Updated 9/24/05
Force 11: Nurses as Teachers
The role of the professional nurse requires a commitment to “life long learning” and a commitment to participate as a teacher – to patients, families, students and colleagues. Quality patient care and education are two of the Medical Center’s primary missions. Our nurses are key to achieving these goals. Historically, Vanderbilt nursing has been synonymous with education and teaching. More importantly, life long learning is viewed as a key strategy to our “Be the Best, Keep the Best” program.
(Source of Evidence 11.1)
The Process of Assessing, Planning, Organizing, Implementing, and Evaluating the Educational Needs of Nurses at all Levels of the Organization
The process of assessing, planning, organizing, implementing and evaluating the educational needs of nurses at every level of our organization is multidimensional. Because one of our primary missions is education, direct care nurses are involved in teaching and learning at every point of patient/family care across the continuum of care. Central to meeting nurses’ educational needs are our unit based Nurse Educators, our Nursing Continuing Education Committee, Clinical Learning Consultants, and our Director of Nursing Education and Development. Direct care nurse are the foundation of teaching provided at the bedside and in our various outpatient and procedural settings.
Meeting Nurses’ Educational Needs: PCC Nurse Educators
Assessing, planning, implementing and evaluating the educational needs of our diverse staff has evolved over the years. In the early 1990’s we had a Staff Development department with primary responsibility for nursing orientation, CPR training, mock codes, and preceptor development. Concurrently, we had about 25 Clinical Nurse Specialists (CNS’s) who partnered with our nurse managers to provide unit based orientation and education as well as teaching the hospital wide specialty courses, such as the arrhythmia and ventilator. With the implementation of managed care in the mid 1990’s, our CNS role transitioned into a CNS/Case Manager role. With that shift of responsibility, some of the overall education functions fell to our unit managers. While CNS/CM still focused on improving the skills and knowledge of others as it related to clinical matters, they were no longer responsible in the same way for the house wide education courses or for planning individual orientations for the staff at the unit level. At about this same time our former Staff Development department transformed into The Learning Center (TLC). The Learning Center broadened its focus to include the learning needs of a wide variety of medical center personnel. Educational principles were universally incorporated to further improve our nursing learning products. With the focused emphasis on collaborative teams and change, consultants in TLC partnered with nursing leadership to provide organizational development in new, creative ways. One focus was the development of nursing leaders through a “Facilitative Leadership” course. This effort began to transform how we planned agendas, conducted meetings, worked to resolve conflict, come to consensus and win/win agreements.
With the changing focus of the CNS role and our staff development department (now TLC), nurse managers looked for other ways to continue to support learning. Managers have been hiring assistant managers since the 1980s and utilize assistant managers to focus on staff nurse skills check offs, unit specific orientations, focused in-services, etc. Then in 2001 the formal role of Nurse Educator with a job description was created. Our Nurse Educators are responsible for evaluating the learning needs of our staff nurses in their respective areas, keeping staff current on “best practices”/evidence-based practice, and provide the educational experiences needed to maintain skills in the areas of practice for direct care nurses. Currently, we have 25 nursing educators who are clinically based in our PCC/specialty areas. [11.1, Book 10, Exhibit A: Nurse Educator Job Description]
While our educators have met together for some time, this group has begun meeting formally on a monthly, or more often, basis. Over the past year, Nurse Educators have brought increasing standardization to the process of assessing, planning, developing, implementing and evaluating our nurses’ learning needs. The Nurse Educators have developed a team charter for The Nurse Educators Council. This council will go before the next Nursing Bylaws Convention to be formally incorporated. The purpose of the Nurse Educator Council (NEC) is to provide staff education which will positively impact our patient care and provide a framework for decision-making and support for our Nurse Educators. Feedback between our educators and our direct care staff nurses occurs formally and informally since the educators are closely aligned with staff on their units. The NEC has six primary purposes:
• Contribute to clinical policy development and revision
• Development of educational standards for nursing orientation/development
• Preceptor orientation/development
• Standardization of clinical competencies
• Support evidenced based practice
• Refine the Nurse Educator role and job description
Further examples of some of our current work are provided in narratives which follow.
