TL2: Nurse leaders and clinical nurses advocate for resources to support nursing unit and organizational goals.
Provide one example, with supporting evidence, of a nurse leader’s advocacy that resulted in the allocation of resources to support an organizational goal.
AND
Provide one example, with supporting evidence, of a clinical nurse’s (or clinical nurses’) advocacy that resulted in the allocation of resources to support a nursing unit goal.
Example 1 – Nurse Leader’s Advocacy
NAME OF INITIATIVE
Pediatric ED Rapid Care Model
BACKGROUND AND PURPOSE
Growing emergency department (ED) volume is a national trend and is not unique to our facility. Homestead Hospital's ED volume, in general, has increased each year since the replacement facility opened in 2005 and has reached near capacity. In particular, the pediatric ED, over the past 3 years, has seen substantial growth in pediatric visits, which account for nearly 27,000 visits yearly.
It has been progressively more challenging to manage the increased volume with both, physical and staff constraints. Volume has increased approximately 5% over the prior year and more than 10% since the move into the new facility. The pediatric ED consisted of a 9-bed unit with 2 medical providers, 1 unit clerk, 1 emergency technician, and 3-4 registered nurses (RNs). There were no plans on expanding the department. Therefore, congestion, patient throughput and satisfaction became a day-to-day struggle for the clinical nurses, ED leadership, and medical staff.
Organizational & Unit Goal
With increasing ED volumes and the requirement to meet national benchmarks for ED throughput, one of Homestead Hospital’s strategic goals for fiscal year (FY) 2013 was to explore means to decompress the ED and meet established targets. (TL2 01 Homestead Hospital FY 2013 Strategic Goal) Consequently, ED Director Sherine Craig, RN and ED Patient Care Manager Netonua Reyes, RN reviewed ED metrics in comparison to the national benchmarks. They identified several opportunities for improvement. Reyes had a similar goal outlined in her annual performance evaluation and embarked on a formal process to address this priority area.
Craig and Reyes proceeded to form the Pediatric ED Rapid Care Task Force to address the identified issues. The main goal of the team was to implement a workflow redesign that would improve pediatric ED throughput. Specifically, the team aimed to
a.Decrease left without being seen (LWBS) occurrences equal to or below the national benchmark of 3%, and
b.Reduce door to provider times to less than 60 minutes, as measured by median time in minutes, from time of arrival to time seen by medical provider.
METHODS AND APPROACH
The Pediatric ED Rapid Care Task Force was under the umbrella of the ED Unit Practice Council (UPC) and as such would report periodically to the council about their progress. During March 2012 to July 2012, the taskforce conducted discussions regarding Pediatric ED’s patient flow challenges during the monthly staff meetings in order to solicit staff input. The frontline staff identified the need for additional space and staffing resources. However, with the urgency for an immediate intervention, the task force made a decision to initiate a “rapid care” process using current staffing guidelines, which would require redesigning the workflow in the department.
Reyes and Craig presented the taskforce’s plan in managing patient flow to senior leadership and obtained their support. As a result, in August 2012 to January 2013, the pediatric “rapid care” process was piloted. The “rapid care” process is a flow pattern, which enabled less sick pediatric patients to be seen quicker in a separate part of the pediatric ED, staffed with a medical provider and a nurse. This replaced the traditional approach in which, lower acuity patients were seen in the main ED and consumed unnecessary room occupancy and nursing resources.
The taskforce monitored metrics described above daily, weekly and monthly. They saw immediate improvements in the numbers. However, the need for additional staff to continuously expedite flow in a safe manner was a recurrent theme in all subsequent staff meetings by both nursing and medical staff. With this information and the support of Chief Nursing Office and Vice President Gail Gordon, RN, Reyes scheduled a meeting with the senior executive team to discuss the need for an increase in nursing personnel in the pediatric ED.
Nurse Leader’s Advocacy
In February 2013, a meeting took place with Craig, Reyes, Gordon, Pediatric ED Medical Director Francisco Medina, MD, and Professional Services Vice President Kenneth Spell. Reyes delivered a presentation on the following topics: (1) successes of the new rapid care process and opportunities for improvement; (2) benefits of increasing the medical and RN coverage during peak census (1 p.m. to 1 a.m.); and (3) the efficiency of ancillary departments in expediting flow in the pediatric ED. In addition, Reyes also proposed the allocation of budgeted monies to train adult ED nurses in pediatric triage to assist in expediting flow.
Homestead Hospital senior leaders approved Reyes’ proposal. In the following months, Craig formulated the FY14 budget with additional 3 FTE’s for permanent staffing coverage from 1p.m. to 1 a.m. (TL2 02 Departmental Responsibility Report [DRR] FTE Approval) The approved positions were posted to hire additional nursing staff.
