TL2.    Describe and Demonstrate how Nurses at Every Level—CNO, Nurse Administrators, and Direct-Care Nurses—Advocate for Resources, Including Fiscal and Technology Resources, to Support Unit/Division Goals.

Introduction

At Northwestern Memorial nurses throughout the organization advocate for fiscal and technology resources to support unit/division goals. This advocacy occurs in several ways.

Michelle Janney, RN, PhD, NEA-BC, our Wood-Prince Family Chief Nurse Executive, formally advocates for resources for our nurses through her roles on senior leadership committees such as the Capital Committee and the VP Operations Committee. In these forums, she regularly advocates for technology and fiscal resources to advance our organizational and nursing strategic goals.

Another formal advocacy mechanism available to nurses across the organization is our nursing shared leadership structure and process. Our shared leadership structure is designed to facilitate both horizontal and vertical communication across the Division of Nursing and includes committees at the hospitalwide, department and unit levels. Each nursing department has representation on each of the seven hospitalwide shared leadership committees (HSLCs), while the department shared leadership committees (DSLCs) have representation from each nursing unit, procedural area, and quality committee within the department. More information about our committee structure and process as well as a diagram of our structure is provided in TL3. (Also see Committee Structure and Purpose in Reference Document A.)

Nurses are encouraged to bring ideas or concerns to the DSLCs. The DSLCs escalate these issues to the HSLCs as needed so they can be discussed and addressed. For example, Nursing Technology and Informatics Committee (NTIC) members recently brought a concern to the Committee about nurses’ understanding of how to order, communicate and document “hold medication x1 dose” orders in PowerChart, our electronic medical record. The group determined that re-education was needed for nurses. Katie Dejuras, RN, MSN, the Clinical Informatics Nurse who sits on the Nursing Technology and Informatics Committee, developed an educational PowerPoint that was sent to unit staff via email on behalf of the committee. (See Appendix TL2-A for a copy of the “Hold Medication for 1 Dose” PowerPoint.)

A third mechanism for advocating for resources is the administrative chain of command. Nurses at every level are expected and encouraged to advocate for needed resources with their managers and directors. Examples that demonstrate how nurses at all levels advocate for resources to support unit/division goals are described below.

Advocacy by Staff Nurses and Nurse Administrators: Staffing Ratios on 11 East Transplant

Historically, the nurses on the 11 East Transplant Unit cared for a population of pre- and post-transplant, trauma and general surgery patients. Medical hepatology patients were admitted to the unit only if they were awaiting a transplant. When planning for the restacking of the medical-surgical units in the Feinberg Pavilion was initiated in fiscal year 2008, a decision was made to place both transplant and hepatology patients on the same unit. This change was seen as a way of helping nurses, transplant coordinators, and transplant and hepatology services to get to know patients and start building relationships with them and their families early in the transplant process so that coordination of care could be improved.

After medical hepatology patients began to be admitted to 11 East in the second quarter of fiscal year 2008, however, the unit experienced a significant increase in patient acuity. Unit nurses recognized this change and raised concerns about their ability to provide the Best Patient Experience in light of their current staffing ratios of 1:4 on days and 1:5 on nights. The medical hepatology patients experienced frequent changes in mental status as well as episodes of fecal incontinence that put them at increased risk for skin breakdown and falls. As a result, they required more frequent nursing assessment, monitoring and intervention as well as more frequent bathing, turning and safety checks by the unit’s patient care technicians.

Nurses expressed their concerns to their then manager, Clelia Dompe, RN, MSN, both in informal conversations and in unit meetings. The situation was escalated by Clelia to Carol Payson, RN, MSN, NE-BC, Director of Inpatient Surgical Nursing. Clelia and Carol held a series of focus groups with nurses and patient care technicians on all shifts to better understand the issues related to patient acuity and current staffing. Subsequently, Carol and Clelia brought the staffing concerns to Michelle Janney, our Wood-Prince Family Chief Nurse Executive. Clelia and Carol were asked by Michelle to benchmark staffing on similar units nationally. They then developed an in depth analysis of the situation and recommended changing the nurse/patient ratio to 1:3.7 twenty-four hours a day. A copy of the analysis is found in Appendix TL2-B.

