles and Candela (as cited in Duclos-Miller, 2011) found that the turnover rate for graduate nurses falls at 30% in the first year and reaches levels of 57% at the second year. The high turnover rate for new nurses causes concern for the future nursing shortage and has become a primary concern for availability of the registered nurse workforce. What is causing new nurses to leave the workforce so quickly? What are the challenges that new nurses face today as they transition from nursing school to a professional career? What can be done to address these challenges and overcome such high rates of new nurse turnover?

Part of the answers to these questions may lie in the history of graduate nurses. Before the induction of computerized testing for nursing licensure in 1994, new graduates worked with experienced nurses for a few months under a provisional license (Dyess & Sherman, 2009). This is much different from new graduates’ experiences today in which they are often thrown into practice after little orientation (Dyess & Sherman, 2009). There is concern that many of these new graduates may not feel ready to take on the immense responsibilities associated with practicing as a licensed nurse. Dyess and Sherman (2009) state that the transition to becoming a new nurse may be even more complex due to, “today’s hospital patients, reduced lengths of stay, staffing shortages, and complex new technologies”.

The decision of nurse leaders to shorten orientation periods and quicken the rate in which they place these new graduates in floor positions is both alarming and unsafe. It is concerning due to the fact that many of these new graduates express fears related to the transition period. It is questioned whether or not quality and safe care can be provided to patients when the new graduates delivering the care have little confidence in their own abilities related to a lack of experience. Berkow, Virkstis, Stewart, and Conway (as cited by Duclos-Miller, 2011) demonstrate that nurse leaders may agree, as they found that only 10% of hospitals and health systems stood by the statement that they felt their new graduates were fully prepared to take on the full responsibilities of providing safe care to their patients. After exploring the research, attention must be given to the exact challenges new graduate nurses face and how to provide the tools and resources necessary to make them feel more confident and supported during their transition into professional practice.

Applying Systems: Impact on the Transition for New Nurses

Understanding the organizational design of a workplace can be challenging for a new nurse. Where do nurses fit in and what is the chain of command? Oftentimes a particular unit of the healthcare setting, especially for a hospital, may have a vertical, centralized organizational differentiation. In this circumstance of vertical organization, the chain of command is very linear: the unit manager, charge nurse, registered nurses, licensed practical nurses, and the certified nursing assistants (Steege, 2014). A new nurse coming into this may feel threatened because not only are there supervisors above them, but there are also other healthcare providers below them to whom they must delegate tasks and supervise. Another implication of this chain of command is the fact that there may be employees who are below the new nurse on the chain, but have been on the unit for many years and have more experience with the patient population than the new nurse. The intimidation factor may play a role in how comfortable a new nurse feels with the other members of the interdisciplinary team they will be working with.

Another aspect is the informal organizational structure, or “office politics”. Linsey Steege (2014), a UW-Madison School of Nursing Professor, described that the interrelated parts of the social structure impact how the staff of the unit work together and communicate with one another. This includes all informalities of the system such as how colleagues get along, what they think of each other, and the work culture that has developed between them (Steege, 2014).

There are also the implications that the culture and climate of a workplace can have on a new nurse’s actions and outcomes. Climate includes the procedures, policies, practices, and work rules that make up an organization. The way in which these aspects are regarded can make a huge impact on the climate of the institution (McGranahan, 2014). Culture, on the other hand, has a much deeper interpretation that goes into further explanation of shared basic assumptions regarding the values and beliefs that make up an institution (McGranahan, 2014). The truths that make up an organization, such as the culture, have a direct impact on the climate of attitudes, relationships, expectations, emotions, and interactions held within the organization. In effect, the climate has a direct influence on the actions of the employees.

A large indicator of whether or not a new nurse succeeds has to do with whether or not he/she feels comfortable in the work climate surrounding them. The support they receive as a new graduate from the other nurses may impact their well-being and also the institution’s outcomes. If a new nurse does not feel supported by his/her colleagues, or feels that the surrounding environment does not support learning, then their dissatisfaction may show in the care they provide to patients. Ultimately, this may impact their choice to leave the institution or the nursing profession all together.

Benner’s Stages of Clinical Competence

According to Benner (1982), a nurse passes through five levels of proficiency as skills are acquired and developed. The five levels include: novice, advanced beginners, competent, proficient, and expert (Benner, 1982; Benner, 1984).

1. Novice: The novice nurse tends to be a beginner with no experience in performing the tasks they have been assigned to do. They lack the judgment, confidence, and initiative that are required to fulfill involved tasks. He/she often requires verbal cues and constant support to achieve safe practice and successful completion of duties. The novice nurse is required to use rule-based information because they lack the experience and prior knowledge that more experienced nurses would use in particular situations. It is almost impossible for completion of the tasks to be successful due to the inability of the novice nurse to recognize when rules do not apply or are inappropriate for the given situation.
2. Advanced Beginner: Advanced beginner nurses have gained some experience and their performance on tasks has improved from that of a novice nurse. Although some supportive cues are still required, knowledge has developed and the advanced beginner is more efficient. He/she may operate on general guidelines which may still require support in the clinical setting because setting priorities is still a weak point. The decision to pay attention to the important aspects of a situation has not yet been established.
3. Competent: It is believed that the level of a competent nurse cannot be reached until two or three years has been completed at the same job. The biggest accomplishment related to the a competent nurse is that he/she has developed confidence in following through with actions and is able to fulfill tasks with coordination and efficiency. Care is delivered by establishing long-term goals and smaller everyday tasks are fulfilled with these bigger goals in mind. Deliberate planning by the nurse allows for more organized care without the need for supporting ques. Feelings of mastery and coping allow the competent nurse to become more efficient and comfortable with the tasks they are performing.
4. Proficient: The proficient nurse has developed a more wholesome approach to care delivery. He/she is better able to anticipate outcomes and is more flexible with changing actions if the situation changes. This level establishes that the nurse will be able to recognize when events are outside of the norm. Thinking becomes less labored because the nurse is more adapted for what to expect and is able to properly prioritize aspects of a situation in order to act on the appropriate ones.
5. Expert: Ultimately the expert nurse has an understanding of total situations. He/she is able to perform necessary tasks without spending long amounts of time thinking or running through scenarios. He/she has developed an instinct to know proper actions and is able to carry them out flawlessly. The high proficiency of his/her actions allows the problem to be zeroed in on to reduce the chances of unproductive thinking or useless courses of action.

In relation to the chosen interest of new nurses, it is valuable to establish that their lack of experience places them at the level of novice nurses. Novice nurses require support and cues when completing tasks because they lack the confidence of experience to complete these tasks otherwise. This can directly correlate with why the transition from new graduate to professional nurse can be so challenging. Formal education and experience are required to make the transition to higher levels of nursing competency (Benner, 1982).

Common Challenges New Nurses Face

The anxiety and nervousness that graduate nurses may experience when starting their career plays a huge role in their success as a professional nurse. From their research, Dyess and Sherman (2009) established multiple main themes related to the challenges that new graduate nurses identified when beginning their new professional role as a registered nurse:

First off, there are confidence and fear issues related to the vast amount of knowledge learned through nursing education and the anticipation of applying this knowledge during patient care. One participant of the study stated, “And I find it’s a fusion, a mix of fear for being the responsible one, and a challenge; to put all my knowledge properly together in every situation, and then it’s a wonderful achievement (Dyess & Sherman, 2009).” This statement establishes the mixed emotions that many new graduates face as they transition without knowing what to expect.

Next, a lack of ability to navigate the interprofessional care team can have major implications on the professional communication that a graduate nurse uses. Less than ideal communication can be intensified when a graduate nurse feels disrespected or looked down upon by another professional of the care team. The invalid use of professional communication also applies to when a novice nurse is required to supervise delegated actions to unlicensed assistant team members.

Longo and Sherman (as cited in Duclos-Miller, 2011) describe horizontal violence as, “any act of aggression demonstrated by a colleague, and it is inclusive of emotional, physical, and verbal threats, as well as innuendo or criticism”. Horizontal violence can have implications on the confidence of new graduates. Due to their already vulnerable position of being new to the profession of nursing, many of these graduates tolerate this behavior even though the vast majority of nurse leaders have established a zero tolerance policy.

Isolation directed towards the new graduates by other nurses may make them feel like they are alone in their new professional role. The chaos of new changes and learning opportunities may be hard on the new nurse if he/she does not feel that they have someone who supports them.

High levels of critical thinking are essential when taking care of high acuity patients who require care delivered through quick decision making. As evidenced by the description of the novice nurse, many new graduates do not have the ability to make important decisions without the opportunity of time to think through the situation (Benner, 1984). One participant of the study stated, “You’ve got to keep going. There is no time to stand still and use your brain (Dyess and Sherman, 2009).” It can be stressful for new graduates to make these decisions without the time to properly reflect on why they would handle a situation a certain way.

Lastly, one of the main challenges new graduates face as they start their career is the contradictory information given to them by staff they are working with. Novice nurses find it challenging to accommodate different ways of doing things and also find it difficult to shuffle through truthful information when they have a variety of sources.

The implications of these challenges novice nurses face make the transition into a professional nurse much more stressful. There are gaps in the education that these nurses are receiving that make a huge impact on their success as newly graduated professional nurses. By focusing on these challenges when improving the transition that new nurses experience, nurse leaders may achieve better success related to lowering the turnover rates for novice nurses.

