Volume 11│Issue 3│Fall 2020 Carilion Medical Center, 1906 Bel leview Ave, Roanoke, VA 24014 https://www.insidecarilion.org/hub/nursing -research-evidence-based-practice nursingresearch@carilionclinic.org (540)266 -6216
Necessity is the mother of invention (Old English proverb. Author unknown) Deirdre Rea, DNP, MSN, RN-BC - Department of Psychiatry and Behavioral Medicine
In the June issue of Within REACH, Dr. Kim Carter focused her editorial on some of the impacts of COVID19 on both our work and personal lives. With an eye toward resources available for best practice, she included links to multiple agencies providing information and assistance with everything from epidemiology to practice and to travel. Now, eight months into the pandemic, enough time has passed for us to begin to look back at our response to the crisis and understand what we have learned. At the forefront, healthcare systems, and nurses specifically, have demonstrated resilience, nimbleness, and an ability to turn on a dime when the CDC or WHO changed recommendations, or when problems or delays arose with equipment and testing and innovative thinking was required. Because the virus was novel, there was little evidence to guide our responses. We were creating our own evidence in real-time. Prior, Delac, Laux and Melone (2020) described their hospital’s multiple approaches to the challenges COVID-19 presented. One was a method of managing just-in-time learning needs with each new, emerging piece of information about the virus. Their hospital system chose to consolidate nursing care to reduce COVID exposure time despite no literature or evidence on the efficacy of such an approach. They created new guidelines and tried it anyway. Resuscitation and intubation procedures had to change to maintain staff safety. Each step had to be assessed and modified and modified again. Sixty to seventy percent of their over-1000 member nursing staff were trained on the changes in six days. The rate of the education was impressive and we might learn from their dissemination practices. But what were the staff and patient outcomes from the new initiatives? Did they have any clinical impact? That might be the next step in the research process. Minissian, Ballad-Hernandez, Coleman, …& Marshall (2020) looked at pre-and post-COVID learning environments and the use of a multispecialty nursing team in improving care. They described using this team to rapidly educate nurses from various areas to re-deploy them to the front lines of COVID care. It demonstrated the flexibility of nurses and their ability to rise to the patient need. But they also introduced other concepts including the use of ‘innovative techniques’ in screening, diagnosis and treatment and the idea that work culture had to change. What a hard concept that was for many nurses to accept. Ultimately the article only reported findings on the reduction of learning time, leaving the efficacy of the ‘innovative techniques’ or the lived experience of the culture change and its impact on nurses and patients completely unaddressed- but ripe for exploration. The pandemic may be on-going, but we have already, whether we realize it or not, learned much. It is time to take stock of our creative experiments and initiatives and begin to test our hypotheses on these new practices. Areas for exploration and study are limitless - staffing models, how education was done, changes in the timing of patient rounding, methods of managing PPE supplies, prone versus supine placement, patient satisfaction, family experience, nursing attitudes and moral distress to name a few. Carilion nurses have been challenged and have prevailed. It is time to begin studying, testing, creating and disseminating the evidence that is needed both now and in the future for unprecedented illnesses like COVID-19. Carilion Clinic Roanoke Campus
~ Deirdre References on page 5
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ARTICLES/NOTIFICATIONS 1 Necessity is the mother of invention 3 4
Deirdre Rea, DNP, MSN, RN-BC 2020 Carilion Nursing Research Virtual Poster Fair Information
Improving professional practice through audit and feedback: Promoting pneumococcal immunization in Presurgical Testing. Deborah Hodges, MSN, RN, CAPA, CNL; Rebecca Clark, PhD, RN & Kim Carter, PhD, RN, NEA-BC 6 Can use of catheter alternatives decrease use of urinary catheters? Amy Lucas, MSN, RN, CCNS, CCRN-K 10 Article Review: Obstacles to end of life care in the Emergency Department Lydia Pope, RN 12 Article Review: Conflict in the surgical critical care unit Caroline Williams, RN
RECOGNITION/EVENTS 13 Congratulations! 2019 Carilion Nursing Research Fellows Graduation 14 Recognitions 18 Citations & Recognition 20 See Where Our Nurses Have Presented their Work! 21 Carilion Nursing Research Classes & Event information We would like to recognize Michele Kosinski’s work as one of our editors on the Carilion Nursing Research Editorial Board. Michele is transitioning to a new position within Carilion and will have to leave her editorial duties in the board’s capable hands. Michele, you are on your way to continue doing great things! Congratulations and best wishes in your new position. **If you are interested in becoming a member of the Carilion Nursing Research Editorial Board, please email your CV or Resume to Kim Carter (kfcarter@carilionclinic.org) for review!** Carilion Nursing Research Editorial Board: Kim Carter, PhD, RN, NEA-BC - Editor-in-Chief Michele Kosinski, DNP, MBA, RN - Co-Editor Deirdre Rea, DNP, RN-BC, PMH-CNS - Co-Editor Reviewers Nancy Altice, DNP, RN, CCNS, ACNS-BC Desiree Beasley, MSN, RN, CCRN, CCNS Ann Beheler, ADN, RN Sarah Browning, DNP, RN-BC Molly Clemons, RN, ONC Monica Coles, DNP, RN-BC, ACNS -BC Sarah Dooley, MPH, BSN, RN Christine Fish-Huson, MSN, RN Shanna Flowers, MA Donna Goyer, BSN, RN, CPAN, CAPA
Cindy W. Hodges, BSHS, RNC, FCN James Ingrassia, MSN, RN Pam Lindsey, MSN, RN Margaret Perry, MSN, RN-BC Laura Reiter, MSN, RN, CCRN, CNRN Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC Vivian Wilson, BSN, RN, CCRP
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*Go to our Nursing Research hub on Inside Carilion for more information!
