2012 Translational Projects
Promoting Effective, Collaborative Practice in the Emergency Department
Nancy Stevens, DNP (c), MSN, FNP-BC, CEN, FAEN, RN
Nancy Stevens’ translational project centers on improved job satisfaction of the nursing staff in the Emergency Department. Programs were developed to promote effective communication be-tween the Emergency Department team members to support independent, collaborative practice. The development and fostering of a collaborative practice arena enhances, enforces and strengthens the working relationship between all healthcare providers.
A focus team was developed to evaluate progress and continually re-examine, redefine and re-prioritize goals of the team as required over time. Team members were encouraged to utilize innovative and creative prob-lem solving methods to increase trust and collaboration between team members. Ms. Stevens conducted a pre- and post-project survey with all nursing staff. Although the post-project survey reflected additional areas of improvement, the overall nursing satisfaction scores reflected a significant improvement (n = 140, r2 = 0.8254). This study reinforces the responsibility of all nursing leaders to demonstrate effective management skills in creating and maintaining a healthy work environment, which is crucial in the overall satisfaction of nursing staff and ensuring safe, effective patient care.
Establishment of a Formal Preceptor Program for Orienting New Graduate Registered Nurses to an Acute Care Hospital
Lynda Ridley, DNP(c), MSN, ACNS-BC, RN
The purpose of this project is to establish a formal preceptor program for orienting new graduate registered nurses to an acute care hospital. This project translates best practice found in the literature into a hospital system utilizing a formal preceptor program for the orientation and “on-boarding” process for new graduate registered nurses. Research has suggested formal preceptorship programs for the new graduate nurse as a way to improve job satisfaction and reduce turnover. Ms. Ridley’s project will attempt to identify in new graduate registered nurses how a formal preceptor based orientation program compared with a non-precepted orientation program affects turnover rate in three months.
Integration of the Homeostasis Model Assessment Among Advanced Nurse Practitioners for the Purpose of Identifying Insulin Resistance
Kim D. Taylor, DNP (c), MSN, FNP-BC
Insulin resistance is a costly condition, reducing the quality of life while increasing risk for chronic disease. The Homeostasis Model Assessment, a simple test to identify patients at risk for disease, is easy to use in clinical practice. Studies indicate that the tool is reliable, has high specificity, and is cost effective. Ms. Taylor states that the use of the Homeostasis Model Assessment by Advanced Nurse Practitioners can be a valuable tool to identify clients with insulin resistance, contribute to evidence-based practice, and assist providers in improving their patients’ outcomes. Reducing the incidence of insulin resistance contributes to healthy populations.
Affecting Primary Care Providers’ Clinical Use of MI Skills to Impact Patient Education
Candace Bishop , DNP(c), MSN, FNP-BC, CHC, RN
Consequences of chronic diseases in the United States have not been addressed in a positive way by traditional patient educational methods. Instead, diabetes and cardiovascular diseases are the leading causes of mortality in the United States. Motivational Interviewing (MI), a patient-centered clinical intervention, was first described in the 1980s by Dr. William Miller for use in the treatment of alcohol disorders and has now been shown to be effective in a variety of medical settings where ambivalence toward behavior change is encountered.
MI utilizes principles of interpersonal communication to elicit and guide behavior change when ambivalence prevents change and internal motivation is lacking. Candie Bishop’s translational project’s objective is to affect primary care providers’ (PCPs) clinical use of MI skills to impact patient education and thus affect risky health behaviors that lead to chronic diseases. Ms. Bishop says this will be accomplished by providing a didactic and practice session of MI. The goal is to increase use of MI in the clinical setting thereby modifying risky health behaviors over time and improving biometric markers of chronic diseases, such as hemoglobin A1C, lipid profiles and blood pressure.
A Collaborative Approach to Improve Communication during Transition of Care
Julie Humble Horton, DNP(c), MSN, RN
The purpose of Ms. Horton’s translational project is to develop a collaboration protocol that will improve communication between primary care physicians and hospital-based practitioners to positively impact rehospitalization rates in a high-risk inpatient population. Twenty percent of Medicare beneficiaries are rehospitalized within 30 days of discharge at an estimated cost of $18 billion dollars to the Medicare program (Jenks, Williams, & Coleman, 2009). Multiple factors contribute to avoidable rehospitalizations, with the transition of care (TOC) from the hospital to the community setting identified as creating the most opportunity for improvement (Stone & Hoff-man, 2010). Van Walraven, Seth, & Laupacis (2002) cite the use of hospitalists as admitting or attending physicians during hospitalization in creating a need for timely communication with pri-mary care physicians (PCPs).
A collaboration protocol will be developed based on the responses from a survey of hospitalists and PCPs to establish perceived needs of timeliness and content of information transfer. The project requires PCPs and hospitalists to complete the survey, understand the new collaboration protocol, and use it during their interactions for high risk inpatient admits. The outcome is the 30-day readmission rate for high risk patients 90 days prior to proto-col implementation, as compared to the 30-day readmission rate for high risk patients 90 days after protocol implementation.
Breast Cancer Related Lymphedema
Lee Ann Brown, DNP(c), MS, ACNP, NP-C
The purpose of Ms. Brown’s translational project is to develop a standardized education program for women undergoing breast cancer surgery concerning their risk for developing breast cancer-related lymphedema. The project will be conducted at the Southeastern Breast Specialists Center in Dalton, Georgia. Studies show that as many as 50% of breast cancer patients that develop lymphedema were not given pretreatment information about their risk for developing lymphedema. It has been shown through evidence-based research that early identification and treatment of lymphedema is more successful in minimizing and controlling progression of the disease process.