Current Practices

The challenges described above were all addressed in a grant-supported transition program called the Novice Nurse Leadership Institute, or NNLI, in South Florida (Dyess & Sherman, 2009). Since starting in 2006, the program has blossomed into a one year transition support program for graduate nurses. Dyess and Sherman (2009) describe the overarching goals of the program to be, “to strengthen the competencies of new nurse along a variety of dimensions, provide ongoing support to reduce turnover in the first year of practice, and create a pool of future nurse leaders to serve the community by developing a leadership mindset in the first year of practice”.

Many of the challenges listed above stem from the pre-interview questions asked of participants before they started in the NNLI program. The program focuses on enhancing clinical judgment and increasing the confidence of these new graduates which directly relates to overcoming their fears, providing support, and giving them the experience that novice nurses need in order to advance to the next level of competency. Building upon basic knowledge, the NNLI provides 20 full-day learning sessions delivered across a span of one year in conjunction with web-based learning modules (Dyess & Sherman, 2009). The topics that are covered assist novice nurses in ways to handle and cope with the challenges that they will encounter in their practice.

Unlike most transition programs, the NNLI includes both associate and baccalaureate degree nurses who have had less than 12 months of nursing experience. Evidence found after the first two years of the NNLI program, it was established that the 20 core sessions taught by the program were all necessary for the success of new graduates entering practice. The research also determined that nurse educators and leaders must advocate for the use of preceptors and extended orientations for the new graduates’ transitions into becoming professional nurses (Dyess & Sherman, 2009). Overall, the program hopes to focus on the positive aspects of nursing that often get overlooked when novice nurses entering the profession have feelings that are overpowered by negativity.

A New Nurse’s Experience

While interviewing a relatively new nurse from the University of Wisconsin-Madison School of Nursing, it was discovered that she faced some of the same challenges described in the research by Dyess and Sherman (2009). The new nurse graduated in May of 2013 and soon started a residency program at UW Hospital shortly after. When asked if she felt isolated as a new nurse she stated that her situation was slightly different because she had worked on the unit previously as a Student Nurse Assistant. However, that added a whole new dimension to her transition because she was now responsible for supervising nurse assistants that she would previously go to with questions. She stated, “Starting on the unit as a nurse was difficult because I felt that the nurse assistants did not respect me and I believe that many of the staff did not know how to accept me in this new role.”

She also experienced an incident of horizontal violence in which another nurse snapped at her during a stressful moment. The event made her question her nursing abilities, but her recommendation to other new nurses is to be sound in what you are thinking. She stated, “It is impossible to get along with every nurse on your floor. It’s easy to say that a more experienced nurse is right and give up on your original course of action. However, you have to be assertive and stand up for yourself.”

At the start of her residency program, the new nurse most feared making an error that could harm a patient. She also found communication regarding the paging system to be difficult. She discussed her frustrations regarding the paging system by stating, “There are many gray areas in nursing so it is never a bad idea to get a second opinion and a new perspective before paging. You should also realize that providers will respond differently to pages and they may feel a different prioritization than you do. Being comfortable with paging will take time, but always trust your gut if you feel like action must be taken by the provider right away.”

When asked about her transition from being a new graduate to a professional nurse, she stated that she would have been at a disadvantage without the residency experience. She feels strongly that other new nurses should complete a residency program because of the continuous support provided by the program. She added, “There are some things that nursing school just can’t prepare you for. So much of nursing is learning on the job and having the experience of real life situations.” The continuing education provided by the program also allowed the cohort of new nurses to form a community in which they could talk about their experiences with others that were going through the same types of challenges. She also felt a strong connection with her preceptor who provided support as the new nurse developed her own style of nursing.

Despite the challenges of being a new nurse she feels that after almost a year of professional nursing, she has now raised the level of her clinical competency from a novice nurse to an advanced beginner. She stated that many new nurses will be surprised by how much information they know, but also by how much they still have to learn. In conclusion, her advice to novice nurses was, “Always, always trust your gut and never choose to overlook things. Identify people on your floor that you feel comfortable asking questions to. Being a nurse can be very stressful, but also very rewarding. You must find an outlet of relaxation that includes time for yourself and never hesitate to be cared for and supported by your loved ones (UW Hospital Residency Program Participant, personal communication, May 1, 2014).”

Nursing Leadership and Voice

Oftentimes, novice nurses are so nervous about making mistakes and being new that they fail to realize the unique perspective they can bring to their workplace. Novice nurses have the advantage of recently finishing nursing school, which allows them to be at the forefront of best practices and the newest nursing policies. They can become great nurse leaders in their new position because they provide a voice of change for the future. They have been trained to think about how actions can be improved and how positive change can impact the workflow of a unit.

Although they lack the experience that other nurses may have, novice nurses must get over their fears in order to take full advantage of the impact they can have on how the field of nursing may grow. In relation to this, the AONE Guiding Principles (as cited in Duclos-Miller, 2011) identified nurse managers as the leaders in ensuring success for newly licensed nurses. The leadership provided by these nurse managers must work towards providing a supported learning environment during the completion of the new graduates’ transitions (Duclos-Miller, 2011).

Systems Theory

In regards to systems theory, the success of a newly licensed nurse greatly relies on the influences of the other parts of the system. The current practice of the transition for new graduates into their professional role is not working. This is evident by the high nursing turnover of new graduates in the first year of professional nursing (Duclos-Miller, 2011). The system is not working because these novice nurses are not getting the support they need from the other parts of the system. In effect, the system is broken. It is obvious that the system cannot function without these new nurses because it would cause a nursing shortage as more experienced nurses continue to retire. So what must be done?

The answer lies in the way that novice nurses transition into their new roles. As mentioned in the sections above, there are many approaches to ensuring better success of new nursing graduates. The implementations of a nurse residency program or a buddy system are two approaches that have been viewed as successful (Duclos-Miller, 2011). Changing the way a system works and the inputs provided for a part of the system may in fact improve the overall functioning of the system.

Professional and Interprofessional Practice

Many new nurses identified that they struggled with the lack of care and concern provided by other members of the care team. It was stated in the literature that new nurses were looking for “reassurance, guidelines, and daily feedback about their development” from colleagues (Duclos-Miller, 2011). In response to this, it is extremely important that new graduates feel supported and respected by other members of the interdisciplinary team.

Duclose-Miller (2011) stated that a supportive environment should be extended past the first 12 months of a novice nurse’s employment and that providing training for supervising staff is essential in order to evaluate the nurse’s progress. On the other hand, it is also valuable for the new nurse to utilize tools and resources that will help them with providing professional communication to other team members and their patients. The manner in which they represent themselves to other contributors of the health care team plays a huge role in their professionalism and the respect they gain from other team members.

Value: The Quality of Nursing Care and Outcomes

Duclose-Miller (2011) expressed that novice nurses have the potential of experiencing role stress. Role stress can be associated with a, “change in status from student to GN [graduate nurse], difficulty with the challenges of the new role, lack of clear consistent information about the behavior expected of them, lack of clearly stated responsibilities, coping with beginning level of competence as a nurse, and their lack of confidence” (Duclose-Miller, 2011). It is easy to recognize how role stress may impact the care provided to patients.

The Institute of Medicine has been advocating for increased residency programs which in turn has established a supportive environment needed to build critical thinking skills, evidenced in the program, has allowed for the delivery of safer and more high quality care (Duclose-Miller, 2011). This goes without saying that providing support during a new graduate’s most vulnerable time of transitioning to a professional nurse establishes a higher quality of nursing care being provided, leading to better outcomes and increased confidence by the new nurse.

Recommendations

In conjunction with the literature from Dyess and Sherman (2009), it is felt that recommendations could be made in order to improve the success and reduce the turnover rate of newly graduated nurses. The implementation of support, especially during the first year, for novice nurses could have very valuable outcomes. This includes both support from the staff and also the healthcare institution. A supportive environment would boost confidence and reduce fears for newly practicing nurses.

Along with support, it is recommended that institutions provide interdisciplinary communication skills and provide training for how to respond in complex situations. Extra training in these two areas will allow novice nurses to be better prepared for difficult situations that they have never experienced prior to becoming a professional nurse. Also, the induction of a preceptor-ship which allows the new nurse to be paired with a more experienced professional who can provide direct guidance, support, and be a resource for questions, is highly recommended.

In addition to these recommendations, it is found that fully accredited nurse residency programs are the most successful in allowing newly graduated nurses to begin their career with the support and guidance that they need. While it is understood that the road to becoming an expert nurse takes time and experience, nurse residency programs allow for a novice nurse to become an advanced beginner in a more controlled and supported setting. There is also the benefit of decreased turnover due to residency programs which ultimately is the future goal for preventing intense nurse shortages. In a research study done by Krugman et al. (2006), the turnover rate after twelve months of completing a residency program was found to be just 9-12%. As mentioned earlier, Bowles and Candela (as cited in Duclos-Miller, 2011) found that the average turnover rate for graduate nurses falls at 30% in the first year and reaches levels of 57% at the second year. In addition to this extraordinary reduced turnover rate, the study found that the residency program decreased the amount of stress expressed by graduate nurses, improved the organization and prioritization skills, led to higher levels of support perceived by the new nurses, and increased the overall satisfaction these new nurses felt after their first year of being a professional nurse (Krugman et al., 2006).