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Improving professional practice through audit and feedback: Promoting pneumococcal immunization in Presurgical Testing. Deborah Hodges, MSN, RN, CAPA, CNL - Presurgical Testing; Rebecca Clark, PhD, RN & Kim Carter, PhD, RN, NEA-BC - Nursing Research Introduction It is often challenging to engage nurses in quality improvement. Their participation is essential for an organization to meet established goals. Audit and feedback is a quality improvement strategy used to improve employee performance1. Using the audit and feedback strategy, professionals are provided feedback regarding performance to achieve goals. Audit, coupled with individualized, timely, actionable feedback, provides information for performance improvement. Pneumococcal pneumonia causes approximately 150,000 hospitalizations annually in the United States, and around 3,600 people died from pneumococcal meningitis and bacteremia in the United States in 20172. Vaccine-preventable illness and death from pneumococcal infections continues to be of concern3.The Centers for Disease Control and Prevention recommends that vaccines be offered in non-traditional settings4. Studies demonstrate that recommendations from nurses and other healthcare providers have a significant impact on immunization rates, yet patients report they often do not receive these recommendations5-6. Identification of problem and purpose of study The department goal was that 50% of eligible patients receive pneumococcal vaccinations, yet the percentage was 33%. The goal of this quality improvement study was to increase the rate of pneumococcal vaccination in our Carilion Presurgical Testing Center by using audit and feedback to achieve the target of immunizing 50% of eligible patients. This work builds upon foundational quality improvement work in the department funded by grants from the Merck, Sharp, & Dohme Investigator Studies Program. . Methods Following updates to the electronic medical record (EMR), nurses participated in the establishment of departmental goals and discussed how to promote immunization of eligible patients. EMR reports provided the manager with monthly performance data that she audited and shared, recognizing nurses who met goal, and sending individualized emails providing actionable feedback for those not meeting goal. Other evidence-based strategies that the team implemented included scripting answers to patient questions, unit champions who mentored outliers, and a video created by peers modeling Presurgical Testing Center visits regarding the benefits of vaccination. Outcomes From October 2018 to September 2019, all nurses achieved the 50% goal. Discussion Setting departmental goals can have limited impact on behavior without ongoing manager involvement. Audit and feedback can assist nurses to understand how their individual performance compares to peers and standards. Peer modeling is useful for those less inclined to participate. Conclusion Audit and feedback can help improve professional practice. Leadership involvement combined with peer influence are key factors to successful improvements in adult immunization rates. Implications for Perianesthesia and future research Audit and feedback is an effective tool to influence professional practice. Ongoing efforts to increase immunization rates will continue to impact decreased pneumococcal disease in the community and ultimately reduce vaccine-preventable hospitalizations. More study is needed to identify strategies to apply the audit and feedback strategy to support nurses to sustain the pneumococcal goal and to achieve other departmental goals.
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References 1. Hysong, S., Smitham, K., SoRelle, R., Amspoker, A., Hughes, A., & Haidet, P. 2018. Mental models of audit and feedback in primary care settings. Implementation Science, 13(73), https://doi.org/10.1186/ s13012-018-0764-3 2. Centers for Disease Control and Prevention. 2019. Pneumococcal Disease. Accessed online at https:// www.cdc.gov/pneumococcal/about/facts.html 3. Pilishvili, T. & Bennett, N. 2015. Pneumococcal disease prevention among adults: Strategies for the use of pneumococcal vaccines. Vaccine, 33(Suppl 4), D60-65. DOI: 10.1016/j.vaccine.2015.05.102 4. National Vaccine Advisory Committee. 2000. Adult immunization programs in nontraditional settings: Quality standards and guidance for program evaluation: A report of the National Vaccine Advisory Committee. MMWR, 49(RR01), 1-13. 5. Lau, D., Hu, J., Majumdar, S., Storie, D., Rees, S., & Johnson, J. 2012. Interventions to improve nfluenza and pneumococcal vaccination rates among community-dwelling adults: A systematic review and meta-analysis. Annals of Family Medicine, 10(6), 538-546. 6. Bridges, C., Hurley, L., Williams, W., Ramakrishnan, A., Dean, A., & Groom, A. 2015. Meeting the challenges of immunizing adults. American Journal of Preventive Medicine, 49(6S4), S455-S464.