The change in ratios was approved by Michelle Janney as part of the fiscal year 2009 budget. Direct nursing care hours per patient day increased from 5.19 in fiscal year 2008 to 6.73 in fiscal year 2009. This resulted in a budget increase of $360,000 for an additional 5.5 RN FTEs. Clelia was empowered to begin onboarding additional RNs immediately so that they could be oriented prior to the start of the new fiscal year. She and her clinical coordinators also worked closely with the unit’s RNs and PCTs to flex ratios to meet patient needs until additional nurses could be hired and oriented.

Carmel Rolon, RN, BSN, then Staff Educator on 11 East Transplant, summarized the perspective of the 11 East nurses as follows, “When it was proposed that 11 East's patient population was to include hepatology patients, the anxiety level on the unit increased ten-fold. We brought our concerns to our manager and she in turn became our advocate. Our unit manager and director of nursing were able to get our nurse patient ratios adjusted to 1:3-4: This has not only increased our staff morale, but improved the quality of our overall patient care. Nurses feel that this is a more appropriate patient load given the acuity of our new patient population. We felt that when we expressed our concerns, they were heard and addressed.”

Advocacy by Directors of Nursing: Upgrades to Prentice Headwall and Prentice Hill-Rom Beds

Early in fiscal year 2009, Betsy Finkelmeier, RN, MSN, NEA-BC, Director of Women’s Health and Pat Murphy, RN, MSN, MBA, NEA-BC, Director of Oncology Nursing submitted a capital request to upgrade the headwall and Hill-Rom bed siderail controls in the Prentice Women’s Hospital. The headwall upgrade was designed to support the Best Patient Experience by linking the Hill-Rom bed exit alarms directly to the nurse call system. This enabled the alarm to be sent directly to the appropriate caregivers via their Ascom portable communication devices. The Hill-Rom bed upgrades involved both new patient control side rails and installation of a system to link the bed exit alarm to the nurse call system and control the patient’s reading light.

Both Betsy and Pat viewed these proposed upgrades as critical to patient safety. Given that Prentice Women’s Hospital units are decentralized, bed alarms are difficult to hear outside of patients’ rooms. Sending alarms directly to caregivers through the nurse call system enabled nurses and patient care technicians to respond quickly to prevent possible falls. The ability for patients to turn the over bed light on and off from the siderails was seen as an additional safety feature particularly for the vulnerable medical oncology patient population.

The Directors discussed these issues with Michelle Janney, our Wood-Prince Family Chief Nurse Executive, and Jean Pryzbylek, RN, MSN, then Vice President, Operations for Prentice Women’s Hospital. Michelle and Jean supported the request and took it to the Capital Committee for discussion. The committee approved $375,000 for this project--$249,000 for the headwall upgrades and $126,000 for the Hillrom bed upgrades. Bed and headwall upgrades were approved and have since been completed for all 242 beds in Prentice.

According to Pat Murphy, both nurses and physicians advocated for the upgrade to the headwall and Hill-Rom beds “as an important patent safety issue. Their collaboration was key to implementing this improvement to prevent patient falls and further support a safe patient environment.”

Advocacy by Staff Nurses via Hospitalwide Shared Leadership Committees: The New Hire Socialization Program

The Nursing Best People and Professional Excellence Committee (NBP&PEC) has as its purpose to develop and implement programs and initiatives that promote recruitment and retention and foster a safe and healthy work environment for nurses. One of its key fiscal year 2009 initiatives was to develop a New Hire Socialization Program—a year-long program designed to enhance the retention of new RN hires at Northwestern Memorial. The initiative was linked to Northwestern Memorial’s Best People strategic goal.

