TL1EO Nursing's mission, vision, values, and strategic plan align with the organization's priorities to improve the organization's performance.
Provide one example, with supporting evidence, of an initiative identified in the nursing strategic plan that resulted in an improvement in the nurse practice environment. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
AND
Provide one example, with supporting evidence, of an initiative identified in the nursing strategic plan that resulted in an improvement due to a change in clinical practice. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example 1-Improvement in Nurse Practice Environment
NAME OF INITIATIVE
Meal Break Project in the Critical Care Unit
BACKGROUND/PROBLEM
Initiative Identified in the Nursing Strategic Plan
One of Homestead Hospital’s nursing strategic goals for FY 2013 was to achieve and/or maintain the National Database of Nursing Quality Indicators® (NDNQI®) RN job enjoyment at a highly satisfied level (T-score of 60 or above). This nursing strategic goal is aligned with the organization’s value and priority for People. The strongest predictor of nurse dissatisfaction is stress in the practice environment. With this in mind, the Critical Care department reviewed and analyzed their latest NDNQI RN satisfaction survey results. They have identified uninterrupted meal breaks as an area of opportunity. This was aligned with the nursing strategic goal.
According to the American Association of Critical Care Nurses’ Healthy Work Environment initiative of 2005, uninterrupted meal breaks promote a healthy work environment and decrease fatigue and stress among nurses. It is also a Baptist Health South Florida (BHSF) corporate policy (BHSF-2295 Uninterrupted Meal Break) to allow 30 minutes of uninterrupted, uncompensated meal breaks to their employees. An uninterrupted meal break means that the employee is completely relieved of work duties during the 30 minute meal break. For a meal break to be considered uninterrupted, the employee must not perform any work during the 30 minute period. A meal break would not be considered uninterrupted, for example, in the following situations:
a. An employee eating lunch in the cafeteria who answers a call about a patient under his/her care.
b. An employee working at his/her station who takes a work-related phone call, does work-related paperwork or engages in a work assignment.
During occasions when employees are unable to have an uninterrupted meal break, they are required to notify their supervisor so the 30-minute automatic deduction for meal break can be reversed.
The 2012 NDNQI® RN Survey results for the Critical Care unit showed that 45% of nurses reported being able to sit down free of patients for a meal break. The results were above the 50th percentile of the national comparison of 38%, but below the 75th percentile of 54%. When the Critical Care Unit Practice Council (UPC) conducted an internal survey in October 2012, the number was even lower at 17%. The team decided to focus on this area to make improvements in the nurse practice environment. This would have a positive impact on RN satisfaction.
GOAL STATEMENT(S)
The UPC established a goal whereby at least 50% of nurses will be able to have an uninterrupted meal break.
The measure used to demonstrate improvement was percent of nurses who reported uninterrupted meal breaks as measured by the pre- and post-implementation survey.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY
In August 2012, the Critical Care Unit Practice Council (UPC) held a meeting and discussed the need to improve the nurses’ ability to have uninterrupted meal breaks. The team brainstormed different ideas and collaborated with Patient Care Manager Leslie Everett, RN and Patient Care Supervisor Liriola Harrison, RN. The UPC appointed Christina Edozie, RN, as the project lead. Edozie had attended the 2012 Magnet Conference and brought back information on the AACN’s Healthy Work Environment, which was useful to the project. Everett provided Edozie with the 2012 NDNQI® RN survey results and discussed the BHSF’s uninterrupted meal break policy and related state regulation.
The UPC utilized the performance improvement model of Plan-Do-Check-Act (PDCA) throughout the project. In the true spirit of shared governance, Edozie sent out a pre-implementation survey in October 2012 to collect more data and obtain input from the nurses on the implementation plan. Once the surveys were returned, she analyzed the results. Edozie, in collaboration with Everett and patient care supervisors (PCS), presented the results of the survey to the nurses in the November 2012 staff meetings, shift huddles, and UPC communication tree.
The nurses decided on using a buddy system as a primary strategy with handing over their phones as a secondary approach. They thought these were the best ways to ensure that meal breaks were made available to all nurses. Initially, Edozie thought both tactics would work. After a brief pilot, she decided to focus on the buddy system alone. The UPC drafted the details of the buddy system during their November 2012 meeting. Each UPC member was responsible for informing their communication tree member of the buddy system and what it would entail. This was further reinforced by Everett and the PCS through staff meetings and shift huddles.
Following the education, the buddy system was implemented in January 2013. Everett purchased a larger assignment board to allow room for the buddy information to be communicated each shift. Patient care supervisors and relief charge nurses were responsible for assigning buddies prior to the start of the shift. If an interrupted meal break was reported through the Kronos payroll system, the PCS explored with the nurse and the buddy the reasons for it.