Acknowledgment: This work builds on earlier work by Rebecca Clark, PhD, RN; Brenda Gilliam, MSN, RN; Julie Jackson, RN; Deborah Hodges, MSN, RN; Kim Carter, PhD, RN, funded in part by the Investigator-Initiated Studies Program of Merck & Co. The opinions expressed in this presentation are those of the authors and do not necessarily represent those of Merck & Co., Inc.
References from page 1 article Necessity is the Mother of Invention: •
Minissian, M., Ballard-Hernandez, J., Coleman, B., Chavez, J., Sheffield, l., Joung, S., Parker, A., Stepien, S., Romero, J., Florindez, L., Simons, C., DeJesus, M., & Marshall, D. (in press). Multispecialty nursing during COVID-19: Lessons learned in southern California. Manuscript submitted for publication. Retrieved from Publons.
•
Prior, M., Delac, K., Laux, L., Melone, D. (2020). Determining nursing education needs during a rapidly changing COVID-19 environment. Critical Care Nursing, 43(4), 428-450.
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Can use of catheter alternatives decrease use of urinary catheters? Amy Lucas, MSN, RN, CCNS, CCRN-K - Clinical Nurse Specialist, Nursing Quality & Safety The purpose of this project was to reduce urinary catheter use at CRMH by providing appropriate products to manage urine in hospitalized patients. Reduction of catheter use should not only decrease risk of urinary tract infection, but also of other complications, such as meatal trauma and bacterial resistance or clostridioides difficile (formerly known as clostridium difficile) infection related to antibiotic overuse1. Literature Review CAUTI (catheter-associated urinary tract infection), the most common healthcare acquired infection in adults in acute care facilities, is associated with higher mortality and longer lengths of stay2. Recommendations to prevent CAUTI, commonly known as the ‘foley bundle’, are to: only place catheters for specific indications, remove them as soon as possible, and maintain them appropriately while in place1,3,4. No guidelines advocate inserting a urinary catheter solely to manage urinary incontinence or to measure output when another method can be used 3,4,5. Despite the recommendations and the evidence that reducing catheter days does reduce CAUTI 6, between 21-50% of urinary catheters may be placed for inappropriate reasons 7. The Association for Professionals in Infection Control and Epidemiology (APIC) 2014 guidelines list several factors that contribute to the delayed removal of catheters, including a lack of supplies to manage incontinence. Scott et al.8 considered this in a project to decrease urinary catheter placement in the Emergency Department (ED). They used focus groups to understand practice related to placing catheters and then created education, a decision support tool, and improved the availability of catheter alternatives for their staff. These interventions lead to fewer catheters being placed in their ED as well as an increase in the use of catheter alternatives. Interventions such as these can ultimately prevent CAUTI by reducing urinary catheter placements and decreasing catheter dwell times. IRB Determination The Carilion Clinic IRB determined that this study did not meet the regulatory definition of human subjects research as outline in the Department of Health and Human Services (DHHS) regulations. Methods and Procedures The project took place in several stages starting in late 2016. First, nursing and medical staff were surveyed about catheter alternatives and their perceived needs for other products. This survey indicated a need for better products for both men and for incontinent and immobile women. Next, products were found to fill these needs. The first products searched for based on the survey were a new device for incontinent women and a better version of male condom catheter. Later, as more needs were identified, a pouch for men who could not wear a condom catheter was also found. These products were piloted and implemented. Finally, champions were recruited from nursing units and educated about the new products, acceptable reasons for a urinary catheter, and current policy. They helped to advocate for and educate about the new products. The clinical nurse specialist also rounded in areas with catheters of long duration to identify opportunities for removal and further needs for different products. Outcome Measures and Data Collection The main outcome measure for this project was catheter use. This was monitored using Infection Control reports of catheter duration that included utilization ratio as well as catheter hours and