Due to the lack of immediately available experienced pediatric ED nurses, Reyes coordinated the cross-coverage between adult ED nurses with pediatric experience to the pediatric ED. In order to facilitate the triage process, more pediatric ED triage nurses were needed. Reyes once again ensured that targeted education for the nursing staff was accomplished. Clinical Nurse Educator Rusette Arends, RN and Clinical Nurses Rosa Rosseau, RN and Rene Bascoy, RN provided pediatric triage education to a few adult ED triage nurses from April to June 2013. (TL2 03 ED Triage Adult/Pediatric Class Roster)
Allocation of Resources
Because of the additional FTEs that they had advocated for, Craig and Reyes were able to make the following changes to the staffing guidelines in order to meet the needs of the department based on the new work flow in October 2013. (TL2 04 Staffing Sheet Reflecting New Guidelines)
Before |
After |
1 designated Pediatric triage RN |
Pediatric triage by all RN’s in department |
2 Zone RN’s |
2 Zone RN’s |
1 ED technician |
2 ED technicians |
Float RN (varied, staff dependent) |
1 Rapid care RN ( 1p-1a) |
|
1 RN Team leader |
PARTICIPANTS
The Pediatric ED Rapid Care Task Force members were:
Name/Credentials |
Title |
Department |
Role in the Team |
Sherine Craig, MSN, RN, CNML |
Director |
ED |
Co-Chair |
Netonua Reyes, BSN, RN, CCRN |
Patient Care Manager |
ED |
Co-Chair |
Rene Bascoy, RN, CCRN, CPN |
Clinical Nurse |
Pediatric ED |
Member; |
Rosa Rousseau, MSN, RN, C-NPT, RNC-NIC |
Clinical Nurse |
Pediatric ED |
Assisted in teaching Pediatric triage classes |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Nursing Administration |
Executive sponsor |
Kenneth Spell, MPH |
Professional Services Vice President |
Administration |
Executive sponsor |
Francisco Medina, MD |
Pediatric ED Medical Director |
Medical Staff |
Member |
Julian DiAvanti, MD |
Pediatric ED Physician |
Medical Staff |
Member |
Pedro Marin, Paramedic |
ED technician |
ED |
Member |
OUTCOMES
Exhibit TL2a: Pediatric ED Left Without Being Seen
Analysis: Above graph demonstrates a significant decrease in percent of pediatric ED LWBS as a result of the implementation of the rapid care process. The team has exceeded the national benchmark and sustained it for 3 consecutive quarters after staff cross training to pediatric ED triage and implementation of new work flow.
Exhibit TL2b: Pediatric ED Door to Provider Time
Analysis: Above graph shows that the rapid care taskforce has achieved its goal of decreasing door to provider time to 60 minutes and below and sustained it for 3 consecutive quarters after the implementation of the rapid care process, cross training and additional pediatric triage nurses.
Summary of Attachments/Hyperlinks/Evidences
TL2 01 Homestead Hospital FY 2013 Strategic Goal
TL2 02 Departmental Responsibility Report [DRR] FTE Approval
TL2 03 ED Triage Adult/Pediatric Class Roster
TL2 04 Staffing Sheet Reflecting New Guidelines
Exhibit TL2a: Pediatric ED Left Without Being Seen
Exhibit TL2b: Pediatric ED Door to Provider Time
Example 2 – Clinical Nurses’ Advocacy
NAME OF INITIATIVE
Advocating for Resources to Support the Baby Friendly Hospital Initiative Education
BACKGROUND AND PURPOSE
Nursing Unit Goal
Embarking on the journey towards Baby Friendly designation was a goal that the Perinatal department has identified in fiscal year 2013. It is an international designation and denotes the Perinatal Unit and staff as providing optimal feeding outcomes with support for breastfeeding and mother/baby bonding. Although the initial challenge of pursuing this designation was suggested by Baptist Health South Florida (BHSF) Chief Executive Officer Brian Keeley several years ago, it was not until Jan Weatherspoon, RN, became perinatal director in 2011 and got the department where it needed to be that they were able to pursue this goal in 2013. The time was right and the nurses felt that it was important for them to attain it because it was the best and right thing to do for their patients. They also felt that this would improve the health of the community. This goal was congruent with the results of the 2013 Community Health Needs Assessment, where maternal and child health was the fourth priority identified, specifically in the areas low birth weight babies, infant death rate and teen birth rate. In 2011, Miami-Dade County had an infant mortality rate of fewer than 5 deaths per 1,000 live births, lower than the statewide rate of more than 6 deaths per 1,000 live births. However, the infant death rate among blacks/African-Americans (9 per 1,000), who constituted about 25% of Homestead Hospital’s clientele, was 3 times that of Hispanics and non-Hispanic whites (both 3 per 1,000). In light of these statistics, the nursing staff felt that supporting breastfeeding helped to ensure that infants in their community would get the best start. Additionally, they felt that the Baby Friendly criteria would help to enhance teamwork and cohesiveness among the labor, postpartum, and nursery staff.