The ideal residency program lasts a minimum of one year, which covers Benner’s transition from novice to expert (Krsek & McElroy, 2009). According to Krsek and McElroy (2009), the program should include, “communication, safety, clinical decision making/critical thinking, organizing and prioritizing, evidence-based practice, role socialization, and delegating and supervising”. The program should allow for a safe and trusting environment in which performance evaluation and suggestions for improvement are commonly given. The UHC/AACN Post-Baccalaureate Nurse Residency Program at the University of Wisconsin Hospital and Clinics is an example of one of these programs (Nurse Residency Program, 2013).

An example of a nurse residency program can be found here (UHC’s Nurse Residency Program, 2012):

Resources for more information

Kelly, J., & Mcallister, M. (2013). Lessons students and new graduates could teach: A phenomenological study that reveals insights on the essence of building a supportive learning culture through preceptorship. Contemporary Nurse: A Journal For The Australian Nursing Profession, 44(2), 170-177. doi:10.5172/conu.2013.44.2.170

Gillespi, M., & Peterson, B. (2009). Helping novice nurses make effective clinical decisions: the situated clinical decision-making framework. Nursing Education Perspectives, 30(3), 164-170.

Saintsing, D., Gibson, L. M., & Pennington, A. W. (2011). The novice nurse and clinical decision-making: how to avoid errors. Journal Of Nursing Management, 19(3), 354-359. doi:10.1111/j.1365-2834.2011.01248.x

https://www.amsn.org/professional-development/mentoring

http://www.vpul.upenn.edu/careerservices/nursing/nurseresidency.php

http://directory.ccnecommunity.org/reports_residency/rptResAccreditedPrograms_New.asp?sort=state&sProgramType=

References

Benner, P. (1982). From novice to expert. The American Journal of Nursing, 82(3), 402-407.

Duclos-Miller, P. A. (2011). Successful Graduate Nurse Transition: Meeting the Challenge. Nurse Leader, 9(4), 32-49. doi:10.1016/j.mnl.2011.05.006

Dyess, S., & Sherman, R. (2009). The first year of practice: new graduate nurses’ transition and learning needs. Journal Of Continuing Education In Nursing, 40(9), 403-410. doi:10.3928/00220124-20090824-03

Krsek, C., & McElroy, D. (2009). A solution to the problem of first-year nurse turnover. Retrieved from https://www.uhc.edu/16807.htm

Krugman, M., Bretschneider, J., Horn, P., Krsek, C., Moutafis, R., & Smith, M. (2006). The National Post-Baccalaureate Graduate Nurse Residency Program: a model for excellence in transition to practice. Journal For Nurses In Staff Development, 22(4), 196-205.

McGranahan, P. (2014). Culture, climate, and communication [PowerPoint slides]. Retrieved from Learn@UW website.

Nurse Residency Program (Post-Baccalaureate). (2013). UW Health. Retrieved May 2, 2014, from http://www.uwhealth.org/health-professionals/internships/nurse-residency/main/31892

Steege, L. (2014). Organizational structures [PowerPoint slides]. Retrieved from Learn@UW website.

UHC’s Nurse Residency Program. (2012, December 20). YouTube. Retrieved May 2, 2014, from http://www.youtube.com/watch?v=4t_gJcJR4eY

 

 

Emerging Roles in Nursing Care and Accountability: Transitional Care, End-of-Life Issues, or Serving the Underserved

Care coordination is the “deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of healthcare services and a function to help ensure patient’s needs and preferences are met over time across all services” (American Nurses Association, 2012a). Care coordination is the connection between community agencies, hospitals, emergency rooms, and medical specialists that creates better relationships and results in patient support and satisfaction. Simply put, care coordination unites health care and can result in better outcomes. Nurses are fulfilling emerging roles to efficiently facilitate patient care coordination.

ANA’s Stance on the Role of Nursing

‘Patient care coordination’ has recently turned into a buzzword(s) and guides the future direction to ideal health care. Yet, American Nurses Association’s (ANA ) response to this new interest is, “what took you so long?” (ANA, 2012a). Popularity with this term is spreading and the popularity is beneficial for funding and to make progress towards better quality, improved patient outcomes, and reduced health care costs. Although ANA supports care coordination, their position statement explains that nursing has been providing care coordination as part of a core professional standard already.The Scope and Standard Practice for Nursing, which is from ANA and is responsible for defining the responsibility of nursing, specifically including accountability for care coordination across populations as a nursing standard (ANA, 2012b). For example, nursing is often responsible for correctly piecing together all parts of the health care puzzle in order to reach patient-centered goals, and has been doing this for years.

The position statement made by ANA takes a clear stance on care coordination, stating that Registered Nurses (RNs) are in the best position to lead in this area, as care coordination is an extension of the nursing role. Nursing has increased bedside time, knowledge, and experience in this role. The position statement also explains the importance of vocalizing how vital nursing services are and then requesting appropriate payment for this care coordination (ANA, 2012a). Nurses are, and have been, the leaders of patient care coordination and therefore need to be supported in their practice. Nursing is in a position to improve patient care quality and outcomes, which will be explained further on.

For future care coordination,  ANA suggests that additional research be done regarding effective care coordination, enhanced education be provided to RNs, and nursing organizations implement care coordination opportunities to improve our health care system.

IOM’s Stance on the Role of Nursing

Experts are continuing an attempt to achieve a care system that has the lowest amount of error, with increased coverage and value. IOM discusses the dire need to improve care, beginning with coordinated care led by nursing. One example of research supporting the IOM’s stance is from Living Independently for Life (LIFE), which is a Program for All-Inclusive Care for Elders (PACE) led by nurse practitioners to coordinate services for low income, frail, and chronically ill older adults that are living at home but eligible for nursing home care (Nichols, Davis, & Richardson, 2010). The LIFE program goes beyond home care because, in addition to home visits, the nurse practitioner takes patients to outings, provides transportation, and continues to coordinate care if hospitalized. The results from this study showed less preventable hospitalizations, less emergency room visits, and less placement in nursing homes, all of which in-turn improve quality and save money (Nichols, Davis, & Richardson, 2010). Specifically, the study resulted in saving one dollar for every fifteen cents spent when nurse practitioners were leaders in care coordination for those in the community that otherwise would be in nursing homes. IOM uses the LIFE program as part of their basis for recommending care coordination led by nurses.

IOM believes that the nursing profession can cause systematic change and this can be evidenced by “100,000 Lives Campaign.” This project was designed to lower care procedure infections and resulted in a recurrent pattern of success that depended on nurses’ support (Nichols, Davis, & Richardson, 2010). Additionally, successful programs have all shared the feature of nursing directing coordination and communication between all team members while providing health care services (Nichols, Davis, & Richardson, 2010). Nursing is at the front line of patient care, and change and coordination is within the grasp of nursing. IOM supports nurse leadership because nursing incorporates more than specific disease knowledge, has the most bedside care, and has education from a psychosocial, spiritual, physiological, family, and community perspective, which is like no other profession.

Care Coordination and Reasons Transition in Care is of Interest

It is important to further increase and truly develop care coordination because of the many common problems with the American health care system. There is a lack of efficiency, which partially reflects the substantial gaps between health care disciplines and their communication errors that result in suboptimal patient care and quality of life. Therefore, care coordination has been deemed a priority by US Department of Health and Human Services to acquire better care and quality services while lowering costs (Nichols, Davis, & Richardson, 2010). Evidence has shown that uncoordinated care greatly increases health care costs, and teams need a specific role to coordinate all the various care (ANA, 2012a). Currently, care is incredibly flawed and care coordination has repetitively shown to be an appropriate and beneficial change to the delivery of healthcare.

Care coordination has the ability to improve each indicator for quality of care that is currently lagging. Care coordination has produced many health improvements through increased access and availability to health care with a leader improving continuity (Steege, 2014). The American health care system spends more money, but achieves much lower health outcomes. Although The United States spends more than any other nation in total, less than 3% of the spending is directed towards public health (Nichols, Davis, & Richardson, 2010). This small percentage of funding is extremely disproportional to the budget and is identified by IOM and many other studies as part of the reason that our outcomes are below most other developed countries. There is large amounts of money spent on specific diseases and specialities but not on prevention or holistic health for individuals.  Care coordination is of strong interest because it has the potential to minimize these current issues and improve outcomes, which this blog will discuss in-depth.

 Outcomes and Quality through Care Coordination 

Multiple studies have concluded that the outcomes and quality of care coordination is highest when performed by Registered Nurses. ANA mentioned that several studies used in their recommendations observed numerous positive outcomes including improved quality of care, increased safety of older adults during transition, reduced overall charges, and significant increase in survival specifically when nurses lead the care (ANA, 2012a). One specific example supporting nursing led quality, by Leveille et al was of coordinated care for a group of 201 chronically ill seniors matched with a geriatric nurse practitioner for disability prevention and disease management (Leveille et al., 1998). The results from this study found that chronically ill patients experience an increase in functioning and lower hospital rates when having regular contact with the specialized nurse practitioners (Leveille et al., 1998). Further recent evidence done by an integrative review of eighteen articles called, “An Integrative Review of Nurse-led Community-based Case Management Effectiveness” concluded management was effective for patient outcomes that were nursing led (Joo & Huber, 2014). Efficiency was defined in the study by hospital readmission rates, length of stay, and emergency department visits. Thus, significant research has concluded that nursing led care coordination increases quality of care and leads to positive outcomes.