The majority of the nurses were receptive to the implementation of the buddy system. There were a few who were resistant to the change. The UPC tackled this by clearing up misconceptions about its purpose through the communication tree. Once the issue was addressed, there was 100% participation among the nurses. PCS Kathie Trivett, RN and Harrison observed the nurses during the immediate implementation phase to encourage consistent participation. In March 2013, nurses were asked to complete the post-implementation survey. Edozie collected results and presented them in the October 2013 staff meeting.
PARTICIPANTS
The members of the meal break taskforce were as follows:
Name/Credentials |
Title |
Department |
Role in the Team |
Christina Edozie MSN, RN, CCRN |
Clinical Nurse |
Critical Care |
Team Leader |
Kathie Trivett BSN, RN, CCRN |
Patient Care Supervisor |
Critical Care |
Resource |
Liriola Harrison BSN, RN |
Patient Care Supervisor |
Critical Care |
Facilitator |
Leslie Everett BSN, RN, CCRN |
Patient Care Manager |
Critical Care |
Facilitator / Resource |
Critical Care Unit Practice Council (UPC) members |
Clinical Nurses |
Critical Care |
Provided input in the implementation plan and assisted in its dissemination |
OUTCOMES
Improvement in the Nurse Practice Environment
Exhibit TL1EOa: Percent of Critical Care Nurses Taking Uninterrupted Meal Breaks
Analysis: Above graph shows that after the implementation of the buddy system, the team has achieved its target with more than 50% of nurses having uninterrupted meal breaks for 3 consecutive data points.
Summary Attachments/Hyperlinks/Evidences
Exhibit TL1EOa: Percent of Critical Care Nurses Taking Uninterrupted Meal Breaks
Example 2 – Improvement Due to a Change in Clinical Practice
NAME OF INITIATIVE
Development of an Inpatient Childbirth Education Program
BACKGROUND/PROBLEM
Initiative Identified in the Nursing Strategic Plan
Prior to the fall of 2013, the Nursing Service Department had identified an opportunity to improve discharge education as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data. This nursing strategic goal is aligned with the organization’s value and priority for Service. To support the hospital’s FY 13 strategic goal, the Nursing Service Department developed objectives to improve the discharge process. More specifically, the Perinatal Department embarked on a journey to develop a robust childbirth education program. It had been some time since there was a formal childbirth education program at Homestead Hospital. Additionally, there was no standardized lactation teaching or support provided in the inpatient setting which created inconsistencies in the education of mothers who were breastfeeding or intending to breastfeed. This was reflected in the Perinatal department’s low scores on HCAHPS discharge information. In the 4th quarter of 2011, the unit’s score was at the 7th percentile.
The need for the program was supported not only by regulatory agencies (Centers for Medicare and Medicaid Services, The Joint Commission) that require hospitals to have a discharge planning process that applies to all patients. This was also endorsed by several professional organizations such as The American Academy of Pediatrics (AAP) and Association of Woman’s Health Obstetrics and Neonatal Nurses (AWHONN). They have set expectations, recommendations and standards about the need for information and educational programs related to perinatal care, including postpartum care of the mother and infant and discharge preparation.
GOAL STATEMENT(S)
The goal for desired improvement was to increase HCAHPS patient satisfaction with the discharge process to the 80th percentile as measured by HCAHPS patient satisfaction survey by providing standardized and evidence-based teaching and information. The measure used to demonstrate improvement was the HCAHPS scores on HCAHPS discharge information domain.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
The first brainstorming session was conducted in March 2012 by Clinical Nurses, Ana Cabrera, RN, and Alicia Johnson, RN. They had noticed that the patients being discharged from the post partum floor were receiving conflicting advice depending on the skill level of the nurse discharging them. Additionally, they were concerned about the low HCAHPS scores and the negative impact on Medicare reimbursement for the hospital. Cabrera and Johnson put together a preliminary plan to present to the new Perinatal Director, Jan Weatherspoon, RN.
In early May 2012, Cabrera and Johnson approached Weatherspoon, with an idea to develop a consistent method of providing discharge information and lactation education to Homestead Hospital’s post partum patients. Weatherspoon encouraged them to analyze the data, identify priorities and develop a plan. She provided Cabrera and Johnson with the HCAHPS discharge information data and suggested they perform further data collection and analysis.