Meeting Nurses’ Educational Needs: The Nursing Continuing Education Committee
Membership of our Nursing Continuing Education Committee (NCEC) includes:
• Nurse Educators
• Clinical Learning Consultants
• Inpatient and outpatient direct care nurses
• Research nurses
• Faculty from Vanderbilt School of Nursing
• Representatives from community based organizations, when appropriate
Nursing education needs are assessed formally and informally through review of quality indicators, direct observation in clinical practice and through written evaluations at established educational programs. Data from these sources are used to design, develop and implement one to three day conferences which provide contact hours to participants. Our NCEC has presented over 100 formal continuing education programs representing over 600 contact hours. [11.1, Book 10, Exhibit B: Nsg. Contact Hours Report] Several recent programs include:
• January, 2005: “Building Workplace Relationships through Effective Communication” (6.3 contact hours) - attended by 115 nurses. This topic was chosen based on feedback from staff satisfaction surveys, the VPNPP and exit interviews.
• October, 2005: “Improving Patient Outcomes through Effective Communication.” (6.7 contact hours) 76 participants rated this program very good to excellent. This topic was chosen based on work with the Studer Group as part of our “Elevate” initiative.
• In addition to designing programs for our own nurses, the NCEC has worked collaboratively with specialty nurses such as regional perinatal nurse educators, other nurse leaders and clinical nurse specialists to develop programs which benefit nurses from across our region. Examples include the “Passport to Nurse Wellness” conference, “Concepts in Fetal Monitoring”, Clinical Management of the Transplant Patient” and “Health Promotion in Practice”.
Critical Care Education
The process for assessing, planning, organizing, implementing and evaluating the educational needs of nurses at all levels also takes a focused approach when appropriate. In assessing the needs of our adult critical care staff nurses, Leanna Miller, RN, MN, CCRN, CEN, PP, Nurse Educator for Trauma/Burn/LifeFlight, and other critical care nurse educators, saw a need for standardization in our critical care orientation and competency/skills verification. After a literature review of best practices, the committee recommended that VUMC critical care areas begin using AACN’s on-line Critical Care Course, “Essentials of Critical Care Orientation” (ECCO). Administrative support was readily obtained from our CNO, the PCC Administrative Directors and critical care manager. Fiscal support ($200 per nurse) was budgeted in all critical care areas for FY 2005-06. Our Critical Care Nurse Educators are meeting regularly to implement AACN’s ECCO program. Pre- and post-tests were developed to evaluate program effectiveness. As of November, 2005, 74 new graduate nurses from our critical care areas have completed the pre-test. Nurse Educators on the units review their scores and assign learning modules for further learning. As of November 2005, 4 of these nurses have completed their assigned learning modules.
Critical care nurse educators are currently developing didactic classes which will use case studies to highlight body systems. These classes will be used to supplement the ECCO program. Richard Benoit, RN, MSN, CCRN, SICU Critical Care Educator, has this to say about the ECCO program: “The ECCO Program has helped us as educators to highlight where we need to focus our education efforts and has provided great learning opportunities to our new critical care nurses.” [11.1, Book 10, Exhibit C: ECCO Meeting Minutes]
Nursing Leadership Education
In addition to investing in our direct care nurses, we have invested in our nursing leaders. We know that leadership is critical to the success of our mission and management/leadership skills require ongoing development. VUMC initiated a Manager Development Task Force (later renamed Leader Development Task Force) in May, 2002 as part of our Be the Best, Keep the Best initiative. The group goals include:
• creating a learning environment supporting excellence in practice
• enhancing the work environment for staff and leadership
• promote the professional development of staff and managers
To further support our leadership development, we partnered with the Advisory Board Company. The Advisory Board Company is a nation-wide group of chief nursing officers from nation wide hospital organizations and provides national, standardized educational resources. Our CNO, Ms Dubree, is a member of the Steering Committee of the Nursing Executive Committee of the Health Care Advisory Board. Nursing leaders across the medical center participated in the Advisory Board’s comprehensive 360 degree assessment. This 360 performance evaluation was essential, allowing our managers to receive anonymous and non-threatening performance feedback which included:
• understanding their personal strengths and areas for development related to leadership competencies
• gathering insight into personal “blind spots”
• revealing hidden strengths
• understanding competing priorities among different respondents in their 360 evaluation and learning techniques for re-aligning others expectations
From this feedback, each manager developed a self-directed plan to improve his/her performance. Specific formal learning sessions were developed and implemented which focus on our greatest learning opportunities. Since 2002 we have had 17 half or full day sessions which have included information on:
• managing costs
• recruitment and retention
• supervising staff
• creative leadership
• fundamentals of finance
• leading nurses through vision
• effective teamwork
[11.1, Book 10, Exhibit D: Nursing Leadership Advisory Board Meetings]
Initially, the Leadership Development Task Force focused on the nurse manager role. However, these sessions were so successful and popular that the focus has expanded to include a broader scope of leaders including assistant nurse managers, nurse educators, case managers and Learning Center consultants.