Care Coordination and the Nursing Model

The nursing model indirectly incorporates the role of care coordination. The nursing model, contained in the ANA social policy, states that the role of the nurse is one that optimizes health and abilities, prevents illness, alleviates suffering, and advocates in the care of the individual, community, and population (ANA, 2014). Based off of the nursing model, nursing is responsible for coordination to optimize health, and therefore falls directly within the scope of nursing practice. The nursing model puts patients and their family as the center focus and works with other members that impact health to reach their individual outcomes. The model places the role of communicating and advocating as the responsibility of nursing. In summary, care coordination falls within the nursing model’s idea of the nurses’ obligations and has proven to be an effective change.

Why Nurses Should Serve this Role & Impact of Nurses on Healthcare

The nurse is the most appropriate care coordinator in the vast majority of cases for several reasons. According to ANA, Registered Nurses are crucial to the care coordination as evidenced by many research initiatives to integrate healthcare as previously mentioned. From the studies, it was shown that nursing led patient-centered care coordination decreased costs while improving patient outcomes (ANA, 2012a). Nurses are in a position to be system innovators to create this positive change. Nursing has the ability to improve patient outcomes and innovate new changes for an evolving care system largely because of patient access and their role as an advocate (Nichols, Davis, & Richardson, 2010). In this new role, part of the responsibility will be to apply research findings and evaluate care plans for patients.

Nurses are appropriate care coordination leaders because of their education, patient contact, and patient advocate role, and they  already serve as the primary coordinator without formal acknowledgment. Care coordination is a professional competency of all registered nurses. Research across a wide variety of settings and diverse patient populations has shown the positive outcomes of nursing led care coordination. Conclusions from one study, “The White Page”, found lower numbers of emergency room visits, a decrease in medication and Medicare costs, and a decrease for in-patient and overall charges (ANA, 2012b).  Additionally,  “The White Pages” found increases in patient savings, survival rates, levels of patient confidence, and improved quality of care and safety during transition with nurse leadership (ANA, 2012b). Another example of research that supports nurses’ vitality in leading care coordination is the case study done at Indiana University Health where a nurse, Angela Barron McBride, became a member of the board with the main focus of improving quality. The focus on quality was developed by nurses because McBride explained that they are most likely to be educated on system issues and experience working within the complete system, thus making them ideal board leaders (Hassmiller & Combes, 2012). In summary, research thus far has proven that when nurses lead care coordination there is an increase in clinical outcomes, increase in patient satisfaction, and reduced costs, which is the ultimate goal of care coordination.

Nursing Leadership and Voice

Care coordination led by Registered Nurses will further the leadership and voice nurses have. Nursing has continuously been a behind-the-scenes leader for patients, but it is important for nurses to transition to active and acknowledged leadership in the future. Currently, most hospitals and health care systems do not have a nurse on the board of directors. Only 6% of board members were nurses in a recent study comprised of over 1,000 hospital boards. However, members agrees that nurses are leaders that are largely overlooked (Hassmiller & Combes, 2012). Care coordination is an additional avenue for nursing to gain further leadership positions and use our knowledgeable voice.

Therefore, care coordination is a great platform to further leadership because of our unique qualifications as a nurse to efficiently coordinate care. In a recent poll, 84% of board members thought nursing specifically could improve healthcare efficiency and reduce costs (Hassmiller & Combes, 2012). This statistic shows that nursing is receiving acknowledgement of importance but has not yet been actively serving these leadership roles, such as becoming a board member. The nursing role fits with the leadership skills vital to coordinate care. Additionally, leaders should be capable of collaboration, organizational awareness, and team leadership, which are already utilized skills by nursing. Nursing can use these qualifications to put them in a position to lead healthcare towards better outcomes.

Systems Theory

True care coordination that provides transitional care to complex patients requires a systematic change. Our current health care system leaves many gaps in care, resulting in care too little too late. The majority of chronically ill patients have several specialists they receive care from. The different specialties have extremely limited communication and considerations when giving recommendations and plans for care. Nursing is left to try to fill the gaps as best as they can when they are available. However,  the way the system is currently set up does not provide enough roles as coordinators, which is why systematic changes are needed to truly improve coordination and patient outcomes.   Reports from IOM have shown that system wide changes are necessary to meet higher standards for quality care (Nichols, Davis, & Richardson, 2010). Coordinating care at this systematic level links research to improved patient outcomes.

Coordination at the system level allows independent groups that comprise an individual’s complete health to connect by having adequate positions and resources to do so. The leadership role of coordination is to improve communication between different structures and disciplines to improve behavior and patient outcomes. A systematic approach analyzes and modifies the system to remove barriers to achieve improved outcomes (Steege, 2014). There have been studies done at the micro and meso level with specific nurses, individuals, and programs. The micro and meso level are where studies are often evaluated, but successful change for care coordination also requires the larger system to be involved. Care coordination at the macro level would further connect the bidirectional relationships in health care through the role of the care coordinator. Available positions and finances are crucial to make the greatest change. Lastly, at a system level it is important to have the government support for funding and implementation. Many research studies have been conducted at smaller subsystems specifically to indicate that the initial budget required pays off and does save money long term.

Professional and Interprofessional Practice

Care coordination requires interprofessional practice in order to be efficient in care coordination. It is critical for health care team members to work together to provide best care and improve provider satisfaction. When health professionals efficiently work together time and effort is saved.The various disciplines and professionals will be communicating with the nurse leader in charge of appropriate coordination but requires effort and commitment by each discipline to look at the individual holistically. A teamwork model is a way professionals can work together to better care for a patient using the patient-centered team (Steege, 2014). Using the teamwork model, care coordination would be successful by having tasks and roles with team processes resulting in greater team effectiveness (LeMieux-Charles & McGuire, 2006). For example, coordinating care for a patient that prefers in-home hospice requires teams members to understand the roles, resources, and composition to attain this patient goal. Interdisciplinary coordination furthers patients’ ability to receive individualized care from the team with proper communication, cooperation, participation, coordination, and decision-making leadership (Steege, 2014). Under the teamwork model the effective outcomes for this in-home patient will be patient satisfaction, along with provider and organizational satisfaction.            

Again, interprofessional practice is extremely applicable to care coordination, and is essentially the premise for care in an attempt to increase patient and provider communication and outcomes. Programs using an interdisciplinary team approach for coordination in care have been studied and one example is, The Guided Care Program (GC). The coordinated care led by nurses performed standardized home assessments and collaborated with the entire health care team while giving evidenced based care. The study gave patients increased access to health care, encouraged patient participation, supported self-management, and efficiently coordinated care. The study differed when the nurse coordinated the interdisciplinary care and showed a 24% reduction in inpatient stays with 15% reduction in emergency visits (Nichols, Davis, & Richardson, 2010). The Guided Care program is an example of a successful model that has improved patient outcomes and quality with reduced health care costs as nursing led the care from multiple health disciplines (Nichols, Davis, & Richardson, 2010). This is just one model that has given proven evidence that interdisciplinary practice led by nurses is beneficial for care coordination.

Value: The Quality of Nursing Care and Outcomes

It is critical for nurses to tap into this role as innovators of care coordinators to improve clinical outcomes and costs for specific groups of patients. (Nichols, Davis, & Richardson, 2010). Nursing needs to take an active role to lead and advocate for the patient services. The quality and leadership of nurses in the care coordination role will expand to improve outcomes. Again, evidence has shown that enhanced involvement of nurses in coordination and delivery of care is critical to reach cost and quality outcomes (Nichols, Davis, & Richardson, 2010). Coordination of care and closing the gap will improve the health of individuals that will in turn reduce costs. The coordination will improve value by improving efficiency and communication so that goals and treatment by others is known to each health care worker.

The quality of nursing care has significant value and strongly influences patient outcomes. Care coordination aims, and from many programs is evidenced by, bettering health outcomes and preventing illness and suffering. For example, the Nurse-Family Partnership is a program in which Registered Nurses are coordinators for at-risk, low-income first time mothers and the nurses make sixty-four planned trips to see the woman and baby over the course of the pregnancy and first few years per mother. This program has resulted in lower incidence of abuse for these children, lower level of arrests, and improved health (Nichols, Davis, & Richardson, 2010). The study concluded that through care coordination, health is optimized and parenting ability and confidence increases. The nurse was able to provide quality care to the specific child, the greater community, and the population and as a result lower abuse and incarceration rates occurred. The value of nursing care can not be minimized because of their capability to truly change lives and improve outcomes.

Rural Elders and Care Coordination

While brainstorming, the group came up with numerous situations or settings in which nurses could potentially improve outcomes or assure quality. The ideas for improvement were mostly describing different vulnerable populations. We discussed populations such as diabetic elders or at-risk infants, but decided that elders living in a rural setting with multiple comorbidities would benefit exponentially from care coordination by nurses. Many healthcare delivery strategies are currently being studied to address the complex physical and mental health of older adults who live in areas geographically removed from appropriate healthcare delivery (Luptak et al., 2010).

