FEBRUARY 2009
Introduction
This month’s issue of eNursingNow
focuses on Models of Care. Models of care
serve as the basis of nursing practice and
as an essential element of success for any
Magnet organization.
At NMH, we use both a Framework for
Nursing Practice based on the work of
theorist Virginia Henderson and models of
care delivery which are based on a patient
centered approach.
duties; it can also divide the work by
function such as "medication nurse"
and "treatment nurse."
•
Primary or Total Nursing Care
A model that generally uses an all-RN
staff to provide all direct care and
allows the RN to care for the same
patient throughout the patient's stay;
UAPs are not used.
•
Patient Focused Care
A model that uses RNs as care
managers and UAPs in expanded roles
that include drawing blood, performing
EKGs, and performing certain
assessment activities.
•
Patient Centered Care Model (PCCM)
This is the care delivery model used in
many areas at NMH. It is an evidence
based approach to providing nursing
care. The model is focused on creating
a healing environment centered on
trust, compassion and the incorporation
of the patient’s personal values into the
plan of care. Individual patients’ clinical
and safety needs are addressed
through monitoring, interventions, and
staffing adjustments. The PCCM also
uses “in the moment” critical thinking to
create a culture of seamless team
collaboration.
Framework for Practice vs.
Model of Care Delivery
Understanding the difference between a
framework for practice and a model of care
delivery can be confusing. Sometimes the
terms “model” and “framework” are used
interchangeably. In reality however, they
are very different from one another.
A care delivery model provides nurses with
guidance regarding how to deliver patient
care within a specific healthcare setting.
Thus, care delivery models typically focus
on nursing practice at the point of the
delivery of care (i.e., at the nursing unit
level). Below are examples of care delivery
models often used in hospitals. Here at
NMH, we use a patient centered model of
care in most practice settings.
•
Team or Functional Nursing Care
A model using the RN as a team leader
and LPNs/unlicensed assistive
personnel (UAPs) to perform activities
such as bathing, feeding, and other
Source:
http://www.nursinglink.com/training/articles/967-overview-ofnursing-practice-models
http://www.ahrq.gov/clinic/ptsafety/chap39.htm
A theoretical framework for nursing care
guides daily practice and clinical decision
making. NMH uses a Framework for
Nursing Practice which identifies both the
physiological and psychological aspects of
care delivery. The framework is based on
the work of Virginia Henderson. Henderson
believed that both a physiological
assessment and an assessment of basic
human needs are important aspects of
nursing practice. The Henderson
Framework for Nursing Practice is
discussed in the following article.
•
Henderson views nursing as an art and
a science. She states that the nurses
must get “inside the skin” of each
patient through listening, being
sensitive to the patient’s non-verbal
communication and through
encouraging patients to express their
feelings.
The Henderson Framework for
Nursing Practice
The Henderson Framework for Nursing
Practice is shown on page 3 of this issue.
Our framework serves as a road map to
guide the daily practice of nurses at NMH.
It is comprised of five components: the
nurse, nursing excellence, the patient, the
family/ significant other, and the patient
care team. Each of these components is
described below:
•
The Nurse
At the top of the triangle is the NMH
Nurse. NMH Nurses demonstrate
nursing’s unique and essential function
through Seven Attributes (i.e.,
advocate, autonomous, collaborative,
compassionate, dynamic,
knowledgeable and professional). The
Attributes are derived from Henderson’s
nursing framework. Henderson views
the nurse as accountable for his/her
practice and for adherence to
professional standards.
Nursing Excellence
The left side of the triangle depicts
nursing excellence which is
demonstrated through a Magnet
environment that fosters shared
leadership, continuous learning and
professional contribution. Excellence
also is one of NMH’s Core Values. “We
continuously strive for excellence. We
are always learning and improving our
skills, programs and services.”
•
Patient Care Team
The right side of the triangle represents
the patient care team of which the
nurse is a key member. Henderson
emphasizes that patient care should be
multidisciplinary with all members
working together to carry out the plan of
care.
