Nursing News

Staff Nurses Leading Practice Changes

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By Debra Wood, RN, contributor 

June 7, 2012 - Most nurses have become masters at adapting to change, but what about serving as change agents?

At a time when much change is occurring in health care--some of it driven by regulatory and reimbursement policies--there are staff nurses at a number of hospitals who are leading the way with improvements in patient care processes and procedures.

“Staff nurses are at the bedside and the first to recognize the need for a change,” said Lindsay Boyd, RN, BSN, CCRN, a staff nurse in the cardiothoracic intensive care unit at University of Washington Medical Center in Seattle, speaking at the 2012 American Association of Critical-Care Nurses National Teaching Institute and Critical Care Exposition (NTI) in Orlando, Fla. “There is a lot of benefit being at the source of the information and knowing how that change can impact in a practical fashion.”

Practice Changes
Lindsay Boyd, RN, BSN, CCRN, encourages nurses to step forward when they see something that needs changing and lead the process.

Boyd talked to NTI attendees about possible barriers to making changes and ways to overcome them; how to identify the routes and resources needed to implement something new, such as reaching out to peers and stakeholders; and the importance of recognizing the positive effects of peer-led projects. She emphasized that nurses should be catalysts for change, rather than sitting back and letting change happen to them.

The University of Washington supports staff nurses taking on projects, Boyd said.

Boyd has led two process changes at the University of Washington Medical Center and is working on a third. She led the revision of the balloon-pump policy, reviewing the literature and expanding it from one to nine pages. Recognizing a need to inform nurses about it, she developed a facility-specific education program built upon a vendor course.

“It was very rewarding and challenging to me, because here I was standing up in front of nurses with 20 to 25 years experience,” Boyd said. “They were receptive, and I took a lot of value from that.”

Next, Boyd tackled pressure-ulcer prevention, a problem on the unit at a time when Medicare reimbursement changed, no longer covering treatment related to hospital acquired decubiti. Boyd led the change to adopt three-times weekly skin-care rounds by two staff nurses with a wound care clinical nurse specialist. Rounds last four hours, as the nurses assess patients and make wound-care recommendations.

Boyd is currently working on a comfort care project.

Peer-led initiatives encourage nurses to adapt evidence-based practice, get them engaged, and establish ownership and accountability of the new processes. She acknowledges that these initiatives consume time, but being a change agent has its rewards, such as increased job satisfaction.

“Taking a leadership role, you feel you are making a difference,” Boyd said. “A big part of the process is to take a change and not let yourself be your own barrier. When you see something that needs to be changed, move forward and do it. When you see an opportunity, take it.”

The University of Washington Medical Center is not the only facility embracing staff nurse-led projects.

University of Pittsburgh Medical Center (UPMC) in Pennsylvania also encourages staff nurses to identify opportunities for improvement, make small tests of change and then roll out successful projects.

“We encourage it, because the front-line staff have the answers,” said Maribeth McLaughlin, MPM, BSN, vice president, patient services, Magee-Womens Hospital of UPMC. “They know what the patients need and what’s happening. They clearly have the knowledge and power to make those changes.”

Nurses at UPMC recognized they were not hitting quality metrics for hospital-acquired conditions and developed the Reliable and Variable Rounder care model to reduce hospital acquired conditions and improve patient satisfaction.

Rather than equally dividing the number of patients among nurses and nursing assistants, this model divides the work between predictable and unpredictable. The predictable tasks, such as morning care, are assigned to the “reliable rounder,” which ensures it gets done, and the unpredictable tasks, such as responding to call lights, are given to the “variable rounder.”

“Nurses on a Transforming Care at the Bedside medical unit took ownership and began to work through the model, trying a variety of different things,” McLaughlin said. “Nursing staff on the unit designed what worked to separate the work out, and they designed a lot of the tools.”

The nurses initially tested it on half of the unit with half of the staff for four hours on one day and then debriefed. After trying it, the nurses felt ahead of where they would normally be by that hour. They then expanded it to the whole unit.

“It was great watching that unit,” said Amy Kowinsky, RD, LDN, improvement specialist at the Donald D. Wolff Jr. Center for Quality, Safety and Innovation at UPMC. “Change is hard, but we encouraged them to hang in there. It does work.”

A second unit wanted to try it; the staff adopted the model to their culture, modifying it to address what mattered to their unit’s patients and staff members. Then in August, 17 additional units at 10 hospitals across system began implementing it, tailoring it as needed. The model builds in accountability for completing all work, because people are responsible for specific tasks that often were left up to “everyone” and yet missed the mark.

The units’ quality metric scores have improved, particularly on response to call lights, McLaughlin said.

The Institute for Healthcare Improvement and the Robert Wood Johnson Foundation launched Transforming Care at the Bedside (TCAB), in 2003, to address workplace quality and safety issues. TCAB fostered the growth of staff nurse-led initiatives. Nurses learned you can move the bar, and TCAB is where they learned it, Kowinsky said.

Cleveland Clinic in Ohio also encourages staff nurses to facilitate positive changes. Mary Beth Modic, MSN, RN, CDE, a clinical nurse specialist at the hospital, shared three examples.

Nurses in the coronary care intensive care unit recognized compliance problems with sequential compression devices to prevent deep vein thrombosis in patients, so they conducted a root cause analysis and figured out the obstacles. They discovered the correct equipment often was not available. Once those issues were addressed--making the right equipment readily available, including changes in workflow and education about the value--the compliance increased from 27 percent to 76 percent.

On a medical unit caring for many older, disoriented adults needing sitters to prevent wandering, nurses worked in collaboration with the physicians and social workers to create a close observation unit. They converted two semi-private rooms into one large, four-bed room and staffed it with one registered nurse and a care technician, who can watch for subtle changes and intervene early. The number of bedside companion hours were reduced from 7,400 in the nine months prior to opening to 3,300 hours in the nine months after it was established, saving the hospital $40,000.

“They have tremendous nurse satisfaction,” Modic said. “This is an opportunity for a nurse with a care technician to be with the patients and intervene before they escalate and are agitated, so it is gratifying.”

Nurses in the neuroICU increased patient mobility to reduce complications of bed rest by identifying patients who met criteria for early ambulation. They reviewed the literature and learned what has been successful in the past and implemented that on their unit, reducing length of stay and improving outcomes.

“We have wonderful people who see the benefit of education and using evidence, and it has an effect on changing length of stay, the degree of suffering that someone might encounter, and patient and family satisfaction,” Modic said. “All of those things are significant. We want to do that so patients can have a better experience and save their lives.”

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