Elder adults in rural settings with multiple health issues would significantly benefit from care coordination because of their numerous risk factors that make them vulnerable to fall into the gaps of healthcare and arrive in the emergency room from preventable events. Living in a rural setting makes getting adequate health care more of a challenge because of transportation, finances, and availability of providers.  Additionally, many rural elders that are isolated struggle with ADL/IADL’s.  They have more health problems, and may develop some cognitive impairment all of which puts them at risk. For example, one group member’s last patient in clinical lived in a rural setting and  was making their eleventh hospitalization in the last three months for exacerbation of heart failure. This shows that rural elders would benefit from nursing led care coordination and studies have concluded benefits of this care.

Recent Example of Rural Elders and Care Coordination

There have been many studies performed that determined this population’s care management needs improvement, and that nursing care coordination is effective to improve their needs. The research study called, “The crisis nature of health care transitions for rural older adults” examined many patients and healthcare providers in a longitudinal rural ethnography that discussed the risks and problems the group of rural elders are facing and how care could improve (Magilvy & Congdon, 2000). The rural elders are often transitioning between health care facilities, which is a susceptible time especially when isolated.  Recommendations from “The crisis nature of health care transitions for rural older adults”were based off of observation and interviews that all concluded comprehensive care management was advised to help this specific group.

Beyond recommendations, care coordination for this population of rural elders has been implemented and studied. In 2010 the VA system began a care coordination project for rural veterans that had frequent hospital admissions and emergency room visits. One hundred and thirty-two veterans were part of the study with the coordinator serving to facilitate primary care, be there to help detect early symptoms, and aid adhesion to medical plans (Luptak et al., 2010). The study’s aim was to provide patient centered care by making providers accessible, encouraging patient participation, giving support for self-management, and coordinating care. This study addressed the main issue of rural elders by coordinating care for those with remote access. The VA study differs slightly with the use of telehealth and does suggest more research to be done. However, the study has the identical premise that more coordination and contact with nursing increases patient satisfaction, with 86% satisfied in the study, and saves money (Luptak et al., 2010). Lessons learned from these studies of care coordination for rural elders is that the health system is leaving many in this population suffering. Increased care coordination for this population shows that vulnerable populations benefit from increased contact and health coordination which saves lives and dollars.

Resources

https://www.youtube.com/watch?v=IajEzbrm87c

//www.healthleadersmedia.com/page-1/NRS-275413/Nurses-Key-to-Care-Coordination

http://mayoclinichealthsystem.org/~/media/Local%20Files/La%20Crosse/La%20Crosse%20Live%20PDF%20Files/FINALResBadgerNurseInsert41912.pdf

http://www.improvingchroniccare.org/index.php?p=Care_Coordination&s=326

http://www.ncbi.nlm.nih.gov/pubmed/23817284

http://www.ncbi.nlm.nih.gov/pubmed/22686111

References

American Nurses Association (2012a). Care coordination and the essential role of nurses. Retrieved from http://www.nursingworld.org/care-coordination

American Nurses Association (2014). Official ANA position statements. Retrieved from http://www.nursingworld.org/positionstatements

American Nurses Association (2012b). The value of nursing care coordination: A white paper of the American nurses association. Retrieved from http://www.nursingworld.org/carecoordinationwhitepaper

Hassmiller, S., & Combes, J. (2012). Nurse leaders in the boardroom: A fitting choice. Journal of Healthcare Management, 57. Retrieved from http://www.thefutureofnursing.org/sites/default/files/JHC-%20Hassmiler%2C%20Combes%20Jan.Feb%202012_0.pdf

Joo, J. Y. & Huber, D. L. (2014), An integrative review of nurse-led community-based case management effectiveness. International Nursing Review, 61 (14–24). doi: 10.1111/inr.12068

Leveille, S. G., Wagner, E. H., Davis, C., Wallace, J., LoGerfo, M., & Kent, D. (1998). Preventing disability and managing chronic illness in frail older adults: A randomized trail of a community-based partnership with primary care. Journal of the American Geriatrics Society, 46 (10). Retrieved from http://www.mdconsult.com.ezproxy.library.wisc.edu/das/article/body/444289427-2/jorg=journal&source=&sp=10439562&sid=0/N/126324/1.html?issn=0002-8614

Luptak, M., Dailey, N., Juretic., Rupper, R., Hill, R. D., Hicken, B. L., & Bair, B. D. (2010). The care coordianation home telehealth (CCHT) rural demonstration project: A sytmptom-based approach ofr serving older veterans in remote geographical settings. Rurul and Remote Heatlh (10). Retrieved from http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1375

Magilyy, J. K., & Congdon, J.G. (2000). The crisis nature of health care transitions for rural older adults. Public Health Nursing (17). doi:10.1046/j.1525-1446.2000.00336.x

Nichols, B. L., Davis, C. R., & Richardson, D. R. (2010). Study context. The Future of Nursing: Leading Change, Advancing Health (2-1-2-18, pp 375-380). Retrieved from http://www.gvna.us/info/FutureOfNursing.pdf

Steege, L. (2014, January 27). Systems approach. [powerpoint presentation]. Retrieved from https://uwmad.courses.wisconsin.edu/d2l/le/content/2359431/viewContent/14164524/View?ou=2359431

Interdisciplinary Practice-Nurses as Full Partners in Care

What Exactly is a Nurse?
According to the American Nurses Association, “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (American Nurses Association, 2014). While this summary of nursing may appear to be somewhat vague and all encompassing, it is an accurate representation of the profession as well as nursing models. Though there are multiple different models, most take on a holistic approach that focuses on treating the patient as an entirety: seeking health physically, mentally, psychologically, socially, and spiritually. Nursing, in short, is a profession in which you help people to function their best through the many different avenues of life. The path traveled may be one of remission from cancer, transition into motherhood, or something entirely different. In order to gain a more comprehensive perspective on what a nurse does, visit the ANA website at http://www.nursingworld.org/especiallyforyou/what-is-nursing.

A person seeking to work as a nurse has the option to pursue any one of the multiple educational pathways that will allow them to gain eligibility to take the National Council Licensure Examination (NCLEX)-RN (ANA, 2014). The various pathways include: a Diploma in Nursing which is offered through hospital-based schools of nursing, an Associate Degree in Nursing (AND) which is a two-year degree at a community college or hospital-based school of nursing, or a Bachelor of Science in Nursing (BS/BSN) which is a four-year degree at a college or university (ANA, 2014). While the AND degree focuses more on the technical aspects of nursing, a BSN allows a person to participate in a wider scope of practice and more flexibility to work in various health care settings.

Lastly, nurses have the option of returning to school in order to obtain a graduate degree. Registered nurses can gain further expertise by completing one of the following advanced degrees: a Master’s Degree (MSN) to prepare an RN for advanced practice nursing such as a nurse administrator or a nurse educator; a Doctor of Philosophy (PhD) program in which individuals can become involved in teaching and/or conducting research; and a Doctor of Nursing Practice (DNP) program, which focuses on leadership in clinical practice (ANA, 2014).

Other Members on the Health Care Team
In addition to nurses, there are a number of other professionals that help to comprise a functional health care team. Each member of the team travels a different route to begin practice, allowing them to have a unique perspective and valuable input which are necessary for the achievement of optimal patient outcomes. Joint collaboration of team members with differing perspectives and expertise allows for increased insight and problem solving techniques that may not otherwise be utilized by a single health professional (Westberg & Jason, 1993). In order to appreciate what fellow team members with differing backgrounds bring to the table, it is important for each health professional to have an understanding of their fellow members’ backgrounds and scopes of practice. There are many advantages to interdisciplinary team care, including: improved care for patients by increasing coordination of services, increased professional satisfaction, heightened appreciation and understanding of other disciplines among students and educators, as well as a greater maximizing of health care resources and facilities (Grant & Finocchio, 1995).

*Physician
One of the more recognizable health professionals, both to patients and health care staff, is the physician or doctor. To many, the physician is the person who is ultimately in charge, calls the shots, and makes the important decisions. The medical model, which is disease focused and centers on diagnosis and treatment of illness, is the model which most patients associate with health care. This model also helps to illustrate one of the most important responsibilities within a physician’s scope of practice: making a medical diagnosis. After speaking with a doctor practicing in emergency medicine on how he perceived his role within the healthcare team, he stated, “As a doctor here in the ER, you are forced to make a lot of big and important decisions in a relatively short period of time. This is why you spend so much time in school and preparing before actually practicing. In many ways I do see myself as a leader of the health care team, but also a collaborator with others. Without others [health professionals] doing their part, it would be a lot tougher for me to do mine.”

When asking a medical student on the extent of education that was required to achieve a Doctor of Medicine Degree, she responded, “First you get your undergrad, and then do four years of med school, and then you must do a residency program in order to begin practicing.” After asking about more specifics, she stated that a typical residency program is three years long, however, specialties such as cardiac surgery, require an individual to partake in a longer residency program lasting up to five years.

The medical student was then asked about her opinion of nurses. It cannot be determined whether or not her response was influenced by the fact that she was aware she was speaking to a nursing student, but her answer consisted of the following, “I think nurses do a lot. We go through separate training programs, but it’s not like one is more important than the other. I know there are a lot of nurses out there who really know their stuff, and once I start my practice I plan to use them as a resource, at least until I know what I am doing more.” While this is the response of an aspiring doctor still enrolled in medical school it would be fascinating to know whether or not her opinion of nurses would change over time. She was aware of the fact the in order for an individual to obtain a nursing degree, they were required to do college coursework. She was a bit confused about what an actual nursing model would be, and defined nursing scope of practice more by what was not included in it: diagnosing conditions.