Our ongoing commitment is to present a well-rounded series of programs which support leadership and align with VUMC’s five pillar Elevate goals. Our educational programs have broadened from focusing on principles and strategies related to VUMC’s growth and finance pillar goals to include focusing on people, service and quality pillar goals.
Julie Foss, RN, MSN, Manager of MICU, 3RW, had this to say about our leader development programs, “The issues which have been addressed in the leadership series have been pertinent and timely for me as a manager. What has helped me the most has been introducing me to best practices, allowing me to apply those principles to my areas of practice.”
Meeting Nurses’ Educational Needs: Director of Nursing Education and Development
As in our narratives, much work and many individuals and teams have focused on meeting the diverse educational needs of our nurses. As a learning organization we have invested in supporting our nurses need for continuous learning through staff and leadership development and working collaboratively in teams such as the Nurse Educator Council and the NCEC. As part of our ongoing commitment, nursing leadership continues to standardize and support learning across the medical center. In April 2005, our Director of Nursing Education and Development, Debianne Peterman, Ph.D, MSN, RNC, began work.
Dr. Peterman has conducted a system-wide assessment of our learning needs which included:
• one-on-one interviews with direct care nurses, charge nurses, educators, assistant nurse managers and nurse managers.
• attending unit boards and staff meetings in VUH, VCH, TVC/VMG and PHV
• formal and informal hospital and clinic rounds
Utilizing this feedback, Dr. Peterman is creating a strategic plan for system-wide nursing education and development. Once the strategic plan is fully developed, our Director of Nursing Education and Development, working in concert with our nursing leadership/teams (TLC Clinical Learning Consultants, Nurse Educators, Managers, other Nurse leaders, the NCEC) will evaluate and implement it. Our learning continues and we continue to evolve toward our ever present goal of addressing nurses educational needs.
(Source of Evidence 11.2)
Facilitating the Transition of New Graduate Nurses
Entry into direct patient care as a new graduate can be challenging, if not downright frightening at times. At VUMC we have established programs to facilitate the transition for new graduate nurses. Several of these programs are described below.
The New Graduate Applicant Role
In 2001 the role of Graduate Nurse Applicant (GNA) was developed with the goal of employing new graduates into a transitional role while they are waiting to take the NCLEX exam. This program was started as a result of feedback from managers, new hires and graduate nurses and accomplished two things:
• Supported us to be more competitive with local hospitals, allowing us to hire more new graduates before passing NCLEX
• Segregated the new graduates into their own orientation with content based on their learning needs
• spread the new graduates orientation out over a longer period of time (vs. concentrated at the beginning of employment)
This staged learning gives our GNAs an opportunity to experience care delivery in their clinical work areas while they are learning. The content for our GNA orientation was developed through a collaborative effort with input from leadership and direct care nurses. GNA orientations are offered during peak hiring times for new graduates, winter and summer. Experienced nurses attend our regular monthly Nursing Orientation. [11.2, Book 10, Exhibit A: Graduate Nurse Applicant Orientation Schedule]
Feedback regarding our program has been positive; the graduate applicants are happy to get to the floor and begin developing skills which do not require a license. Once they have passed the N-CLEX, they are oriented to those functions that require an RN license.
In her own words, Mitzi Fudge, RN, MSN, Manager on the Obstetrics and Gynecology unit, has this to say about the GNA role, “I have hired approximately 10 graduate nurse applicants over the past 3 years. Most of these nurses still work on our unit. They have provided valuable feedback for our orientation process, helping us to revise our unit orientation process and make needed improvements. They have participated in focus groups related to our house-wide orientation, sharing their experience, both good and not so good. All in all, this program has made our orientation more efficient and customer friendly.”