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number of catheters used. The numbers were compared between the baseline year (2016), the implementation year (2017), and a follow up year (2018). Results • There was a statistically significant decrease in the number of catheters used in 2017 and 2018 compared to 2016 (p=0.0001). There was also a statistically significant decrease (p=0.0003) in the number of hours a catheter dwelled in the patients over the three-year period (see figure 2). • For the years 2016, 2017, and 2018, there was a statistically significant positive association (p=0.015) between catheter duration in hours and CAUTIs. However, the decrease in CAUTIs over the three years was not statistically significant (p=0.1213). Additionally, this association between catheter duration in hours and CAUTIs did not sustain, and infection rates increased in 2019. Practice Implications While the cause of the decrease in CAUTI cannot be unequivocally attributed to this project due to other initiatives, such as enhanced unit director accountability and better reporting of documentation that occurred during the same time, the decrease in CAUTI in 2017 did seem to coincide with the introduction of the new products. Use of the new products was associated with a decrease in catheter use at CRMH, and this decrease in catheter use was associated with a decrease in the number of CAUTI; however, despite often having lower catheter use than our peers, CRMH continues to have a higher CAUTI rate, indicating that we still have work to do. Avoiding or decreasing duration of catheters is only one part of the bundle. In addition to continuing to assess and address needs for products to manage urine, we must ensure that all parts of the foley bundle are being followed. References
1. Lo, E., Nicolle, L., Coffin, S., Gould, C., Maragakis, L., Meddings, J., et al. (2014). Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 35(5), 464-479. 2. Centers for Disease Control and Prevention. (2010, April 26). CAUTI FastFacts. Retrieved November 7, 2016, from cdc.gov: http://www.cdc.gov/hicpac/CAUTI_fastFacts.html 3. Association for Professionals in Infection Control and Epidemiology (APIC). (2014). Guide to preventing catheter-associated urinary tract infections. Retrieved from APIC Implementation Guides: http:// www.apic.org/Professional-Practice/Implementation-guides 4. Gould, C., Umscheid, C., Agarwal, R., Kuntz, G., Pegues, D., & Committee, H. I. (2009). Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Retrieved April 24, 2014, from Centers for Disease Control and Prevention: http://www.cdc.gov/hicpac/pdf/CAUTI/ CAUTIguideline2009final.pdf 5. Meddings, J., Saint, S., Fowler, K. E., Gaies, E., Hickner, A., Krein, S. L., & Bernstein, S. J. (2015). The Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results Obtained by Using the RAND/UCLA Appropriateness Method. Annals of Internal Medicine, 162(9), S1– S34. https://doi.org/10.7326/M14-1304 6. Bernard, M., Hunter, K., & Moore, K. (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urologic Nursing, 32(1), 29-37. 7. Chenowith, C., & Saint, S. (2011). Urinary Tract Infections. Infectious Disease Clinics of North America, 25, 103-115. 8. Scott, R., Oman, K., Makic, M., Fink, R., Hulett, T., Braaten, J., et al. (2014). Reducing indwelling urinary catheter use in the Emergency Department: A successful quality-improvement initiative. Journal of Emergency Nursing, 40(3), 237-244.
*See additional information next page
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Figure 1. Foley Catheter Use from 2016 to 2018 at Carilion Roanoke Memorial Hospital.
Note: The Kruskal-Wallis test results (Chi-Square = 18.31, DF = 2, p=0.001) indicate that there is a statistically significant difference for Foley Count over the three years. The Dwass, Steel, Critchlow-Fligner (DSCF) multiple comparison post-hoc analysis indicates a statistically significant difference for Foley Count for 2016 compared to the counts in 2017 and 2018. However, there is no statistically significant difference in Foley Count comparing 2017 to 2018.
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Figure 2. Number of Hours a Catheter Dwelled in a Carilion Roanoke Memorial Hospital Patient from 2016-2018.
Note: Over these three years there was a statistically significant decrease (p=0.0003) every year in the hours that Foleys have been used.
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Article Review: Obstacles to end of life care in the emergency department Lydia Pope, RN, Nurse Resident - Emergency Department Editor’s Note: Ms. Pope wrote this paper as part of her Carilion Nurse Residency experience. Article Reviewed: Beckstrand, R. L., Corbett, E. M., Macintosh, J. L., Luthy, K. E., & Rasmussen, R. J. (2019). Emergency Nurses’ Department Design Recommendations for Improved End-of-Life Care. Journal of Emergency Nursing, 45(3), 286-294. doi:10.1016/j.jen.2018.05.014 Emergency Department (ED) nurses are required to provide end of-life-care in what is commonly thought to be a busy and impersonable environment. In 2013 alone, it is estimated that over 130 million patients died in EDs across the U.S. (Beckstrand et al., 2019). The sheer number of deaths occurring in EDs requires reflection concerning the nature and quality of these experiences. Beckstrand, et al. (2019) surveyed 158 U.S. ED nurses who had taken care of at least one dying patient to identify variables that impeded or assisted an ED nurse’s ability to provide end of life care. These nurses were asked to share their personal experiences regarding the care of these patients as well factors that negatively or positively impacted these events (Beckstrand et al., 2019). Through the shared experiences of ED nurses, Beckstrand et al. (2019) identified three major obstacles to providing end-of-life care to patients in the ED: 1. limited space to allow room for both staff and family members 2. limited privacy for the dying and their loved ones 3. lack of areas for appropriate body stowage after death.
