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TL5 - Nurse Leaders Lead Effectively Through Change

 

Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully guide nurses through unplanned change.

AND

Provide one example, with supporting evidence, of the strategies used by nurse leaders to successfully guide nurses through planned change.

 

Example One: Unplanned Change

The Birthing Center census rose 38% in the last six months of 2013 compared with 2012. Some of this resulted from the closing of nearby Geneva General Hospital's Obstetrical (OB) unit; some was due to the addition of three new providers to the Canandaigua Medical Group's Obstetrics and Gynecology group. Projections for 1st Q 2014 were 25% above 1st Q 2013. Unexpected nurse turnover at the end of 2013 complicated the staffing situation.

The surge in census resulted in more shifts where staff were so busy providing patient care that ancillary tasks suffered.  It became a common occurrence for fetal monitors to be missing cables, rooms not to be fully stocked after discharge, or supplies not to be replenished in the nursery. The need to interrupt work flow to correct these issues added more stress to an already challenging work process.

In alignment with the nursing strategic goal to "Excel in the delivery of health care" the Birthing Center staff, Director, and the CNO identified the need to re-engineer the process for establishing core staffing, based on patient census and procedures performed such as outpatient testing, labor induction, and scheduled cesarean deliveries. The nurses were asked to review the processes of patient flow, and identify areas which required a change in staffing. Once the staffing needs were identified, the nurses needed to devise strategies to improve work flow to manage the census.

Strategies:

  • Trended data was collected on outpatient visits, inductions, and elective c/sections. The data collection allowed the Director to advocate for an additional RN on Monday, Thursday, and Friday. That additional 0.9 Full Time Equivalents (FTE) for the day shift was created by combining existing part time FTEs
  • Director was relieved of oversight of 2 West medical surgical unit, to focus exclusively on OB, providing clinical as well as administrative support.
  • Charge Nurse position was changed from five 8-hour shifts to five 12-hour shifts, providing additional nursing support during the busy evening shift. This change was completely driven by requests from staff nurses, and supported by the trended data.
  • While new personnel were orienting, clinical nurses (RN's) were paid significant premium pay to work extra shifts.
  • Director worked with the OB provider office to get monthly electronic report of Estimated Delivery Dates for accurate delivery census projection.
  • Two 0.9 FTEs were approved to establish the base staffing for the night shift at four RNs, instead of the current level of three RNs. These positions were supported by trended data on the times of deliveries, and also the frequency of call-back time on the night shift. See Exhibit TTL5.1
  • Two 0.9 tech FTEs were approved to provide a second tech on the day shift Monday- Friday, and to cover night shifts as needed for vacation.
  • The RNs were charged with re-evaluating the role of the techs and determining tasks they could assume as unlicensed personnel that would free up the nurses to provide bedside care.

Exhibit TL5.1 -Presentation for additional staffing based on trended data

TL5.1a Night RN and tech requestJune3 2014.pdf

TL5.1b RN request.pdf

Exhibit TL5.2 Birthing Center Newsletters

TL5.2a Birthing Center News.pdf

TL5.2b Birthing Center NewsAug2014.pdf

TL5.2c Birthing Center NewsAug 24 2014.pdf

The two tech positions are filled and the techs have begun orientation.  The Director encouraged nurses to get creative in re-imagining the work flow.  The nurses identified several tasks that the techs will assume once they are fully in place.  They will enter all vital sign data and feedings and elimination in the electronic medical record for newborns.  They will perform and input all vital signs and intake and output on adult patients.  Twice weekly, one tech will be assigned to inventory each patient room, each delivery case cart, each fetal monitor cart, and the nursery.  They will ensure they are fully stocked and all outdated items are removed.

The Director is present on the unit providing clinical support as well as soliciting feedback from staff on the changes to the unit.  She is sending an electronic newsletter periodically to all staff, keeping them informed of the status of hiring and orientation.  The two RN positions have not yet been filled.  Feedback from the nurses indicated they were not comfortable adding a nurse without OB experience to the night shift.  Two qualified applicants are scheduled for interviews in September.

The Director identified that her presence on the unit was a calming as well as unifying influence and she has made the effort to be as available as possible.  The unit is one year into the new volume and patient flow has improved considerably.  The nurses have demonstrated a heightened ability to huddle and re-group when the census surges, re-assigning patient care after prioritizing the most critical tasks.  Indicative of the efficacy of these strategies is the maintenance of Tier I status on the Morehead Associate Satisfaction Survey.  The survey was run in the midst of these changes, prior to any new staff being oriented, yet the scores for the unit actually increased from the 2013 survey.

 

Example Two: Planned Change

 

FF Thompson Hospital is constantly evolving to meet the healthcare needs of the community. In April 2013, the decision was made by the Joint Executive Team (JET) to bring inpatient dialysis into the hospital. This was made possible by the affiliation of the University of Rochester to have this service at the Thompson site. The transformation began with abatement and construction in June, 2013 and the announcement and discussion regarding educational rollout to the nursing staff took place in July 2013 at Nursing Practice Council (Exhibit TL5.3).

Exhibit TL5.3 Nursing Practice Council minutes

TL5.3 July NPC Meeting Minutes.pdf

Excerpt from July Nursing Practice Council Meeting Minutes

 

While the updating of the soon-to-be new dialysis wing was taking place, Adrian Hordon, MSN, RN, Clinical Nurse Educator, partnered with Michelle Hunt, RN, Acute Clinical Nurse Manager of Fresenius (contracted dialysis provider), to create and present "Care of the Dialysis Patient" education. The education was uploaded to our intranet, and was a requirement for all clinical nursing staff that would have any care interaction with the patient receiving dialysis. Exhibit TL5.4 shows a screenshot of the education presented to the nursing staff built through a program called Articulate. A post test was created to identify areas of concern and promote competence. The results of the posttest are tracked through a program called Articulate, which provides an interactive learning experience while tracking completed quiz questions. These  completed educational components are then uploaded into the individuals Ultipro account and can be tracked from unit to unit.

Exhibit TL5.4a Screenshot of educational powerpoint

 

TL5.4b - Complete PowerPoint Educational Training

TL5.4b Dialysis Presentation.pdf

Elizabeth Alexander, MSN RN, CN-E,  Director of Medical Surgical Services, was involved in the strategic roll out and completion of the online training for the clinical nursing staff. Part of the strategy used by Elizabeth, was to use electronic communication processes to provide a blanket effect to all nurses involved. Multiple reminder emails were sent with the new process and changes taking place, along with who to contact if a dialysis patient was going to be treated on a specific unit (Exhibit TL5.5). This communication provided guidance to the nursing staff related to prioritization of completing the required education to provide safe and competent care to our newest patient population served. The Dialysis Unit just celebrated its one year anniversary, which provided 84 treatments, 34 of which were inpatients that would have had to been transferred out of their community setting.

Exhibit TL5.5 Communications to the clinical nurses, patient care technicians and unit secretaries

 

 

Elizabeth made sure to stay in communication with the nurses to identify any and all changes that took place during the initial phase of the dialysis unit's launch. The collaboration and guidance from leadership through this planned change helped create a seamless transition in the care of a new patient population.

 

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