Post-baccalaureate Nurse Residency Program
The Post-baccalaureate Nurse Residency Program is a national demonstration project and is a collaborative endeavor between University Health System Consortium (UHC) and the American Association of Colleges of Nursing. This effort was sparked by the disproportionately high turnover of nurses in the first two years of practice, reported in the literature to be 35%-60% nationally.
The study began in 2002 at six academic medical centers (alpha study sites) and is currently underway at 27 different sites across the country. As a gamma site for this study, VUMC enrolled 34 participants in the winter of 2004. These nurses represented ten universities and are working in our critical care and general care areas. A second cohort of 100 participants was enrolled the summer of 2005. The criteria for enrollment in this study includes being a graduate of an accredited generic baccalaureate or master’s degree program within the previous six months and have no prior nursing experience.
The objectives of the program include supporting the graduate nurse as they:
• Transition from advanced beginner nurse toward competent, professional nurse in the clinical environment
• Develop effective decision making skills related to clinical judgment and performance
• Provide clinical nursing leadership at the bedside
• Strengthen commitment to nursing as a professional career choice
• Formulate an individual development plan related to their new clinical role
• Link research based evidence to practice outcomes.
During the course of their study, participants attend monthly seminars which include didactic presentations, case scenarios with application, and guided group conversation.
Direct care nurses and nurse educators serve as facilitators of small group activities providing valuable, practical input to each discussion. [11.2, Book 10, Exhibit B: Resident Facilitator Job Description] Key themes throughout these sessions include critical thinking, patient safety, leadership at the bedside, communication, evidence-based practice, and professional development.
Our program is guided by an advisory board currently made up of Vanderbilt staff including, nurse educators, assistant nurse managers and managers and representatives from select local Schools of Nursing. Direct care nurse input is channeled through unit based educators and other VUH staff on the advisory board. Our plan for 2006 is to involve several Nurse Residency graduates in the advisory board.
Program evaluation includes review of turnover data of the participants and survey data the participants complete specified points over their first year of employment. This information is trended to measure nurses’ overall satisfaction in their role, satisfaction with extrinsic factors and perception of control over practice. Preliminary results from the alpha and beta test sites have shown a significant reduction in turnover rates among participants. Additionally, they report higher job satisfaction scores than other nurses surveyed. Statistically significant increases were noted in terms of competency, ability to organize, prioritize, provide safe care, ability to communicate and provide leadership.
Because this program is viewed as a success already, we have created a parallel residency program for nurses who do not meet study criteria of MSN or BSN. Thus, all new nurses coming to VUMC, whether they are AD, BSN or MSN, are enrolled in a Nurse Residency Program. Of the 144 new nurses who came to work at VUMC in summer of 2005, 100 were enrolled in the UHC/AACN Post Baccalaureate Nurse Residency Study and 44 were enrolled in Vanderbilt’s parallel program for AD nurses. [11.2, Book 10, Exhibit C: UHC/AACN Nurse Residency Flyers]
Transition into the Pediatric Critical Care Unit
From her own words, Trish Campbell, RN III, VCN Pediatric Critical Care Unit:
“The Pediatric Critical Care Unit (PCCU) has been involved in the VCH graduate nurse program for some time. I was lucky enough to be part of this program when I graduated from nursing school. It is designed to help new nurses get the feel for an ICU and to help them develop clinical skills and critical thinking. However, our turnover rate in the unit was still too high and we thought a revision of our new graduate nurse program could help improve our retention. I led this initiative with Erin Mayo, RN II, another direct care nurse from the PCCU. We were supported by Vicki Thompson, RN, MSN, Nurse Manager, Jackie Smith, RN, BSN, PCCU Nurse Educator, and Debbie Arnow, RN, MSN, CAN, BC, Director of Education and Professional Development for VCH.
Based on our research, conversations with nurse educators at another hospital and focus groups within the PCCU, we identified some potential areas for improvement. New graduates stated they learn best in an environment that is stable. While it was not possible to create a sense of stability with regard to patients whose conditions rapidly change, we decided to create stability for our new nurses by standardizing PCCU’s orientation process. To do this we decided that each week our orientation would focus on one body system. The new graduate will focus on that system even if that is not their patient’s primary health problem. By focusing on systems in an organized manner, preceptors found it helped all new PCCU nurses receive the same information necessary to provide patient care.
