EP2EO Clinical nurses are involved in the development, implementation, and evaluation of the professional practice model.
Provide one example with supporting evidence, of an improvement resulting from a change in clinical practice that occurred because of clinical nurses’ involvement in the implementation or evaluation of the professional practice model. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
NAME OF INITIATIVE
MS4 Pain Project
BACKGROUND/PROBLEM
PPM Evaluation
The development of annual nursing strategic goals was spearheaded by the Nurse Governance Council (NGC) whose members included nurses across all levels – the chief nursing officer (CNO), nurse leaders, directors, supervisors, nurse educators and clinical nurses (represented by the Unit Practice Council [UPC] chairs of each nursing department).To accomplish this, NGC held a 1-day retreat. In the process of identifying the goals, nurses in the retreat evaluate each component of the Professional Practice Model (PPM) to determine its relevance and importance to the nursing strategic goals. For fiscal year (FY) 2011, one of the goals under the Service pillar was exceeding the national benchmarks on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) nurse-sensitive questions such as the one on “Pain Control”. This goal espoused the clinical practice and care delivery system (patient- and family-centered care and Comfort theory) components of the PPM.
In the March 2011 UPC meeting, MS4 Clinical Nurse and UPC Chair Kimberly Figueroa, RN, discussed that the results of the department’s HCAHPS “Pain Control” domain score was trending down. Some of their weekly scores were in the 10th percentile. The UPC continued monitoring the weekly report card. Figueroa reported a further drop in the score during the April 2011 UPC meeting. When they drilled down, the “Pain well controlled’ question was particularly low. The score improved to 68th percentile in May 2011 but still below national benchmarks. In June 2011, Clinical Nurse Veronica Zamoyski, RN reported a pertinent discussion in the Clinical Practice Council meeting about establishing a pain goal for each patient. This jumpstarted a conversation among the UPC members to explore pain interventions that would help improve their HCAHPS score.
GOAL STATEMENT(S)
The MS4 UPC’s goal was to improve the score on the HCAHPS “Pain well controlled’ question.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
PPM Implementation
In June 2011, the MS4 UPC decided to embark on a pain project using pain signs at the bedside. In July 2011, they started posting pain signs, which they adopted from the Studer Group, on the wall in each patient’s room. The signs showed the patient’s pain medications; pain goal; last time medicated; and time next dose was due. They piloted the pain signs in English first and laminated them so they can be wiped clean. They collaborated with the Marketing department in developing signs in Spanish and Creole. The UPC members also sought the guidance of Nurse Scientist Maria Ojeda, ARNP, who sent them additional research articles on the topic. Clinical Nurse Rachael Santi, RN reviewed the articles.
In the August 2011 UPC meeting, Figueroa informed the group that she submitted an abstract of the project for the hospital Best Practice Fair to be held later that month. She asked the team to help reinforce to the staff to keep pain signs in the patient’s room after discharge. Housekeepers would be able to clean the signs after the patients left. She also related to the group that Clinical Nurse Pamela Burney, RN reported favorable anecdotal feedback from patients on the use of pain signs when she made discharge call backs.
In December 2011, the UPC revised the pain signs and included the indication for the pain medication. They also made them bigger. After some discussion, the UPC determined that nurses should also give basic, non-pharmacological pain interventions to make patients as comfortable as possible during their stay. This would complement the effect of the pain medications. Clinical Nurses Kelly Borgardt, RN and Carrie Bilek, RN made an education poster that was displayed in the nurse’s station to remind fellow nurses of alternative comfort measures for pain.
When the other inpatient units heard of this project, they started putting up their own pain signs at the bedside. This resulted in varying versions of the signs floating around the hospital. During the December 2011 Nurse Governance Council (NGC) meeting, clinical nurses commented on how patients became confused upon seeing different pain signs from unit to unit and even from one hospital to another. NGC approved to standardize the pain signs and delegated the project to the UPC chairs.