At NMH, the team is committed to
integrity, teamwork and providing safe
and effective care. Integrity and
Teamwork are NMH Core Values.
Integrity entails “adhering to an
uncompromising code of ethics that
emphasizes complete honesty and
sincerity. Through our words and
actions, we earn the complete trust of
our patients and their families, our
community and our coworkers. We do
the right thing.”
•
Teamwork means working
collaboratively with others. At NMH, “we
achieve our mission and goals through
the collective and coordinated efforts of
our employees. We use our diverse
talents, backgrounds, ideas and
experiences to benefit patients and
create solutions. We value team
success over personal success.”
•
Safe and Effective Care is one of the
core components of the hospital’s
quality strategic plan. NMH is
committed to providing patients with
care that is evidence-based and error
free.
•
Patient and Family/Significant Other
The center of the triangle represents
the patient and family/significant other.
Henderson views the patient as the
center of care delivery. NMH’s Core
Value of Patients First states: “We put
the patient first in all we do. Caring for
the individual patient and his or her
family is the heart of our mission and
our philosophy.”
In summary, the Henderson Framework for
Nursing Practice is consistent with our
NMH core values and our Patients First
philosophy. The framework serves as a
road map to guide nurses in their daily
practice and decision making. It helps us
stay focused on those things that are
consistent with our organizational values
and essential to providing the Best Patient
Experience.
Care of the Critically Ill Oncology Patient
DMAIC Project
Approximately five patients per week, more
than 200 NMH patients per year, have
been transferred from the medical
oncology units to an ICU. In 2008, the
preventable code rate on the oncology
units was 0.60 codes per 100 discharges
or one code for every ten patients
transferred to the ICU. When the
hematology oncology units moved to
Prentice Women’s Hospital last year, the
travel time to an ICU from the oncology
units increased from about two minutes to
10-12 minutes. The increased distance
along with other barriers to a safe and
effective transfer created the need for
proactive identification of critically ill
patients.
The DMAIC team identified the primary
indicator for a safe and effective ICU
transfer as a low preventable code rate.
They set a project goal to reduce the
preventable code rate by one-third.
Multidisciplinary team members included
Pat Murphy, RN, MSN, MBA, Director of
Oncology Nursing; Barbara Gobel, RN,
MS, AOCN, Oncology Clinical Nurse
Specialist; physicians from both oncology
and internal medicine; Semico Miller, RN,
Rapid Response Team; Tarrah Merjudio,
RN, MICU; Sara Witt, RN, OCN, Staff
Educator, 15 PWH; Deb Mast, RN, OCN,
Clinical Coordinator, 16 PWH; and
Annaliza Rodriguez, RN, MSN, OCN,
former manager of 15 Prentice. Mark
Schumacher supported the project as the
quality improvement leader.
The team identified three primary factors
that served as barriers to safe and effective
transfer:
(1) difficulty in differentiating the
symptoms of neutropenic fevers from
critical conditions that require critical
care transfer,
(2) difficulty in using established
thresholds or indicators of acuity or
clinical deterioration because of the
overall acuity of illness in this patient
population, and
(3) the common view that these patients
are best cared for on the oncology
units by Oncologists and oncology
trained nurses.
The team built a protocol to identify and
proactively intervene with critically ill
patients. The protocol uses both a serum
lactate level and the Modified Early
Warning Score (MEWS) at a lower
threshold than that used by the Rapid
Response Team (RRT) to identify patients
at risk for clinical deterioration.
Since the implementation of the new
protocol in March, 2008, the preventable
code rate on the oncology units has
dropped 75% from 0.60 per 100
discharges to 0.15 pr 100 discharges.
There have been only four preventable
codes in the ten months since the protocol
has been implemented. The total code rate
has also dropped dramatically.
This improvement is being maintained
through a control plan that emphasizes
ongoing data tracking, ad-hoc code review
meetings, and ongoing education and
support for the staff. The most important
factor in achieving and exceeding the goal
was the collaboration among RNs, MDs,
and the RRT.