Based on our experience, we learned the importance of having well trained preceptors supporting our new graduates. Preceptors need tools to support new staff. Thus, we developed a guide book for our preceptors. Our guide includes specific teaching plans, resources available on the web, and strategies to deal with difficult situations such as the death of a child. We included pictures of cardiac defects, which is the most common diagnosis of our patients. The notebook is given to each preceptor. In addition, the PCCU created a 2 day PCCU preceptor workshop (see below for more details).”
Preceptor Program
Though our Preceptor program is not limited to new graduates, it is considered essential for providing new graduates a smooth entry into clinical practice. Our most recent preceptor program revision occurred in 2004. At that time our preceptor’s initial training was expanded from 2 to 6 hours. Preceptors and nurse educators also reviewed and revised our preceptor workshops which are now offered 3-4 times per year, serving 100-150 preceptors annually. Though most attendees are our direct care nurses, we have also had a number of other staff who are preceptors to a variety of other individuals attend as well.
Topics covered in our preceptor workshops include:
• Identifying and meeting the learning and socialization need of orientees
• traits of preceptors
• Benner’s novice to expert stages
• learning/teaching styles
• basic principles of adult learning
• strategies which promote critical thinking
• conflict resolution
• dealing with generational diversity
To foster continued growth as a preceptor, a monthly e-mail, “Preceptor News You Can Use”, is sent to those who have attended workshops. It includes links to articles, websites and other resources of interest to preceptors. [11.2, Book 10, Exhibit D: Sample of “Preceptor News You Can Use”]
Unit specific Preceptor Training is Being Planned
In addition to hospital wide Preceptor workshops, specific units, like the Pediatric Critical Care Unit, are working to strengthen their preceptors. The PCCU has created two - four hour workshops for PCCU preceptors. These sessions teach their preceptors how to use each section of their unit specific preceptor guide (mentioned in the narrative above).
Development of Ongoing Training for the Future
We are currently assessing what preceptor education will be needed going forward for our current preceptors. Utilizing a Critical Care Nurse preceptor need survey and focus groups; data from respondents will be extracted, shared, and used to develop a plan for ongoing preceptor education and development.
Additional Supportive Initiative
Between August 2003 and April 2004, the work of the Recruitment and the First year Committee (Be the Best, Keep the Best) contributed to the ongoing development of the preceptor workshops. Traits and characteristics of ideal preceptors were identified, the roles of specific groups of individuals in the orientation process were outlined, and generic templates were developed for units to use. This work was shared in Nursing Leadership Board and is currently being used in our preceptor training. In addition, our Recruitment and the First Year committee is developing an assessment template for evaluating unit-based orientation plans. Results of these unit-based assessments, coupled with unit turnover data, will help develop a plan to support units as they work to successfully bring new staff on-board. [11.2, Book 10, Exhibit E: RN Orientation Roadmap]
(Source of Evidence 11.3)
How Orientation and Continuing Education is Developed for Clinicians, Administrators, and other nursing-role specialties at all levels of the organization
Nurses throughout VUMC have opportunities to enhance their knowledge base and skill level whether they are entering new or expanded roles or continuing in practice. We provide examples of our manager orientation and development, as well as programs developed to meet the special educational needs of our nurse case managers and neonatal nurse practitioners.
Leadership Development: Manager Orientation Pathway
As described in Force 1, Source of Evidence 8, nursing leadership development is one of our recruitment and retention strategies, “Be the Best - Keep the Best” initiatives. One of the task forces is Leader Development. We recognized the critical relationship between our nurses and management staff and the concomitant impact on nurse satisfaction and retention. Among our existing nurse managers, we had a mixture of new and experienced managers. We saw a wide range of differences in how managers developed and maintained relationships with their staff. Thus, our goal was to support nurse leaders in becoming “nurse retainers” by giving them the essential skills and tools needed to develop their staff.