In the January 2012 UPC Chair Collaborative meeting, the UPC Chairs reworked the pain signs based on everyone’s input. For the next 5 months, the group endeavored on finalizing it. They obtained input from Palliative Care Manager and Pain Champion Linda Long, ARNP. They consulted with the Privacy Office to ensure that they are in compliance with Health Insurance Portability and Accountability Act (HIPAA). They also worked with the Graphics Design department to come up with a presentable and polished product. ICU Clinical Nurse and UPC Chair Sherry Stathers, RN, took the lead and became the liaison for the group. When the project neared its completion, it was brought to Stathers attention that there was a system-wide Signs and Symbols Accelerated Change Team (ACT) that approved all signs or posters placed inside the patient’s room. Thus, the pain sign was on hold pending approval from the ACT. At this point, Homestead Hospital Risk Manager Susan Bunting, who was also a member of the Signs and Symbols ACT, became the spokesperson for the project. The UPC Chairs also requested CNO and Vice President Gail Gordon, RN to advocate for the endorsement of the pain sign to the Patient Care Leadership (PCLC), which consisted of CNOs across the system. Thereafter, the Signs and Symbols ACT collaborated with PCLC on revising the pain sign to meet all BHSF privacy and patient- and family-centered care guidelines. In September 2013, the Signs and Symbols ACT approved the pain sign and rolled it out to all the entities with an accompanying What-You-Need-To-Know (WINK) document.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Kimberly Figueroa, RN |
Clinical Nurses |
MS4 |
UPC Chair and spearheaded the project |
Kelly Borgardt, RN, CMSRN |
Clinical Nurses |
MS4 |
Developed the education poster |
Carrie Bilek, BSN, RN, WCC, CMSRN |
Clinical Nurses |
MS4 |
Developed the education poster |
Rachael Santi, BSN, RN, CMSRN |
Clinical Nurse then; Promoted to Clinical Nurse Educator |
MS4 |
Reviewed the literature |
MS4 RN UPC members |
Clinical Nurses |
MS4 |
Assisted in the development and revision of the pain signs. |
Sherry Stathers, BSN, RN |
Clinical Nurses |
ICU |
Acted as liaison for the UPC Chairs during the finalization and approval process |
HH UPC Collaborative RN members |
Clinical Nurses |
Various departments |
Worked on developing a universal hospital pain sign |
Linda Long, MSN, MBA, ARNP, ANP-BC, GNP-BC, CHPN |
Manager |
Palliative Care |
Gave input on content of pain sign |
Maureen Allen, BSN, RN, CMSRN |
Patient Care Manager |
MS4 |
Provided support and guidance |
Maria M. Ojeda, DNP/PhD(c), MPH, ARNP, NP-C |
Nurse Scientist |
Nursing & Health Sciences Research |
Acted as consultant for the teams |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Nursing Administration |
Executive sponsor and advocate at the system level |
Susan Bunting |
Risk Manager |
Risk Management |
Project spokesperson at the system level |
OUTCOME(S)
Exhibit EP2EOa: MS4 HCAHPS Question Score on “Pain Well Controlled” Question
Analysis: Above graph demonstrates the MS4 UPC has met its goal of improving HCHAPS scores on the “Pain Well Controlled” question after the implementation of pain signs as evidenced by scores above the 90th percentile for 9 quarters.
Change in Practice
Clinical nurses’ involvement in the development, implementation and evaluation of the PPM promoted its ongoing visibility. This process also enabled nurses to look to the PPM in guiding their nursing practice. In this exemplar, the annual nursing strategic retreat was an excellent opportunity for clinical nurses to evaluate the importance and relevance of the PPM to the Department of Nursing Services goal. Once the priorities were established, clinical nurses in MS4 through their shared governance structure were able to focus on projects that supported the nursing goals and the PPM. The MS4 UPC was able to realize a practice change with the implementation of pain signs that resulted in excellent patient outcomes. Their project also promoted practice changes at the hospital and system levels.
Summary of Attachments/Hyperlinks/Evidences
Exhibit EP2EOa: MS4 HCAHPS Question Score on “Pain Well Controlled” Question