*Unit Clerk
Unit clerks, sometimes referred to as receptionists, can be found working in almost every type of health care facility. While many of these positions do not require a college degree in a specific area, many who work in this role have some advanced education. Depending on their specific place of employment, job duties include, but are not limited to: answering phones, ordering supplies, and helping both health professionals and patients “navigate” their surroundings. In order to gain more insight about a unit clerk’s role, an interview was conducted with a young woman working as a unit clerk at a long-term care facility. She stated that each day was different, some slow and some overly busy. She is responsible for what some people may take for granted, such as ensuring appointments are arranged and kept. In regards to her education, she stated that she has a high school degree and her Certified Nursing Assistant (CNA) license. In addition to working as a unit clerk, she works as a CNA on other days of the week. Though asked, the unit clerk stated that she was unaware of any practice model that pertained to her job.

Unit clerks are great members of the health care team to utilize if you have a question. They may not know the answer themselves, but they are often able to point you in the right direction. At another time, the Director of Nursing (DON) of this facility was heard saying, “[name of the unit clerk] is the mortar between the bricks of this building. Without her the whole thing may just fall apart.”

After asking the unit clerk about how she perceived nurses, she replied “They seem busy, really busy. And stressed out. I’m glad I don’t do what they do. I think I would be too stressed out.” While nursing, or rather any personalized care of individuals, has the potential to be a highly stressful job, it is somewhat concerning that the impression given off by some nurses is that nurses are constantly stressed. This may blind others to the rewarding sides of nursing, such as seeing a patient improve and overcome a major hurdle on the road to becoming healthier. The unit clerk was knowledgeable about the education required to become a practicing nurse, knowing there are several different education pathways that can be taken, some two and others four years in length. She defined the nursing model as “helping patients to get better and back to their old selves.” In regards to scope of practice, she felt that nurses may technically have a limited number of things they can do, though exercise a lot of decision-making. In her mind, nurses at the facility often were the leaders in patients’ care, and involvement of the physician usually just consisted of gaining his or her approval by the nurse.

*Pharmacist
For many in the community, the pharmacist is a person whose role is easy to define: they are experts when it comes to medications. They can tell you what a medication is used for, as well as its side effects. What many do not always realize is the amount of education it takes to become a pharmacist. In order to be an expert on medications, the pharmacist must first understand the body. To practice as a pharmacist, one must obtain their Doctorate of Pharmacy Degree (PharmD). The requirements for obtaining this degree include: two years of undergraduate coursework, a passing score on the Pharmacy College Admission Test (PCAT), followed by a four-year pharmacy program, accompanied by a series of 7-10 rotations in a variety of clinical and pharmaceutical settings each lasting 4-6 weeks in length (About.com, 2014). Though all this education could potentially be completed in six years, most students will end up taking eight years of college to finish with their degree (About.com, 2014). More information on becoming and practicing as a pharmacist can be found by clicking on the following link: http://healthcareers.about.com/od/healthcareerprofiles/p/PharmacistJobs.htm.

When asking a pharmacist about his practice he said “Yes, we [pharmacists] do make pretty good money, but there is a lot we are expected to know.” With the ever increasing number of drugs on the market, the reliance on a knowledgeable pharmacist continues to increase. It is clear that doctors, nurses, and other health professionals utilize pharmacists as a valuable resource in the emergency room setting. During a trauma situation, the pharmacist is often present in the room, drawing up drugs and handing them over to be administered as the doctor orders. In an emergency setting, this is the most effective and efficient way in which a doctor can order a medication to be administered based on assessment findings and the pharmacist can check and approve the order before actual administration.

After asking the pharmacist about his opinion of the nursing profession he pointed out that nurses do more hands on work with patients than pharmacists do. As a pharmacist, he felt that he needed to be able to communicate with patients, but he thought patient communication was even more important for someone going into the nursing profession. He also stated that he enjoys when people [doctors, nurses] come to him with questions because it makes him feel useful and respected that others acknowledge his expertise. His impression of the nursing model, was that nurses are to help the patient achieve optimal functioning. Working with a lot of nurses, he was well aware that a lot of practicing nurses, at least employed at hospitals, had acquired a Bachelor of Science in Nursing Degree.

Barriers to Effective Teamwork Among Health Professionals
After investigating interview responses, it is clear that one’s perspective about nurses or other health professionals is strongly influenced by where one actually practices. While most professions have an idea of the amount of education required of other professionals (extensive education, undergraduate coursework, etc.), many are unaware of the exact requirements and clinical experience obtained. This leads to an undermining of the expertise associated with different professions, resulting in decreased effective collaboration and utilization of valuable members on the health care team.

One point of interest was the perception of nursing that was held by other health professions. While many acknowledged the fact that nurses play an important role in patient care, many healthcare members seemed unfamiliar with what nurses actually do and where their expertise lies. This lack of knowledge about the nursing profession is not necessarily a bad thing, but rather shows the beauty of nursing. Nurses have the ability to fill so many different roles, in so many different settings, working with very diverse populations. While this expansive variation makes nursing a very exciting profession to enter, it makes it a challenging profession to define to others.

The struggle to define one’s profession to others can very easily be misunderstood. It can be perceived as a lack of competence and knowledge regarding one’s own practice. Perceptions such as this lead to decreased confidence in the health team member, resulting in decreased collaboration and non-optimal teamwork. To overcome this, individuals should be asked to reflect on their roles and scopes of practice, as well as encouraged to share this information with others on the health care team. This may help to increase the level of trust and understanding amongst team members, helping to set the stage for enhanced quality care.

Lastly, it is clear that many health care professions require education regarding basic functions and pathophysiology of the body. It is interesting that the learning of this material is often separated for each profession. Why not let individuals from various professional backgrounds learn this information together? This could allow for connections to be made across professions, leading to enhanced teamwork down the road.

Nursing Leadership and Voice
In order for nurses to take on leadership roles when it comes to interdisciplinary health care teams, they need to have a thorough understanding of their unique profession, as well as the professions of those with who they collaborate. Without this understanding, a lack of confidence in oneself is a likely culprit for why many nurses shy away from roles as leaders. In order to increase nurses’ confidence in their leadership abilities, nursing schools should promote exercises involving interdisciplinary situations. This will help students pursuing a variety of professions to become comfortable interacting with those who have different educational and clinical backgrounds, helping each to strengthen their voice and contribute to the team.

Systems Theory
The interdisciplinary health care team is in and of itself a system. It is multiple interdependent parts (the various professions) regularly interacting with each other to form a unified whole (the health care team). What can be improved is the degree to which these parts are unified. To improve this unification, the structure of the system could be modified from a more traditional hierarchy model to one that places team members on a single level playing field. This encourages collaboration and allows each member to take full responsibility of their contribution to the group. Relationships could be improved between system parts, or rather members, by implementation of more extensive interdisciplinary education. Greater unification leads to increased efficiency, enhanced safety, and improved patient outcomes. By helping individual health professionals to understand that they are an integral part of the health care team, or “whole,” this will help the entire team to ensure that the “whole” patient is being properly cared for.

Professional and Interprofessional Practice
Changes to professional and interprofessional practice are more easily made when starting further down the totem pole, at the education level. Those who have been in practice for several years are often more resistant to change because they may be more comfortable with doing things a certain way. Young minds, still in school, are somewhat more malleable, allowing for the budding idea of increased interprofessional practice to really grow. Integrating the concepts of interprofessional practice and collaboration into educational programs and curriculum holds the potential to revolutionize health care. Health care in which the patient does not just visit with their doctor, but seeks the care and support of a comprehensive health care team. A patient will never feel comfortable doing this, unless they are confident that a team actually exists. In order to develop teams, teammates must begin to “play together” and in order to play well, the team must first practice. This practice is interdisciplinary education, a time in which team members learn to work together and develop trust.

Value: The Quality of Nursing Care and Outcomes
As stated in the article “Interdisciplinary Evidence-based Practice: Moving from Silos to Synergy,” (which can be accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998190/), “Interprofessional collaboration is foundational for improved patient care” (Newhouse & Spring, 2011). As disciplines are better aware of each others’ backgrounds and scopes of practice, each will also become increasingly aware of what others expect of them. This expectation results in a heightened sense of responsibility among nurses and other professionals, leading to a higher standard of care to be delivered. The increased collaboration between professions and the migration of an increasing number of nurses into leadership roles will help nursing maintain a strong voice regarding care provided to patients.

Implementation of Strategies to Improve Interdisciplinary Practice
The importance of interdisciplinary training and practice is evidenced by strategies included in the U.S. Department of Health and Human Services Maternal and Child Health Training Program (MCH). The program “…Provides national leadership and direction in educating and training our nation’s future leaders in maternal and child health. Special emphasis is placed on the development and implementations of interprofessional care…” (U.S. Department of Health and Human Services, 2014). Several strategies are listed as to how to achieve the program’s goal of promoting interdisciplinary training, practice, and collaboration. These strategies include supporting interdisciplinary graduate education and training programs that emphasize leadership, as well as facilitating interdisciplinary practice opportunities for students and faculty in MCH training programs (U.S. Department of Health and Human Services, 2014). MCH’s acknowledgment of the need for improved interdisciplinary practice clearly demonstrates their belief that improvement in this area will lead to better patient outcomes.