In planning the program, the NBP&PEC analyzed fiscal year 2008 retention data on new hires. They discovered that 62% of our new nursing hires are between 22 and 30 years old and that 65% of nurses who stayed less than one year terminated their employment within six months of their start date.

The primary architects of the program were two staff nurses, Abby Jones, RN, BSN, NSICU and Rachel Johnson, RN, BSN, CMSRN, 12 East Feinberg. Both are members of the NBP&PEC. Abby and Rachel reviewed and summarized the literature and developed a proposal for the program that included assigning a mentor to all new RN hires and providing education sessions and social activities at various points throughout the year. The target group for the program was new hires in the 22-30 year age category.

According to Abby, “Our program aims to provide new hires with someone they can turn to with concerns or ideas as they transition into their new careers and environments. It’s definitely a challenge to start a new career, and many of Northwestern Memorial’s new nurses move to Chicago without a lot of knowledge of the city. This program is designed to help them see they are not alone.”

One concern identified by Abby, Rachel and their colleagues on the NBP&PEC was how to fund the program. Money was needed to pay for mentors’ time out of staffing and provide lunch for the education sessions. Assistance was also needed to obtain speakers for the monthly education sessions and develop the mentor orientation program. The facilitator of NBP&PEC, Deb Livingston, RN, MSN, NE-BC, then Director of the Emergency Department, brought the concern to Michelle Janney, our Wood-Prince Family Chief Nurse Executive, who asked that Abby, Rachel and Deb present the program formally to the CNE, Senior Vice President of Human Resources, and the Director of Professional Practice and Development.

Following the presentation, Michelle and Dean Manheimer, the Senior VP of HR agreed to support the program. Dean offered the services of the NM Academy to assist with the mentor orientation program. Michelle asked Jill Rogers, RN, PhD, NEA-BC, Director of Professional Practice and Development, to assist with program planning, pay for mentors’ time out of staffing, and provide lunch for the eight education sessions offered throughout the year. The total cost of the program for the first year was approximately $12,000 for the mentors and $7,500 for activities, outings and food.

The program was implemented in January of 2009 with 30 new hires and 10 mentors. One year post-implementation, all 30 program participants are still employed at Northwestern Memorial. Several outcome metrics are being tracked on a regular basis to evaluate the engagement of these new hires with the organization and their mentors. Participants are consistently rating their relationship with their mentors very highly. Sample metrics for the program’s four measurement cycles are shown in the table below.

New Hire Socialization Program Participant Responses

Item

March 2009
n=20

May
2009
n=14

October 2009
n=9

January 2010
n=9

New hire’s relationship with mentor

 

 

 

 

I trust my mentor

3.85

3.86

3.77

3.77

My mentor is a good match with me.

3.85

3.86

3.66

3.44

My mentor is available in a way that suits me.

3.90

3.86

3.66

3.88

With guidance from my mentor, I have been able to handle difficult situations.

3.59

3.86

3.55

3.55

New hire’s relationship with Northwestern Memorial

 

 

 

 

My values and the hospital’s values match

3.75

3.7

3.77

3.4

I am supported by people on my unit

3.45

3.43

3.66

3.4

New hire’s plans for the future

 

 

 

 

I plan to apply for a position on a different unit

2.70

2.43

2.88

1.8

Scale = 1 (Not at all)        2 (To a slight extent)          3 (To a moderate extent)          4 (To a great extent)

The following comment by Emily Williams, RN, BSN, a staff nurse and new graduate on 11 East Transplant, one of the new hires participating in the program, sums up the value that participants are experiencing: “The first nursing job you have is an important one where opinions and impressions are made that can determine whether you want to continue working as a nurse or in that particular facility. I love that I have such a large group of individuals that care and want to help me make this important transition into the nursing role!”

