EP7EO Nurses systemically evaluate professional organizations’ standard of practice, incorporating them into the organizations’ professional practice model and care delivery system.
Provide one example, with supporting evidence, of an improvement resulting from a change in clinical practice due to the application of professional organizations’ standards of nursing practice. The example provided may be at the unit, division, or organizational level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
NAME OF INITIATIVE
Implementation of Couplet Care
BACKGROUND/PROBLEM
Nurses Systematically Evaluate Professional Organization’s Standard of Practice
In May 2012, Perinatal Director Jan Weatherspoon, RN, reviewed the nursery and post-partum standards of care and care delivery system to ensure congruence with the nursing Professional Practice Model (PPM) and Care Delivery System (CDS). Homestead Hospital’s CDS depicts the independent role of nurses in evaluating nursing practice against existing regulatory standards and new guidelines/recommendations. Perinatal Services had always practiced the traditional post-partum and nursery care which separated mothers and newborns shortly after birth. Newborns were receiving their transitional care at night in the nursery instead of being roomed-in with their mothers and would spend several hours during the day separated from them. Nurses took care of approximately 6 mothers of mixed acuity in the post-partum unit while nursery RNs managed 1 to 4 newborns in the nursery. Studies have demonstrated unfavorable effects on the dyad when care is given in separate locations. Parting mothers from their infants delays critical bonding, skin-to-skin contact, baby’s transition from intrauterine to extrauterine life, and breastfeeding. Through her professional affiliation with AWHONN, Weatherspoon came across an evidenced-based model called couplet care. Couplet care is supported by the American Women's Health, Obstetric, and Neonatal Nurses (AWHONN), the American Academy of Pediatrics (AAP), the American College of Gynecologists (ACOG) and the World Health Organization (WHO). In this model, mothers and newborns remain together for the entire hospital stay, that is, from the time transition occurs in the delivery room until discharge. This provides several benefits such as facilitating mother-baby bonding through skin-to-skin contact and breastfeeding. It takes advantage of the “golden” hour after birth when neonates are wide awake and stimulated enabling them to do the “breast crawl” and initiate the latch to breastfeed. Also, couplet care supports patient-and family-centered care which was an integral part of the PPM and CDS. Consequently, in May 2012, Weatherspoon sent an email to the staff through the Perinatal distribution list asking for information and best practices on couplet care.
GOAL STATEMENT(S)
The goal was to provide mothers and their infants with evidence-based care by adopting the couplet care model and by doing so increase exclusive breast milk feeding percentage among total mothers discharged by 9%, from a baseline average of 6% to 15%.
The measure used to demonstrate improvement was the Exclusive Breast Milk Feeding component of The Joint Commission (TJC) Prenatal Core Measure set. TJC defines exclusive breast milk feeding as: “newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.” Breast milk feeding includes expressed mother’s milk as well as donor human milk, both of which may be fed to the infant by means other than suckling at the breast. While breastfeeding is the goal for optimal health, it is recognized that human milk provided indirectly is still superior to alternatives. The formula utilized in calculating exclusive breast milk feeding was as follows:
Percent of Infants Exclusive Breast Milk Feeding with All Feeding Methods Represented = Infants Receiving Exclusive Breast Milk Feedings divided by Total Mothers Discharged times 100
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
Incorporating Standards into PPM and Care Delivery System
After Weatherspoon compiled several best practice information, some of which came from her staff, she met with her nurse leaders and clinical nurse educators and drafted the implementation plan for couplet care. During her June 2012 staff meeting, she announced to the team the decision to pursue “couplet” care, its rationale and advantages. She also presented the implementation plan and solicited their input in the process. Weatherspoon and Patient Care Manager Leah Williams-Jones, RN, engaged different groups –nurse, physicians, technicians and clerks – in dialogues via staff meetings, interprofessional meetings and focus groups to identify areas of concern and barriers to implementation. Staff raised several concerns when the decision was made to convert to the couplet care model. These concerns included: reaction of parents to the new practice especially those who gave birth in Homestead Hospital under the traditional model; increased nursing time; lack of knowledge to adequately support breast feeding; parental reaction to procedures done at the bedside that involved pain to the infant, such as blood draws and immunizations; staffing issues if a parent requested the infant to go to the nursery; and impact on staff retention due to practice change. Weatherspoon and Williams-Jones assured the staff they would be provided adequate training to become competent in caring for the mother/baby couplet. They also assisted the staff in scripting responses to patients about the new care delivery system.
Weatherspoon and Williams-Jones advocated for support among the physicians and engaged them in planning the roll-out. In July 2012, the Perinatal nursing leadership team and the clinical nurse educators presented the plan to adopt couplet care at the OB/ Newborn committee meeting. The committee is comprised of the physicians that serve as primary care providers on the unit, namely: Obstetricians, Pediatricians and Neonatologists. The meeting was led by the OB Chief Charles Augustus, MD. During the presentation, the physicians were asked for their support, suggestions, and insights on any foreseeable barriers, and assistance with the change process. Weatherspoon realized that adopting a new care delivery system would involve a lot of education. She proposed adding a clinical nurse educator to Chief Nursing Officer and Vice President Gail Gordon, RN. Gordon approved her request and in August 2012, Patient Care Supervisor Nancy Martinez, RN became the Mother/Baby clinical nurse educator.