Clinical Nurses
As childbirth education and lactation resource nurses, Clinical Nurses Carey Acosta, RN, Ana Cabrera, RN and Laura Houwers, RN, they became intimately involved with the journey and initially constituted the Baby Friendly core group. Acosta and Houwers developed the Baby Friendly Hospital Initiative (BHFI) work plan which provided them with a gap analysis and step-by-step instructions to follow in order to meet the required criteria for designation. (TL2 05 BFHI Pathway Model Action Plan).
Advocacy
One of their major tasks was identifying and developing the plan to meet the education requirement. This included training of all health care staff in knowledge and skills necessary to implement this initiative, specifically, on breastfeeding based upon their function and level of responsibility. Acosta, Houwers and Cabrera reviewed in detail the educational requirements needed for all hospital personnel. This included:
- Fifteen hours of didactic training and 5 hours of hands-on training and documentation of competence for those staff (nurses included) who have direct contact with breastfeeding families. At the time, they could not find training programs offered within the health system. They were aware that they would either have to develop it quickly or enroll in one that was already available. The journey was progressing quite well and they did not want to stall the momentum in any way. They were facing an enormous job. Their initial decision was to develop a home-grown computer-based training (CBT) that could be placed as on online module in Baptist Health University (BHU) and made available to all staff throughout the entities. Due to the huge volume of information to be entered and other competing projects, Acosta, Houwers and Cabrera determined that going through this route, though cost-effective, would take several months to complete. They needed a quicker way of delivering the required education so as not to lose momentum. This led them to conduct an internet search for both free programs and those for purchase. They evaluated the quality, number of hours and price of the programs. They did not find any free programs. Eventually, they obtained a quote from a reputable vendor. They presented the quote to Weatherspoon and made the case for contracting an online education for this project. In addition, these were mandatory training. So, Acosta, Houwers and Cabrera also advocated for approval of compensation for time spent on education.
- Three hours training for all physicians and mid-level providers.
- Hospital wide-training for all employees regarding the 10 Steps for Baby Friendly, protecting breastfeeding, and the International Code of Marketing of Breast Milk Substitutes. Training for all employees involved taking a 30-minute online module in BHU which was made mandatory by April 1, 2014. In addition, Acosta, Houwers and Cabrera advocated to Weatherspoon for the approval to purchase Baby Friendly badge buddies and for the chief executive officer (CEO) to include Baby Friendly information in the mandatory employee forum to be held in October 2013 which usually generated greater than 90% attendance.
- Community Education
METHODS AND APPROACH
Resources Allocated
The online module’s cost of $64 per student would include tracking the percentage of program completion as well as 20 hours of approved nursing continuing education units (CEUs). Weatherspoon approved their proposal and went to the Foundation to ask for the funds ($4864) which would pay for 76 seats. She also approved the cost of the badge buddies and staff remuneration for the 15 hours of online training. (TL2 06 BFHI Online Training and Badge Buddy Purchase Orders) All Perinatal nurses had to complete 15 hours of online didactic education on breastfeeding and 5 hours of hands-on training that Acosta, Houwers and Cabrera provided for. The online education was done on nurses’ days off so as not to interfere with regularly scheduled staffing.
Hospital Staff Training
After the purchase of the online module, all Perinatal nurses started the 15-hour didactic training in April 2014. Acosta, Houwers and Cabrera provided the 5-hours hands-on component of the training. Clinical Nurse Binay Reynolds, RN, assisted with the hands-on training of her peers. Unit Practice Council (UPC) Chair and Clinical Nurse Debra Zornes, RN, helped champion the education drive and assisted in training the nurses with newborn transition in Labor and Delivery (L&D). Houwers developed the 30-minute CBT module for all employees titled “Baby Friendly Train” and partnered with the Clinical Learning department to load the program in BHU. This was made available to staff in July of 2014 and allowed them 24/7 access to the material. She also attended multiple staff meetings in January and February 2014 across the hospital to provide an alternative education method for employees who preferred the live training. Additionally, Acosta started attending the monthly new employee orientation in February of 2014 to introduce to new employees BFHI and lactation services. Houwers coordinated the distribution of badge buddies to all employees in January of 2014. (Exhibit TL2c) CEO Bill Duquette incorporated BFHI information in his October 2013 employee forum. He encouraged staff to complete the BHU online module by April 1st of 2014. This particular forum generated 94% attendance rate which ensured a hospital-wide dissemination of the information. It also demonstrated organizational support of BFHI.