References:
About.com: Pharmacist jobs. Retrieved 4/20/14 from http://healthcareers.about.com/od/healthcareerprofiles/p/PharmacistJobs.htm

American Nurses Association: What is nursing. Retrieved 4/20/14 from http://www.nursingworld.org/especiallyforyou/what-is-nursing

Grant, R. W., & Finocchio, L. J. (1995). Interdisciplinary collaborative teams in primary care: a model curriculum and resource guide. California Primary Care Consortium Subcommittee on Interdisciplinary Collaboration.

Newhouse, R., P., & Spring, B. (2011). Interdisciplinary evidence-based practice: moving from silos to synergy. Nursing Outlook, 58(6): 309-317. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2998190/

Retrieved 4/21/14 from http://www.hometownhealthcare.net/wp-content/themes/hometownhc/images/img-team.jpg

Retrieved 4/21/14 from http://www.lincolnpedi.com/wp-content/uploads/patient-centered-medical-home-diagram.png

Retrieved 4/21/14 from http://www.nacc.org

U.S. Department of Health and Human Services: Maternal and child health. Retrieved 4/20/14 from http://mchb.hrsa.gov/training/about-national-goals-G3.asp

Westberg, J., & Jason, H. (1993). Collaborative clinical education: the foundation of effective health care. New York: Springer-Verlag.

Systems Thinking: To Aspirate or Not to Aspirate?

Community health settings tend to differ greatly from a clinical setting. One significant difference is that the nursing staff often practices independently and they do not supervise each other performing nursing cares. The facility that will be the object of discussion is a correctional facility in the upper Midwest that currently has a capacity of 684 individuals, with nursing staff provided by the facility (Wisconsin Department of Corrections, 2014). The patient to staff ratio is approximately 3:1 (Wisconsin Department of Corrections, 2014). It is commonly seen in community clinical settings such as this that nursing staff will aspirate when doing intramuscular (IM) injections in order to see if there is blood return. The previous protocol stated that if there is blood return, the nurse has injected into a vein and must withdraw, get a new needle and re-stick the individual.

The problem is that the practice of aspirating when doing an IM injection is outdated and unnecessary (Goldbach, Ipp, Parkin, Sam  & Taddio, 2007). It has been found that aspirating upon IM injections actually causes increased pain which is a problem especially with children during IM vaccinations (Goldbach et al., 2007).

A System Level Issue

The micro level issue in these types of settings is with the nursing staff. It is the most intricate piece of the puzzle when it comes to this practice. When asking a nurse about whether or not she aspirates when giving an IM injection, her response was “Well yes of course.” When asked why, her response was, “That is the way that it is has always been done.” Becoming creatures of habit in the nursing field is a common situational issue, especially in correctional facility settings because there is not as much of a collaborative environment related to the autonomy of staff. Whether or not nurses aspirate is commonly dependent upon when they were in nursing school and what type of environment they practice in at this point. It is also common for these settings to hire nursing staff from all levels, including ADNs, LPNs and RNs, which can affect how skills are performed (Wisconsin Department of Corrections, 2014). There are generally two nurses available at this facility and certain practices do not require two nurses. For this reason, many nurses are not seeing each other perform skills (Wisconsin Department of Corrections, 2014).

The facility itself is part of the reason that this practice is still in place with some of the staff members. Although the facility does have a policy regarding IM injections, it does not address the previous and outdated practice of aspirating.  Up-to-date education for nursing staff regarding the appropriate, most effective way to administer IM injections is not provided. Also, nursing staff is not provided education for other practices that may have changed over the years. Similar facilities to this particular correctional facility generally have long term patients with chronic conditions (Wisconsin Department of Corrections, 2014). Because of the patient population that is present, most nursing staff are not required to perform routine skills that may be seen more frequently in hospitals.

Another important aspect affecting the policies and procedures of the system at a facility level is how much contact the Director of Nursing has with the nursing staff. In correctional facilities, the Director of Nursing may oversee multiple facilities and divide their time between the institutions; they are also often more behind the scenes workers and not in direct contact with the nursing staff while performing cares. There is on site supervision of all healthcare providers by the warden, however, the warden does not supervise direct patient cares of the nursing staff. It is difficult to justify the warden overlooking the medical staff as the warden is not a nursing position itself so they may be unaware of the up-to-date practices.

Aspirating when giving an IM injection needs to be an addressed issue at an upstream policy level in facilities similar to this correctional institution.  The first place that this needs to be focused on is in nursing schools around the country. The current practice that is taught is to not aspirate when giving an IM injection (Davidson & Rourke, 2013). However, aspiration does occur when performing intravenous injection and this may be the source of nursing staff continuing to aspirate during IM injections (Godlbach et al., 2007). Many states do not require continued education credits for nursing staff and for this reason the staff is not informed of the updated procedures. It may be difficult to find continuing education courses available in community health settings in these states as well.

Another upstream consideration is the political will and desire to provide high quality of care in correctional organizations. This is highly variable by facility, but if staff does not feel the inclination to provide the highest quality of care while decreasing the harm/pain induced to patients, then their performance of basic skills will decrease significantly. The culture of nursing in these facilities must be focused on highest quality of care with non-judgmental attitudes by the healthcare staff.

Nursing Leadership and Voice

There is currently nothing in the facility’s policy about how to administer an IM injection regarding aspiration. It should be addressed that aspiration is not necessary because without this information, nursing staff is unknowingly choosing to perform tasks incorrectly (World Health Organization, 2013). Nursing staff that continues to aspirate are generally those that have been in practice for many years and those who have not practiced in a clinical setting for some time. New nurses that come onto the scene may not feel comfortable expressing the new practice of not aspirating when doing injections. There is a sense of seniority in many healthcare settings and newer nurses do not feel that they are able to voice their concern or knowledge on the more current practice guidelines. Empowerment is a crucial aspect of community health and new nurses should feel empowered and confident enough in their skill to bring up the appropriate clinical practice that is in place at this time. The Director of Nursing may also step in regarding this issue and advocate for the need for increased education opportunities and/or funding.

Systems Theory

Due to IM injections being a fairly independent practice, there is less collaboration when it comes to this basic nursing skill and there is not the opportunity to watch other nurses perform this task. This also may make for a less than cohesive environment for the patients because they may notice that different individuals are performing tasks differently. This can create an anxiety provoking situation for patients who are noticing that there is no standard practice that is in place.

There has not been an analysis of this system in the organization, prior to this investigation. The systems analysis will allow for a more consistent, improved quality of care for all patients. If this task was assessed and policy was looked at to determine how to create a higher level of cohesiveness, it may be discovered that other aspects of care are also inconsistent and require an investigation of practice as well.

Professional and Interprofessional Practice

As was discussed previously, nurses who have been in practice for a longer amount of time are the ones who are aspirating when they give IM injections. The younger nurses do not feel comfortable stepping on any toes or crossing any hierarchical lines. This makes for a silent culture and does not allow for growth and learning from the new information that new nurses have upon entering into practice. The Director of Nursing is the one who is creating policy and procedures and working toward continuity of care between all healthcare professionals. From this standpoint, they should be the one assessing and maintaining up-to-date practices in the facilities that they oversee.

Another important interprofessional aspect of this system is the coordination of care between physicians and nursing staff. There are psychologists, physicians, physical therapists, nurse practitioners, opthamologists and dentists available for care at these types of facilities. It is their duty to write out orders and carry out the evaluation of these orders; physician-nurse relationship is crucial to the overall functioning of the system. This is not a teaching environment so there is not the exchange of knowledge between care givers as there may be in other clinical settings (especially without residents, nursing students, etc. coming through the system).

Value: The Quality of Nurse Care and Outcomes

When administering IM injections, it is important to understand that this may be painful and can cause anxiety in patients. The nursing staff has the opportunity to make this a less severe situation. Not aspirating will result in decreased pain as well as the risk of a needle stick to the nurse that is administering the injection (Davidson & Rourke, 2013). IM injections pose the risk of cellulitis, tissue necrosis, granuloma, hematoma and injury to the blood vessels (Cocoman & Murray, 2006). Although these complications are uncommon, there is a risk associated with each IM injection. The longer that the nurse has the needle in place, the higher the risk for the patient. If a nurse is choosing to aspirate when giving an IM injection, they have to stabilize the needle while using both hands. By eliminating this step, it is a simpler, safer process.

Current Theory

In order to encourage everyone to begin performing IM injections in the same manner, education is necessary. A required short refresher course on how to perform this skill would be the best way to help get consistency as well as facilitate communication among nursing staff at the facility. A teaching guide has been written by Kathleen Marie Davidson and Liam Rourke that would serve as a road map to the course (Davidson & Rourke, 2013).

The first step in the IM injection would be to find the spot that you are going to give the injection by utilizing landmarks (Davidson & Rourke, 2013) The next step is to choose if you are going to “bunch” the skin/squeeze it, or flatten the skin (Davidson & Rourke, 2013). Although there are some discrepancies in the literature, flattening the skin of adults is best while bunching the skin of geriatric and pediatric clients is best (Davidson & Rourke, 2013). It is important to remind the staff to match the needle length to each and every patient so that the injection is not going in too deep or too shallow.