The survey respondents noted that many ED rooms are extremely cramped, and nursing staff often “trip” over other staff members, medical equipment and family while attempting to care for dying patients, particularly in acute or code situations. Large resuscitation bays may be unavailable for palliative use, and even if empty, these rooms must be kept open for possible in-coming patients (Beckstrand et al., 2019). This flaw in department layout at some organizations has the potential to create a challenging environment to provide care efficiently and respectfully while simultaneously including the family should that be their wish. Family members may need to wait in nearby rooms or often must stand in the hall to observe critical moments or resuscitation attempt, and grieving family members may only be allowed to the bedside one at a time (Beckstrand et al., 2019). Further, curtained rooms and the loud nature of the ED may inhibit the privacy of the dying individual and their loved ones. Patients and their family members often must contend with noisy and sometimes intoxicated and distracting patients in adjacent rooms. Private information may be overheard by others in the department (particularly in curtained rooms), and even rooms near nurse’s stations may encroach upon patient privacy as laughter and conversation from staff may appear insensitive during end-of-life situations (Beckstrand et al., 2019). Further, many of the surveyed nurses stated that stowage of the deceased was also an issue when providing end-of-life care in the ED. Many EDs are not equipped with areas in which the deceased can be stowed prior to transport to the hospital’s morgue while necessary documentation and post-mortem care is completed, as rooms are needed to turn over for the next patient. Per the authors, this has led to improper stowage of bodies. One participant of the study recounted that at their facility, a body was once stored in an elevator which was thought to be disabled. The elevator, however, was not properly disabled and locked, and a family member discovered the body ascending and descending the elevator shaft (Beckstrand et al., 2019).
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Proper areas for bodies appear to be a pressing and disturbing issue for some EDs. In reflection, the study identified several major obstacles to end-of-life care; however, the authors did not include a plan to apply or utilize the collected information. A very small sample of nurses were surveyed, which limits interpretation for a broader population. Further, the article only briefly mentioned variables that positively impacted nursing care at the end-of-life, thus lacking a true solution. While surveys are a useful tool, satisfaction surveys of patient families could further reveal obstacles to end-life-care in the ED. The results of the article raise further questions regarding the end of life in the ED and prompt further research Having been a nurse for only a year, my personal experience providing end-of-life care in the ED is relatively limited. My exposure to such situations has largely been positive thanks to the excellence in practice of my fellow nurses, ED providers, and the indispensable work of our ED patient representatives. When comparing the determined obstacles of this study to what I have witnessed in Carilion’s ED, there is thankfully little overlap. At times, space can be a limiting factor when providing end-of-life care, and families (either by choice or due to necessity) may not be present at the bedside. This is remedied by good communication and frequent updates between providers and family, often facilitated by a patient representative dedicated to caring for the family. Maintaining patient privacy has at times been a challenge depending on where the patient has been roomed. Curtained rooms are less desirable in these situations (as expressed by the study participants), but there is a definite effort made to place these patients in rooms with doors when possible. Carilion’s ED also has access to a palliative room which provides patients and family members a more secluded and quiet area to receive care. The most significant obstacle to end-of-life care I have noted in Carilion’s ED is the pace of ED work. Due to the great diversity of patients treated in EDs, ED nurses (as well as other members of ED staff) must act as a jack of all trades in a fast-paced, ever-changing environment. However, ED staff may not have the specific end-of-life training or resources to function at the same caliber as units dedicated to hospice and palliative populations. In addition to caring for dying patients and their families, ED staff must continue to monitor, assess and treat a full patient load. Delicately balancing these patient assignments can be difficult and even emotionally distressing for both staff members and patients. The mitigation of this issue would be multifaceted and would require the input and expertise of all members of ED staff. Further education regarding end of life care could enhance the ED’s ability to care for these patients. Exploring partnerships between palliative and hospice units to assist the ED in caring for these patients may aid in relieving pressure on ED staff and promote optimal care of patients during the end of life. Surveying our staff would provide more insight to other possible obstacles to providing end-of-life care in our ED as well as means by which to overcome these obstacles.