Cabrera and Johnson proceeded to research national and community standards of care related to childbirth education and breastfeeding support. They quickly realized that Homestead Hospital fell short in meeting the needs of their patient population and community. They formed a taskforce consisting of clinical nurses from all of Perinatal specialties. The team utilized the performance improvement model of Plan-Do-Check-Act (PDCA) to ensure proposed changes were implemented and measured successfully.
The taskforce designed a teaching plan which included formal childbirth classes to be provided in the department conference room. Cabrera and Johnson proposed to provide discharge teaching classes, focusing on primigravidas (first-time mothers). The class would be divided into 2 parts: the first part focusing on mother and baby care and the second part on lactation education for mothers who are breastfeeding or intending to breastfeed. To capture as many patients as possible, Monday, Wednesday and Fridays were selected. Additionally, the support person would be encouraged to participate in the sessions to address the “help at home” HCAHPS survey question. Cabrera and Johnson enlisted the help of additional RNs in the department to assist them in developing the modules and teaching the classes. They created a schedule to ensure a Spanish speaking nurse was available to run the Spanish classes.
Cabrera and Johnson’s team designed a PowerPoint presentation at the 6th grade reading level consistent with literature recommendations. Their presentation was aligned with the evidence-based information contained in the discharge booklets provided to the mothers upon discharge. This ensured consistency of information in visual, auditory and written formats. The presentation was also available in English, Spanish and Creole. A group of 8 RN’s were trained to present the PowerPoint by observing Cabrera, Johnson and Clinical Nurse Carey Acosta, RN, teach the class. They were then observed teaching their own classes and were signed off as competent to teach. Acosta taught and validated the breastfeeding portion of the class.
The pilot for inpatient childbirth/lactation education classes began in June 2012. The instructors encouraged breastfeeding mothers to bring their infants to the class so they could directly observe their techniques. The staff provided invitations to all patients with the class times and strongly encouraged them to attend. Patients who declined were provided tailored teaching by the core group trained to teach the class based on an individual needs assessment.
In August 2012, Weatherspoon hired Acosta as the lactation resource nurse. With Acosta on board, the lactation education, initially part of the discharge teaching, was expanded and separated. This helped address complex breastfeeding issues of the hospital’s high risk population and supported the journey to becoming a Baby-Friendly Hospital. The inpatient childbirth education pilot was well received by the patients and a full roll-out of the classes was done in August 2012. Consequently, Weatherspoon designated Cabrera as the childbirth educator in January 2013.
As the program developed, Cabrera became aware of the need for discharged patients to call for advice on mother and baby care. The Joint Commission had indicated that the transition period from hospital to homecare would become an expectation; therefore, Cabrera established the discharge hotline in January 2013. Staff provided mothers with a refrigerator magnet which displayed important phone numbers they may need, including the perinatal hotline number. The line was open 24/7 and patients could speak directly to the lactation resource nurses or childbirth educator, when available. When they were not available, patients could leave messages which the childbirth educator or lactation resource nurses would answer back within 24 hours.
PARTICIPANTS
The RNs involved in this initiative were as follows:
Name/Credentials |
Years RN/Specialty Experience |
Title |
Department |
Role in the Team |
Ana Cabrera, BSN, RN, RNC |
22 years / |
Childbirth Educator |
Perinatal Services |
Co-Chair / Discharge class educator |
Alicia Johnson, BSN, RN, RNC |
14 years / |
Clinical Nurse |
Perinatal Services |
Co-Chair / Discharge class educator |
Carey Acosta, RN, IBCLC |
8 years / |
Lactation Resource Nurse |
Perinatal Services |
Lactation educator |
Maria Garcia, RN, RNC |
7 years / |
Clinical Nurse |
Perinatal Services |
Member / Discharge class educator |
Edelmys Mederos, BSN, RN |
4 years / |
Clinical Nurse |
Perinatal Services |
Member / Discharge class educator |
Sunil Varghese, BSN, RN, RNC |
15 years / |
Clinical Nurse |
Perinatal Services |
Member / Discharge class educator |
Jan Weatherspoon, MSN, RN, NEA-BC |
30 years / |
Director |
Perinatal Services |
Nursing leadership sponsor |
OUTCOME(S)
Improvement of Clinical Practice
Exhibit TL1EOb: Perinatal Services HCAHPS Discharge Information Domain Scores
Analysis: Above graphshows an improvement in the HCAHPS survey discharge information domain after the implementation of the inpatient childbirth education classes with more consistent scores meeting the internal benchmark of 80th percentile for 3 consecutive quarters.
Summary Attachments/Hyperlinks
Exhibit TL1EOb: Perinatal Services HCAHPS Discharge Information Domain Scores
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