The next step of the course will focus on not aspirating upon giving an IM injection. There is no scientific evidence to support aspirating when giving an IM injection so this will be removed from the procedure (Davidson & Rourke, 2013). There is a small chance of hitting a blood vessel when administering an IM injection, and there is an even smaller chance of staying in the blood vessel if the needle hit it to begin with. To effectively aspirate, it must be done for 5-10 seconds which realistically does not happen in practice (Davidson & Rourke, 2013). Aspirating only increases pain at the injection site and does not prove to be beneficial, so at this point it is an outdated practice that should no longer be done in facilities.

Addressing IM injection protocol is crucial at a systems level. This will improve the overall practice and establish a more efficient way of providing this care. By performing a systems analysis we may be able to see if there are other processes that are being performed with an out-of-date procedure. This evidence produces fear that this skill is only the tip of the iceberg and there are other procedures that are not being performed correctly.

To see an IM injection performed, click on the link below:

For more information, the following resources are available:

Centers for Disease Control and Prevention (2013). Vaccines. Retrieved from

Click to access vacc_admin.pdf

Cocoman, A. & Murray, J. (2006). IM injections: How’s your technique? Retrieved from
http://www.inmo.ie/MagazineArticle/PrintArticle/5676

Davidson, K. M. & Rourke, L. (2013). Teaching best-evidence: Deltoid intramuscular injection technique. Journal of Nursing Education and Practice, 3 (7). doi: 10.5430/jnep.v3n7p120

Excellence Injections (2014). [Image] Retrieved from http://www.excellenceinjections.com

Gladbach, M., Ipp, M., Parkin, P. C., Sam, J. & Taddio, A. (2007). Vaccine-related pain:
Randomized controlled trial of two injection techniques. Archives of Disease in Childhood, 92 (12): 1105-1108.     doi:10.1136/adc.2007.118695

Oregon Public Health Division (2009, November, 3).  Administration Technique for Intramuscular influenza vaccine Retrieved from http://www.youtube.com/watch?v=jdboI3SKgR0

Wisconsin Department of Corrections (2014). Welcome to the Wisconsin department of corrections. Retrieved from http://doc.wi.gov/home

World Health Organization (2010). WHO best practices for injections and related procedure toolkit. Retrieved from http://whqlibdoc.who.int/publications/2010/9789241599252_eng.pdf

 

Structural Analysis of Agrace HospiceCare

(Agrace, 2014)

What is Agrace HospiceCare?

Agrace Hospice is a non-profit organization that has provided physical, emotional, and spiritual services for patients and families dealing with advanced illness since 1978 (Agrace, 2014).

Mission: “Agrace  believes that individuals diagnosed with life-limiting illness deserve to live as fully as they can. Agrace’s mission, ‘Partnering with patients and families to improve quality of life throughout serious illness’, embodies these core beliefs” (Agrace, 2014).

Vision: “To lead the evolution of hospice and palliative care through innovation, education, and access- one patient, one family, one community at a time” (Agrace, 2014).

Values such as compassion, integrity, collaboration, excellence, and stewardship drive their practice, and help them to carry out their mission.  Agrace has both an inpatient and residential facility on their campus in Madison, which is the largest in the Midwest. Agrace also provides care to patients in homes, hospitals, or other residential facilities throughout the entire region of southern Wisconsin, sometimes caring for up to 650 patients per day. Generous community support ensures that those living with life-limiting illness will have access to the comprehensive palliative care they deserve (Agrace, 2014).

What is the organizational structure of Agrace HospiceCare?

Agrace Hospice employs more than 500 people, with a major portion being their nursing staff. An executive leadership team is responsible for the oversight and overall guidance of this organization, which is under the direction of CEO Lynn Myers. She specializes in “managing local healthcare operations with specific expertise in strategic business planning in the evolving healthcare climate” (Agrace, 2014). The medical services team is responsible for ensuring proper coordination of care for these patients. Agrace is also made up of two non-profit entities, The Agrace HospiceCare Inc. Board and the Agrace Foundation Inc. Board, each with it’s own board of directors. The Agrace HospiceCare Inc. Board is “responsible for operations of the organization and the delivery of care to patients and families” (Agrace, 2013). The other entity, Agrace Foundation Inc. Board,  is “responsible for fundraising and management of current and future needs” (Agrace, 2013).

The formal structure of Agrace HospiceCare is functional. There are essentially four major ‘teams’ within this organization, each involving groups performing similar tasks. In order to provide appropriate and continuous care, these teams must work together to promote collaboration, an esteemed Agrace value (Agrace, 2013). As Agrace provides care in multiple settings, the structure is also flat, with a somewhat decentralized organization as focused teams are responsible for different settings (Agrace, 2014). The decentralized organization promotes power and independent decision-making, which provides nurses with extensive autonomy in the clinical setting. Autonomy expressed by nurses and the many different settings of care could hinder communication among the care team, as members may not be as readily accessible.

As seen in this chart, there are three levels between the typical staff nurse and the CEO, who is the chief decision maker. A staff nurse would report to their team leader, who would then report to the team of clinical services, which is under the direction of the CEO. 

How does nursing fit within this organization?

Agrace employs Palliative/Hospice Nurse Practitioners, Registered Nurses, and Licensed Practical Nurses as part of their nursing staff. Nurses at Agrace are part of an interdisciplinary care team. This team includes physicians, social workers, CNAs, chaplains, and volunteers, and more, highlighting the importance of interprofessional practice at Agrace (Agrace, 2014). However, team leaders within hospice organizations have traditionally been nurses. The interdisciplinary team in hospice settings originated from a model for healthcare including biological, psychological, spiritual, and social services (Hale, 2007).

(Agrace, 2014)

Agrace HospiceCare uses a systems approach to healthcare, as the patient and family is truly at the center of care. Patients are able to choose what care they want and need, whether it be medical, pharmaceutical, spiritual, or emotional (Agrace, 2014). In 2012, Agrace served 2,788 patients. Within this patient population, Agrace has dramatically reduced ER visits (5 in 2012) and hospitalizations (4 in 2012), demonstrating the value of quality nursing care and outcomes within this organization (Agrace, 2013).

In a video testimony, two nurses at Agrace stated very positive feelings about their role as staff nurses within this organization. One specifically stated she feels as if she is working within a team of equals, and that her career allows her to express autonomy in a clinical setting. They feel that Agrace HospiceCare seeks a top of the line, intelligent nursing force. These testimonies speak to the organizational climate at Agrace, and help bring to light the nursing leadership and voice within this organization (Agrace, 2014).

http://vimeo.com/6155553

(Agrace, 2014)

New theory in organizational structure

“Design of high reliability organizations in health care”, an article from a journal called Quality and Safety in Health Care, describes an organizational model of health care to provide for increased safety and reliability within the organization. In relation to organizational structure, they recommend centralized control, with decentralized expertise. For example, centralized control could be demonstrated by confining decision-making to as few people as possible. Decentralized expertise could be practiced by allowing many staff members to share the responsibility of developing policies, procedure, and practices, as knowledge can be gained through the sharing of ideas. This article also states that organizational design should encompass not only formal structures, but also procedures, incentives, and informal culture and communication (Carroll & Rudolph, 2006).

Resources:

–http://www.nhpco.org/quality-10-components-quality-care/organizational-excellence

–http://www.nhpco.org/national-council-hospice-and-palliative-professionals/nchpp-structure

–http://www.agrace.org/images/stories/pdfs/Annual_Reports/AR12Final-WebReady.pdf

–http://intqhc.oxfordjournals.org/content/19/6/341.full.pdf#page=1&view=FitH

–http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464869/

–http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070356/

References:

Agrace 2012 annual report. (2013, January 4). Retrieved February 15, 2014, from
Agrace website: http://www.agrace.org/images/stories/pdfs/Annual_Reports/
AR12Final-WebReady.pdf

Carroll, J. S., & Rudolph, J. W. (2006). Design of high reliability
organizations in health care. Quality and Safety in Health Care, 15(1),
4-9. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464869/

Hale, B. A. (2007). Hospice interdisciplinary team processes and effectiveness.
Retrieved February 15, 2014, from http://www.nursing.arizona.edu/Library/
Hale_B.pdf

Learn about us. (2014). Retrieved February 15, 2014, from http://www.agrace.org/
about-agrace.html

McGranahan, P. (Presenter). (2014, February 3). Culture, climate, and 
communication. Lecture presented at Nursing 415: Organizational
Influences on Interdisciplinary Practice, UW-Madison School of Nursing, WI.

Steege, L. (Presenter). (2014, January 27). Systems approach. Lecture presented
at Nursing 415: Organizational Influences on Interdisciplinary Practice,
UW-Madison School of Nursing, WI.

Steege, L. (Presenter). (2014, January 29). Organizational structures. Lecture
presented at Nursing 415: Organizational Influences on Interdisciplinary
Practice, UW-Madison School of Nursing, WI.

The hospice team. (2014). Retrieved February 15, 2014, from
http://www.agrace.org/the-hospice-team.html

Why is this blog here?

This blog is one of student group blogs in Nursing 415, a course taught at the University of Wisconsin-Madison School of Nursing during the Spring semester of 2014.

For more information about the course, the blog assignment, and to access other group blogs in this course, and to see a list of online resources, including video tutorials, and mobile apps that may be useful in helping you get familiar with WordPress.com, visit http://n415son.wordpress.com/, the main “hub” blog for this project.