Julie Dziak, RN, BSN, a Staff Nurse in the Renée Schine Crown Neonatal Intensive Care Unit who is an experienced nurse, shared a similar perspective, “Although I am not a new nurse, I am new to Northwestern. I have had a great experience with the New Hire Program. Having another nurse as a mentor has made the transition to Northwestern a very pleasant one. I enjoy the activities, the friendships, and the support. I am proud to be a part of this program as a start to my career here at Northwestern.”

Advocacy by the Chief Nurse Executive and Nurse Administrators: Implementation of “Smart-Pumps” throughout Northwestern Memorial

In fiscal year 2007, Northwestern Memorial began the process of selecting a new IV pump to replace its then current pump technology. The goals of the IV pump replacement project were to consolidate multiple infusion devices into a single piece of equipment and to enhance patient safety by purchasing a pump with advanced medication safety software that included drug libraries and clinical profiles. This project supported our Best Patient Experience Strategic Goal and the Long Range Quality Plan goal of providing care that is safe and error free. The project was also supported by a quality study done at Northwestern Memorial that demonstrated that the use of advanced pump technology could avert at minimum one harmful medication error daily (Husch, Sullivan, Rooney, Barnard, Fotis, Clarke & Noskin, 2005). (See Article in Appendix T2-C)

To choose a pump that would meet Northwestern Memorial’s needs, nurses from across the organization were invited to participate in a trial of pumps from two vendors: Cardinal Alaris and Hospira. During the trial, nurses had an opportunity to operate the pumps and examine their individual features. Based on the trial, the majority of our nurses indicated a preference for the Cardinal Alaris PC IV infusion smart pump with Guardrails. The recommendation from the nurses was advanced to our Wood-Prince Family Chief Nurse Executive Michelle Janney by Carol Payson, RN, MSN, NE-BC, Director of Inpatient Surgical Nursing, who was the designated project leader. The cost of project was $7,158,954. A request for project funding was brought to the capital committee for approval where it was championed by Michelle.

One of the key features of the new infusion pumps was Guardrails medication safety software. This technology enables clinical profiles and drug libraries to be created for various nursing specialties such as critical care, medical-surgical, labor and delivery, and neonates. Information about IV medications is stored in the drug libraries and “guards” drugs with alerts to prevent over- or underdosing if a nurse or other designated user incorrectly programs the pump. Pharmacists, nurses and physicians were involved in developing drug libraries for identified specialties.

Susan Eller, RN, BSN, CEN, then staff educator of the Emergency Department, was one of the nurses identified to develop the drug library for critical care. She offered the following reflections on her involvement in the project, “What impressed me most was the level of nursing involvement in the design and implementation of this safety-enhancing device. Nurses were instrumental in designing all of the drug profiles. For example, in the critical care library, Rebecca Wetzel, RN, BSN, CCRN, staff educator, CTICU and I went over each item line by line with the project manager. She listened to our expertise for the drug limits and how we used them in our specific units. She was always willing to modify or add items based on our recommendations and then verify with established resources. Nursing also assisted with the instructional design of the educational program. Having nurses work so integrally with the pharmacists, Cardinal representatives, education representatives, materials management, and others on a project that resulted in safer care for our patients was a very profound and rewarding experience.”

Roll out of the pumps hospitalwide, which occurred in June of 2007 required extensive education and training. More than 300 nurses were trained as “super users”, i.e., experts at the unit or department level who could assist their peers by troubleshooting questions or problems with the new technology. In addition, all nurses completed a computer-based training module and received 1.5 hours of hands-on training. Drop-in sessions were also held over a one week period to provide nurses with extra practice, and each unit and department was given a pump to use for practice purposes until the go live date. The cost of the training was $124,245.

Since the roll out, Pharmacy has monitored compliance with the use of Guardrails. Our data indicate that nursing compliance has been consistently above 90%. According to Alaris, the benchmark is typically 70-75%.