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Article Review: Conflict in the surgical critical care unit Caroline Williams, RN, Nurse Resident - CRMH 6S ICU Editor’s Note: Ms. Williams wrote this paper as part of her Carilion Nurse Residency experience. Article Reviewed: Pecanac, K. & Schwarze, M. (2018). Conflict in the intensive care unit: Nursing advocacy and surgical agency. Nurs Ethics, 25 (1), 69-79. Doi:10.1177/0969733016638144 Intra-professional stress and frustration between nurses and surgeons is an unfortunate but stark reality for most in either profession. Heightened by the already present anxiety brought on by caring for critically ill patients, there is often conflict between surgeons and nurses regarding lifesaving interventions in surgical critical care units. The purpose of Pecanac & Schwarze’s (2018) study was to gain further understanding of the different perspectives between nurses and surgeons regarding care of surgical patients in the intensive care unit. Moreover, the researchers examined how those perspectives are formed, how differing perspectives contribute to intra-professional conflict, and what can be done to help improve an understanding of each profession’s responsibilities with the goal of reducing intra-professional distress. This qualitative study researched articles, books and professional documents to gain descriptions of nurses and surgeons’ responsibilities to patients. The study used discourse analysis (the study of language in the everyday sense of which most people use words) to gain an understanding of what “responsibility for patients” means to each profession broken down into “advocates” for nurses and “agents” for surgeons which were used to search the text. Eighteen sources were searched with the terms “patient advocacy” and “surgeon responsibility/agency” to gain an understanding of overall clinical responsibility for patients from both nursing and surgical views. After the analysis, the results were broken down into themes organized around professional perspectives. Themes from the nurse as advocate perspective included: responsibility to support autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as intermediary between the physician and the patient, and responsibility to support the well-being of the patient. Themes from the surgeon as agent perspective included: personal responsibility for the patient’s outcome, commitment to patient survival, and responsibility to prevent harm to the patient from surgery. These results show that while each profession meets the same goal of providing quality, safe care for the patient, nurses and surgeons have very different routes to lead them to the same goal. Moreover, the results demonstrate the potential for conflict between nurses and physicians in two primary areas: goals of treatment and relationship with the patient. Nurses’ primary goals for treatment encompass patient autonomy and well-being, whereas surgeon’s view focuses on personal responsibility for patient survival. These differences surface when a patient faces the need for a life sustaining treatment that the physician feels personally responsible for performing where the nurse may feel it simply prolongs death and thus ultimately prohibits the patient’s wishes or well-being. Additionally, surgeons may feel push back from nurses who advocate for the patient against burdensome treatments. The relationship with the patient is another source of conflict as each professional builds a very different relationship with the patient. Nurses feel as if they know their patients, their family and their desires usually starting with their postoperative experience. The nurse spends hours at the bedside engaging in conversation with the patient about their concerns, goals and needs. However, the patient relationship with the surgeon begins in the preoperative phase where the potential benefit to the patient’s life is discussed. Conflict arises between the physician and the nurse when it is felt that the goals have changed; however, the surgeon is respecting the patient’s wishes to proceed with prior plan of care. The results of this study bring forth a broader understanding of the root of surgeons’ practice and demonstrate the very significant difference in responsibility felt between surgeon duty and nursing advocacy. The results also bring to light the importance of having care management discussions where the goals of care are discussed from a multi-disciplinary standpoint. The moral distress experienced due to prolonging patient death is not an uncommon feeling or theme for a critical care nurse. It is important for nurses to feel like they are advocating for patients in the same way that it is important for surgeons to discuss their duty to the patient and how those goals may change throughout a patient’s hospital stay. I would recommend this article to colleagues as understanding the depth to which surgeons feel duty to a patient brings a greater respect for lifesaving measures in dire patient situations.
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Congratulations on your Graduation! 2019 Carilion Nursing Research Fellows Ellen Dalton Ward, MSN, RN, WCC CNRV Surgical Care Unit 2019 Carilion Nursing Research Fellow Title:
Impact of Influenza Vaccination on the Orthopedic Surgical Patient Mentor: Cindy Ward, DNP, RN-BC, CMSRN, ACNS-BC Unit Director: Rebecca Bishop, BSN, RN
Ellen Dalton-Ward
Jon Behnisch, BSN, RN & Lisa Girani, BSN, RN CRMH Emergency Department 2019 Carilion Nursing Research Fellows Title:
Preventing Unplanned Inpatient Upgrades Within 24 Hours of Admission from the Emergency Department Jon Behnisch
Mentor: Donna Bond, DNP, RN, CCNS, AE-C, CTTS Unit Directors: Raechelle Balthis, MSN, RN & Ashlie Ikenberry, MSN, RN
Lisa Girani
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Commitment! CRMH 11 West Nursing Staff Unit Director - Brooke Hickman Commitment to Patient Safety The CAPS team announced that the staff from 11 West submitted the most non-anonymous Near Misses/Unsafe Conditions (Great Catch!) through Safewatch for the month of July! The team from 11 West submitted 11 non-anonymous SafeWatch reports.That’s 11 opportunities to create a safer environment for our patients and care teams.11 West’s COMMITMENT to patient safety is shining through! Please continue placing SafeWatch reports through the portal or calling our 7-SAFE line.