Condition Help Program
Effective February 16, 2009, all inpatient
units will participate in a new program
called “Condition Help”. This program will
assist NMH to provide The Best Patient
Experience and supports our Patient’s First
philosophy, a key component of the
Henderson Framework for Nursing
Practice. The Condition Help program also
meets one of The Joint Commission’s new
National Patient Safety Goals.
The Condition Help program provides
hospital patients and their family members
an additional resource to call when there is
a sudden change in the patient’s medical
condition and nursing staff are not present
to assist, or when the patient and/or family
member has already spoken with a staff
member, but still have urgent concerns.
The program has been piloted on 12 West
in Feinberg since October 2008. The
admitting nurse educates the patient and
family about the program and there is a
placard placed in each patient room to
display instructions and the activation
phone number.
Patients and/or family members are
instructed to use their call light for medical
emergencies or urgent concerns first.
However if they experience a delay in
Response, they are encouraged to use
Condition Help by dialing 2-1111 from the
phone in the patient room. The call is
answered by an operator who dispatches a
page to the Charge Nurse who addresses
the call and escalates the issue, as
appropriate, to the necessary personnel.
The success of the program has already
been demonstrated on the pilot unit when a
patient activated the system. This patient
was trached and required suctioning, but
was unable to reach his nurse by using the
nurse call system because it had been
accidentally disconnected from the wall.
Condition Help was activated and the
process worked beautifully. Staff on 12
West intervened quickly to prevent a
possible respiratory arrest.
Rebekkah has been a nurse since 2005,
and has worked at NMH since she
graduated from nursing school. Rebekkah
also serves as a nurse liaison this year.
Rebekkah’s future educational plans
include enrolling in an Adult Nurse
Practitioner Program in the Fall of 2009.
Her career goal is to become a Heart
Failure Transplant Coordinator or work in a
Heart Failure Clinic.
Currently, Rebekkah is focusing on the
continued development of her leadership
skills and nursing knowledge through
serving as Clinical Coordinator, Nurse
Liaison and by being involved in
committees.
To assist with the roll-out of Condition
Help, nurses are being asked to complete
a Computer Based Training Module (CBT).
This module is currently available and may
be accessed via NM Connect.
For additional questions on the Condition
Help program please contact Ashley
Currier at acurrier@nmh.org or Katie
Erickson at kaericks@nmh.org
Nurse Leaders
Rebekkah Beil, RN, BSN, Clinical
Coordinator, 11 West, CVT Stepdown Unit,
is Chair of the Nursing Professional
Practice Committee. She has been a
committee member since September 2008.
Pictured: Rebekkah Beil, RN, BSN
Given her experience as the Chair of the
Nursing Professional Practice Committee,
Rebekkah believes that the shared
leadership committees positively impact
nursing care by developing and modifying
policies and protocols that guide nursing
practice on a daily basis.
Note: In last month’s Nurse Leaders’
column, we stated that Sarah
Buenaventura BSN, CMS RN, had been
the chair of the Nursing Best People and
Professional Excellence for the past three
years. Actually, Sarah became the chair in
May of 2008. Prior to Sarah’s tenure,
Blanche G. Calomarde, BSN, RN, CNRN
Clinical Coordinator 10SE Neuro/Ortho
Spine/Plastics, served as the chair of the
NBP/PE Committee. We apologize for the
error.
Accolades
Melanie Shepley, SICU
Critical Care Nursing Certification
Poll Question
Hand Hygiene Compliance
20%
35%
2%
3%
11%
9%
20%
Place more signs and more gel dispensers in patient care areas to remind staff members to wash their hands
Have the Infection Control team provide in-services to educate staff on proper hand hygiene compliance
Have each member of the unit's quality committee rotate in a "sheriff" role to identify and address non-compliance with colleagues "in the moment"
Hold staff member who don't wash their hands accountable for their actions
Both the first and second choice
Both the third and fourth choice
All of the above