Once the plan was finalized and support was obtained from key stakeholders - administration, physicians and the majority of the staff - the implementation began. Staff education was divided into 2 phases: didactic and hands-on. The classroom training was the first phase of the implementation. It occurred over a 2-month period, September and October 2012. For the nurses, it involved 4-hour classes covering newborn transition; maternal and newborn assessment; skin-to-skin; and breast feeding taught by the clinical nurse educators and the lactation resource nurses. Clinical Nurse Educators Katherine Adamson, RN, and Martinez afforded individualized training tailored to the nurse’s knowledge and experience. They also provided education to the care partners, technicians and clerks.
After the classroom training was completed, the second phase of the implementation began. Hands-on training started in November 2012, with clinical nurses from labor and delivery (L&D), nursery, and post-partum cross-training each other in the transitional newborn care and maternal/newborn assessment. The first unit cross-trained was L&D. The L&D nurses were cross trained to newborn transition care and assessment. Clinical Nurse Danielle Harrison, RN, developed an educational binder to help nurses that had never cared for newborn infants in the transition period. Clinical Nurse and part-time Lactation Resource Nurse Laura Houwers, RN, came in on her days off to teach her coworkers about transition in L&D. Thereafter, L&D nurses were cross-trained to mother/baby care. Then cross-training of the post-partum nurses to newborn assessment and care took place. During this time, Weatherspoon also hired experienced medical-surgical nurses and new graduates who were in the Versant residency program. These new nurses received training from the clinical nurse educators on couplet care from the start. The couplet care training was completed in early February 2013.
Change in Clinical Practice
Couplet care went live on February 15, 2013. It was implemented in its purist form, as envisioned by Weatherspoon, where mother/baby stayed in L&D for about 2 hours after delivery then transferred to the post-partum unit together, bypassing the nursery. Weatherspoon consolidated the Nursery and post-partum cost centers into mother/baby unit (MBU). Nurses in MBU started taking care of 3 couplets. The patients embraced the new model and responded well to the changes. However, the staff went through a steep learning curve. Some wanted to revert to the old ways because they felt uncomfortable with the new process and did not have the confidence to take care of both mother and baby. Weatherspoon reemphasized to her team that babies belong with their mothers, not the nursery, and reassured them that it was the right thing do. Cognizant that changing the staff’s mind-set and developing confidence in their skills would not happen overnight, she extended the competency validation portion of the hands-on training and allowed staff’s comfort level to drive their readiness. Clinical time varied depending on completion of the competency checklist. (EP7EO 01 Couplet Care Competency Validation Checklist) Weatherspoon allowed nurses who were not yet comfortable taking care of the couplets to continue with the hands-on training. These nurses spent more time with the clinical nurse educators and buddied up with peers who were experienced with couplet care. This process took about 6 months and was instrumental in allaying staff’s fears about the change and removing barriers to the assimilation of the practice change. Weatherspoon revised the Perinatal CDS in March 2013 to reflect the practice change. (EP7EO 02 Revised Perinatal Care Delivery System)
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Jan Weatherspoon, MSN, RN, NEA-BC |
Director |
Perinatal Services |
Change agent and coordinated the process change |
Leah Williams-Jones, MSN, RN, RNC, CNML |
Patient Care Manager |
Perinatal Services |
Provided direction and support to the staff |
Nancy Martinez, BSN, RN, RNC |
Clinical Nurse Educator |
Perinatal Services |
Conducted staff education |
Katherine Adamson, BSN, RN,RNC |
Clinical Nurse Educator |
Perinatal Services |
Conducted staff education |
Carey Acosta, RN, IBCLC |
Lactation Resource Nurse |
Perinatal Services |
Assisted in staff training |
Danielle Harrison, BSN, RN |
Clinical Nurse |
Perinatal Services |
Assisted in staff training |
Laura Houwers, BSN, RN, RNC-OB, IBCLC, LM |
Clinical Nurse and Part-time Lactation Resource Nurse |
Perinatal Services |
Assisted in staff training |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Administration |
Provided administrative support |
OUTCOME(S)
Exhibit EP7EOa: Percent Exclusive Breastmilk Feeding with All Feeding Methods Represented
Analysis: Above graph depicts that the department has achieved their initial goal of increasing exclusive breast milk feeding among all discharged mothers to 15% for 7 consecutive months. There was a slight dip in October 2013 attributed to the number of infants transferred to higher levels of care with medical conditions that required formula supplementation. Since then the department has attained a positive calculated trend line and decided to gradually increased their goal to 17%, then 19% and has met them as well.
Summary of Attachments/Hyperlinks/Evidences:
EP7EO 01 Couplet Care Competency Validation Checklist
EP7EO 02 Revised Perinatal Care Delivery System
Exhibit EP7EOa: Percent Exclusive Breastmilk Feeding with All Feeding Methods Represented