Courage! Daniel Terrell, MSN, NP CCMOB Gastroenterology Practice Manager - Martha Devinney Recipient - Jonas Nurse Scholar The George Washington University School of Nursing was awarded a grant from Jonas Philanthropies, a leading national philanthropic funder of graduate nursing education, to tackle the nation’s most pressing health care issues through support of high-potential doctoral nursing scholars. GW Nursing usea the grant to improve the quality of health care by investing in nursing scholars, such as Daniel, whose research and clinical focus specifically address our nation’s most urgent needs. Daniel is a DNP student whose focus will be on the priority topic area of preventative health. He will be working to empower individuals within LGBTQ communities to communicate effectively with health care providers about their needs.
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Collaboration! Sylvia Atkins, BSN, RN Unit Director CRMH 6W CCDU CRMH received Chest Pain Center with Primary PCI Accreditation from the American College of Cardiology Under Sylvia’s leadership, the interdisciplinary CPC Committee collaborated to support numerous efforts promoting patient outcomes. The committee included representatives from Emergency Services, Cardiovascular Institute, Quest Imaging, Community Health and Outreach, HR Education and Organizational Development and community partners such as our local EMS agencies and the Compress and Shock Foundation. Hospitals that achieve this accreditation undergo a rigorous evaluation of the staff’s ability to evaluate, diagnose and treat patients who may be experiencing a heart attack. It was a true team effort, but congratulations go to Sylvia for heading up this successful initiative.
Curiosity! Ellen Dalton-Ward, MSN, RN Department of Orthopedics - ION 2019 Nursing Research Fellow - Changing Practice! Ellen Dalton-Ward was accepted as a 2019 Carilion Nursing Research Fellow. She completed the year long program, developing and disseminating her study, the Impact of Influenza Vaccination on the Orthopedic Surgical Patient. Ellen was concerned that patients were not receiving the influenza vaccine. She conducted a retrospective research study with mentor Dr. Cindy Ward. Ellen’s study clearly demonstrated that there were no differences in infection-mimicking outcomes (temperature, WBC) between patients who were and those who were not immunized and that readmissions were resulting from those who were not adequately immunized. Ellen presented this study to the Joint Council, and the council immediately decided to offer the vaccine to orthopedic patients. Congratulations to Ellen for questioning practice, conducting an exceptional research study and for impacting patient care.
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Curiosity! Monica Coles, DNP, RN-BC, ACNS-BC, CDP Clinical Nurse Specialist - Nursing Professional Practice Scholar in Creating Interprofessional Readiness for Complex Aging Adults (CIRCAA) Monica was selcted to be a Scholar in Creating Interprofessional Readiness for Complex Aging Adults by the Virginia Geriatric Education Center faculty and clinician development program. The program is 1 year in length.
Courage! Dan Freeman, MSN, NP Trauma Services - Director WVEMS Regional EMS Award Awarded the WVEMS Regional EMS Award for Nurse with Outstanding contributions to EMS. Regional winners have been nominated for Governor’s Awards to be announced later in the year.
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Practical Applications of Nursing Inquiry
Collaboration! Jennifer Bath, MSN, RN, AGCNS-BC, CEN, TCRN Clinical Nurse Specialist - Trauma Services TEACH Scholarship recipient Jenn is the recipient of the TEACH Sholarship of Teaching and Learning Award. The TEACH Scholarship of Teaching and Learning award recognizes outstanding achievements in research, scholarly activity, and creative accomplishments that focus on the effectiveness of teaching methods.
Courage & Compassion! Carilion Roanoke Memorial Hospital COVID-19 Units The Professional Recognition Council acknowledged Carilion’s COVID-19 units for their fearless and compassionate care of patients and the support of their peers who work on these units. Senior executive leadership participated in the ceremony. Thank you to our nurses and nursing assistants, the frontline heroes!