Exhibit TL2c: Baby Friendly Badge Buddies
Community Education
In April and May 2013, Acosta and Cabrera held a 2-day workshop and trained 16 workers from En Familia, Inc. a community-based group that provided educational programs to help improve and preserve family life for a large population of migrant farm workers and low-income families in Deep South Miami-Dade County. They also conducted free monthly breastfeeding classes in the hospital. In January 2014, they started coordinating a monthly support group for both inpatient families and those from the community. This was facilitated by a lactation consultant from Women, Infants and Children (WIC), a federally funded public health nutrition program providing nutrition education, nutritious foods, breastfeeding support, and healthcare referrals for income-eligible women who were pregnant, breastfeeding or postpartum, with infants, and children up to age 5.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Laura Houwers, BSN, RNC, IBCLC |
Lactation Resource Nurse (Advanced Clinical Nurse) |
Perinatal Services |
Advocated for education resources; taught, helped develop educational plan and course in BHU, establish community outreach |
Carey Acosta, RN, IBCLC |
Lactation Resource Nurse (Proficient Clinical Nurse) |
Perinatal Services |
Advocated for education resources; helped to teach, coordinate hands on training, trained with En Familia, new employee orientation |
Ana Cabrera, BSN, RN, RNC |
Childbirth Educator |
Perinatal Services |
Advocated for education resources; developed and taught En Familia, helped to do hands on training, new employee orientation |
Binay Reynolds, RN, CLC |
Clinical Nurse |
Perinatal Services |
Help with education of peers and support efforts to train |
Debbie Zorns, RN |
Clinical Nurse |
Perinatal Services |
Provided information to staff and championed efforts, helped train with transition of infants in labor and delivery; UPC Chair |
Jan Weatherspoon, MSN, RN, NEA-BC |
Director |
Perinatal Services |
Championed efforts to pursue Baby Friendly and provided administrative support |
Leah Williams-Jones, MSN, RN, RNC, CNML |
Patient Care Manager |
Perinatal Services |
Championed efforts to pursue Baby Friendly and provided administrative support |
OUTCOMES
Perinatal nurses completed the 20-hour training by July 2014 with 65 RNs finishing the course. (TL2 07 BFHI Completion Report) The rest of the hospital staff finished their training in June 30th, 2014 with 1238 employees completing the CBT. (TL2 08 Baby Friendly Train Completion Report) The majority of medical staff and mid-level providers have completed their training with a goal of finishing it by September 1, 2014. Houwers revised the infant feeding policy in June 2014 and incorporated the Baby Friendly philosophy. (TL2 09 HH-400-2640-708 Infant Feeding) The unit is on the third stage of a 4-phase journey to Baby Friendly Designation. The nursing staff is focusing more efforts in promoting bonding and breastfeeding.
Utilizing the Kirkpatrick’s 4 Level Evaluation Model as framework, the Baby Friendly education program was evaluated as follows:
- Step 1: Reaction – Initially, most of the staff was not very excited about the training because sometimes mandatory training can have a negative connotation. But later on, learning new information and evidence-based practices promoted RN engagement in the BFHI.
- Step 2: Learning – After the hands-on training sessions, Acosta, Houwers and Cabrera validated nurses’ competencies. They observed that nurses were able to assist mothers with initial breastfeeding techniques, troubleshoot basic breastfeeding problems, and educate patients with up to date, evidenced-based information.
- Step 3: Behavior - Nurses began to show a consistency in what was taught and said to patients as evidenced by patient teach back and nurses’ documentation. They also referred more appropriate consultations to the lactation resource nurses because they were able to manage breastfeeding of the normal postpartum mother and neonate.
- Step 4: Results - Less mothers were giving up on breastfeeding and more were exclusively breastfeeding. Exclusive breast milk feeding percentage (with all feeding methods represented) has increased from an average of 6% (October to December 2012) to 28% (April to June 2014).
Summary of Attachments/Hyperlinks/Evidences
TL2 05 BFHI Pathway Model Action Plan
TL2 06 BFHI Online Training and Badge Buddy Purchase Orders
TL2 07 BFHI Completion Report
TL2 08 Baby Friendly Train Completion Report
TL2 09 HH-400-2640-708 Infant Feeding
Exhibit TL2c: Baby Friendly Badge Buddies