Education concerning breast cancer-related lymphedema (BCRL) begins with the staff who are taught the pathophysiological process of lymphedema formation and how to screen and measure to detect BCRL at its earliest point in development. They are also responsible for initiating education for the patients on BCRL through video presentations and handouts, administration of the Lymphedema and Breast Cancer Questionnaire (LBCQ), and review of the Lymphedema Risk Reduction Behavior (LRRB) checklist. Outcome goals include: increased knowledge among healthcare workers and patients concerning BCRL, increased awareness concerning physical signs and symptoms of BCRL, early recognition of symptoms and prompt referral to lymphedema (LE) specialists, increased public awareness, prevention of BCRL, reduction in physical and psychological discomfort, empowerment through knowledge and self-efficacy skills, and reduction in healthcare costs. With more than 1 million cancer survivors having a lifetime risk of developing lymphedema, the need for increased awareness, standardized assessments, and improved preventive measures is becoming increasingly critical.
Using Social Norms Media Strategies to Affect Perceived Norms of Peers’ High Risk Sexual Behaviors in College Students
Yasmine Kangles Key, DNP(c), MSN, NP-C
The purpose of this exploratory study is to determine the effect on college students’ perceptions of peer high risk sexual behaviors when exposed to a social norms campaign around campus. Social norms media campaigns have been successful at lowering actual high risk behaviors and traditionally have been used in alcohol, drug and tobacco campaigns. In order to lower the high risk behaviors, the normative gap of the behavior must be closed between the perceived and actual norm. To determine the actual and perceived norms of high risk sexual behaviors, a thorough review of the literature was conducted and data from the American College Health Association National College Health Assessment for the Southeastern United States were reviewed.
Data regarding sexual health were reviewed and contributed to development of print materials for a poster campaign on the University of Tennessee at Chattanooga’s (UTC) campus. Posters were created targeting UTC students. A focus group of upper level students reviewed the posters for believability, content, concept comprehension, and overall graphic and visual appeal. Written and verbal feedback was given and taken under advisement for the campaign. Four different poster designs were launched over a six week period in the most high traffic areas around the campus. After six weeks, an electronic survey was sent to all students to evaluate the campaign based on believability, retention of the messages, recall of the poster designs, and perceptions of high risk sexual behaviors. Data were analyzed to see if the perceptions of high risk sexual behaviors changed.
A Focused Care Program for Observation Patients
Janice C. Keys, University of Tennessee at Chattanooga
The purpose of this project was to implement a focused care program for observation patients to improve length of stay, reduce cost of care, and decrease the number of patients that leave the Emergency Department (ED) prior to medical screening. The project plan is to admit short-stay observation patients to a designated observation unit (OU), configured for safety, quality and efficiency independent of the ED. Clinical oversight of the unit is a co-management model provided by a Hospitalist and an Advanced Practice Registered Nurse (APRN). Evidenced-based practices such as multidisciplinary rounds, bedside shift reports, and unit huddles were used on the observation unit to impact length of stay, emit a reduction in cost, enhance patient throughput and therefore yield a decrease in patients leaving the emergency department prior to medical screening.
Background: Observation services are provided to patients with an acute clinical condition whose need for acute care hospitalization is unclear after their initial evaluation and management. Centers for Medicare & Medicaid (CMS) defines hospital observation services as those services that are reasonable and necessary to evaluate the outpatient's condition or determine the need of that patient's admission to the hospital as an inpatient. Prior to the implementation of this project, the process for providing care for these patients at Erlanger Medical Center was holding them in the ED for extended monitoring or admitting them to an inpatient bed throughout the hospital. The literature validates that a focused care program utilizing standard protocols for treatment and multidisciplinary rounds, bedside shift reports and units huddles for communication is an effective process for managing observation patients. The researched articles principal implications were: appropriate patient selection, the use of standardized protocols, ancillary support, unit supervision of a physician and a nurse, and the necessity for monitoring quality and financial metrics. Encouraging a collaborative work environment supports autonomy, empowerment and accountability among all the caregivers and results in positive outcomes with quality, costs and operational efficiency. Hospitals that continue to manage observation patients in the ED may be limited on bed capacity and experience increased diversion of patients and poor clinical outcomes due to the overcrowding. Support from The Board of Trustees and Administration is vital to sustain the observation unit and the commitment from the Medical Staff to embrace the practice environment is key to the success of the observation unit.
Recommendations and Impact: Implementation of an OU requires a collaborative practice environment among the stakeholders to provide the foundation for a designated unit for observation patients. The impact will be a reduction in cost, decreased length of stay and improved throughput.
Nurse Practitioner Preceptorship
Amber Roache, MSN, APRN-BC, FNPNurse practitioner preceptors are expected to be experienced health care providers who teach, supervise, role model, and evaluate students. While preceptors are generally experts in their area of practice, they have little to no experience in the area of teaching and evaluation. A pilot study based on Bandura's (1977) self-efficacy theory was designed to address nurse practitioner preceptor training. A self-efficacy questionnaire was administered pre-presentation and post-presentation to eight nurse practitioner preceptors. The self-efficacy questionnaire was compared pre/post-test. Statical analysis demonstrated improvement in preceptor self-efficacy after the presentation. The qualitative portion of the project supported why nurse practitioners continue to precept students. Feedback provided by the participants post-presentation also demonstrated a need for more formalized training for preceptors. This pilot study supports the need for more in-depth training programs for nurse practitioner preceptors.
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