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June 2020 - October 2020 (& past presentations not noted prior to this edition) Ward, C. October 2019. Taking Shared Governance to the next level. NGB Professional Development Day, Centra Health, Lynchburg, VA Whitehead, P. October 10, 2019. CNS impact on research, evidence-based practice, performance improvement/quality improvement. National Association of Clinical Specialists (NACNS) Continuing Education Webinars. Archived at https://nacns.org/professional-resources/education/ archived-webinars/ Whitehead, P., Klaess, C. February 21,2019. Exploring pain and opioid conversions. National Association of Clinical Specialists (NACNS) Continuing Education Webinars. Archived at https://nacns.org/professional-resources/education/ archived-webinars/ Lucas, A. May 18, 2020. Bladder management: Where does the CNS fit in management of patients with urinary retention? National Association of Clinical Specialists (NACNS) Continuing Education Webinars. Archived at https://nacns.org/ professional-resources/education/archivedwebinars/ Alderman, A. August 26, 2020. A tale of two vascular access algorithms. Association for Vascular Access Webinar Jones, B. September 9, 2020. Enhancing patient experience during COVID-19. Health Connect Partners Hospital O.R. & Surgical Fall Virtual Conference. Lebanon, TN
Jennings, C. October 20, 2020. Engaging Nurses in Quality Efforts. American College of Cardiology’s Quality Summit 2020, Virtual. Ward, C., Mitchell, T. October 22-25, 2020. Nursing burnout with substance using inpatients: A new hope. 29th Academy of Med/Surg Nurses Annual Convention, Las Vegas, NV (Virtual)
Carver, M., Jones, N., Djuric, D., Butt, C., Markham, C., Brookman, J., Reece, C., Smith, Jamie. April 15-18, 2020. Improving care transitions through risk reduction with machine learning support. American Academy of Ambulatory Care Nursing (AAACN) 45th Annual Conference, Chicago, IL. *Accepted to present, conference was cancelled due to COVID-19. McCormick, J., Smith, L. June 24-26, 2020. Operating room orientation: Bridging the gap from classroom to OR with simulation. International Nursing Association for Clinical Simulation and Learning (INASCL) - Virtual Mccormick, J., Kline, K., Kazemi, A., Saccocci, M., Moses, C., Bond, B. June 24-26, 2020. Keeping staff cool during MH crisis and OR orientation: Bridging the gap from classroom to OR with simulation. International Nursing Association for Clinical Simulation and Learning (INASCL) - Virtual
Whitehead, P. May/June 2019. Pain management pillars for the clinical nurse specialist: Summary of a national association of clinical nurse specialists opioid pain management task force. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. 33(3), 136-145. https://doi.org/10.1097/ NUR.0000000000000449 Alhaider, A., Davenport, P., Morris, Melanie. September 2019. Command and control for managing patient flow. Proceedings of the International Symposium on Human Factors and Ergonomics in Health care, 8(1), 273-274. Alhaider, A., Davenport, P., Morris, Melanie. April 2020. Distributed situation awareness: A health-system approach to assessing and designing patient flow management. Ergonomics, 63(6), 682-709.
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Whitehead, P. August 2020. How can we ethically care for our patients pain? Virginia Nurses Today, 28(3),16. Whitehead, P. Sept/Oct 2020. The story behind Florence Nightingale: Visionary for the role of clinical nurse specialist. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 34(5), 191-193. https://doi.org/10.1097/ NUR.0000000000000548
Linkous, H. June 2020. Television Ad Highlights Nurse Practitioners. Nurse practitioners are highlighted in this TV ad for stepping up during the Covid-19 pandemic. Carilion’s own, Heather Linkous, NP, a palliative and supportive care provider is highlighted in the picture collage near the end of the commercial. Check out the ad using the link below:
https://www.aanp.org/news-feed/new-television-ad-highlightsnurse-practitioner-np-role-amid-covid-19-pandemic
Bond, D. September 2020. Received grant from the Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare at the Ohio State University College of Nursing. The grant will support Donna’s study titled Respiratory Rate Assessment Grounded in Evidence –based Practice and her work to promote best practices at the frontline of care for respiratory rate assessment.
Practical Applications of Nursing Inquiry
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Within REACH
“The World is a book, and those who do not travel read only a page.” – Saint Augustine United Kingdom
Nottingham
Natl. Harbor, MD Williamsburg
Palm
Anaheim
Greenville
Lake Buena Vista
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Practical Applications of Nursing Inquiry
CLASSES & EVENTS FOR THE REST OF 2020
Carilion Nursing Research 2020 Virtual Poster Fair!
Open for viewing - December 7, 2020 – February 1, 2021 For more information, go to: Inside Carilion/Departments & Services/Nursing Research & Evidence Based Practice/under Highlights/ click 2020 Carilion Nursing Research Virtual Poster Fair ***************************************
Advanced Research II: Methods & Stats NR-CE373L November 19, 2020 - 8am-11am - VIRTUAL CLASS Register in Cornerstone! *************************************** Basic Research for the Healthcare Professional NR-CE333L December 3, 2020 - 1pm-5pm - VIRTUAL CLASS Register in Cornerstone! VNA Continuing Education Credit received! ****************************************
Follow us on our Nursing Research & EBP hub at Inside Carilion for updated information about: • • • •
Nursing Research Classes for 2021! Nursing Research Fellowship for 2022! Virtual presentations from your peers! Copies of our Within REACH publication!
Login to Inside Carilion/Departments & Services/Nursing Research & Evidence Based Practice/Highlights
Need editorial support to publish your work? Contact Nursing Research & EBP for: • Assistance with writing your abstract • Peer review • Manuscript submission nursingresearch@carilionclinic.org
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