The initial analysis of our manager orientation showed wide variability in how our new managers were oriented to their roles. Thus, our initial work was to standardize our nurse manager orientation. Our first manager orientation pathway was developed through work by the Nurse Manager’s Council. Currently, this tool is used by managers, formally and informally, during their orientation. Betty Sue Minton, RN, MSN, Co-Chair for Leader Development Task Force, said this about the manager orientation pathway, “Our manager orientation pathway is a great tool that serves as a guide to new managers so that they don’t miss important information that may have come before they came into their management role. It really has been helpful in standardizing our orientation.” To underscore the success of this tool, the manager orientation tool is being adapted by managers for use with assistant managers and our Nurse Educators. [11.3, Book 10, Exhibit A: Pathway for Manager Orientation – Modified for Assistant Manager]
Nursing Case Manager Orientation
All new Nurse Case Managers (NCM) in VUH and VCH receive an individualized comprehensive 4 week orientation program, designed to meet broad team and role specific case management objectives. These objectives are clearly defined in our Case Management orientation manual. Each orientation program includes weekly meetings with the VUH or VCH Coordinator of Case Management Practices, daily “shadowing” of other NCM in their areas of specialty, computer classes, on-line and pen and paper learning tasks to accomplish with post tests or sign offs, and one-on-one meetings with 16-20 key stakeholders across VUMC and in the community. Case Management also has a comprehensive orientation checklist which is signed off as learning tasks are completed. Our orientation materials and program underwent an extensive upgrade in the fall of 2005. We are currently working on creating a Case Management Web site and most of our orientation materials will be available on-line.
Case Manager performance and competency are assessed using a 360 evaluation process at the end of their 6 month orientation period and yearly thereafter. Individual case manager and team functions are assessed by the Director of CM, the NCM, as well as their peers, staff nurses, physicians and managers with whom they work.
Continuing education/learning needs for NCM’s are met through brown bag presentations, Case Management Staff Meetings and Council, and the many clinical and other presentations offered throughout our Medical Center. “Brown Bags” bring together all members of our case management team on a periodic basis. Examples of past topics include:
• Stress Resilience
• Veritas (on-line event reporting system for occurrences)
• Using Your Personality Strengths to Improve Relationships
• The Elevate Quality Pillar Metrics: Connecting to the Real World
• Update on Case Management Emergency Preparedness Plan
• TennCare Update and Changes
• Understanding Medicare Part D
Weekly VCH Nurse Case Manager meetings include speakers that provide continuing education credit for the participants. Case Manager Staff Council, as established by the Nursing Bylaws, was established in 2004 to serve as a professional advisory body for the department leadership, providing support for orientation and continued professional development.
Revision of Orientation Plan for Neonatal Nurse Practitioners as role expands
Initially, our Neonatal Nurse Practitioner (NNP) role was created to assist with the management of chronically ill infants in our NICU. However, as Vanderbilt sought to meet the growing demands of our community, the NICU has expanded its services to provide coverage in other outlying hospital nurseries. This, coupled with the recent changes in the physician residency program work requirements, influenced VCH to expand the NICU NNP role to include attending all deliveries and transports as well as managing of our own NICU infants.
With the expansion of our NNP role we looked at expanding their orientation as well. The experience requirement for our NNP includes having worked 2-3 years as a RN in a level III nursery. Formerly, our NNP orientees learned transport processes, delivery room procedures, routine patient care and the basic hospital systems over a period of several weeks. However, many of the technical skills now required of our NNP, such as intubations and placement of unbilical artery catheters, are not within the RN job description and needed inclusion in NICU NNP skills check off.
Our NNP coordinator, Kelly Shirley, RN researched other orientation models and found that they were geared predominantly toward staff nurses or manager’s needs. Thus, our team developed an orientation that would meet the needs of our NICU NNP. Our more experienced NNPs assisted in the development of a manual of “what you need to know to get through the day”, which included treatment guidelines and the skills required. Kelly developed a self-education packet that contains all of our NICU protocols. These are mailed to a new NNP prior to beginning orientation; each new NNP is expected to be familiar with the self-education materials at the beginning of orientation.
To augment the learning experience of our NNPs, a preceptor program was developed. During their initial orientation, the NNP orientee and our NNP preceptor spend one to two months, depending on level of prior experience in each of three areas: 1. NICU caring for patients, 2. learning to lead on transports and 3. attending in the delivery room. After the orientation process, the NNP orientee selects an experienced NNP to serve as an ongoing mentor. [11.3, Book 10, Exhibit B: NNP Orientation]
Our revised orientation process has assisted with the transition of our new NNPs into their role. New NNPs are supported to develop the necessary skills to perform required tasks and the confidence necessary to be successful in their role. With the role of the NNP evolving, the orientation process will continue to evolve to ensure that our NNP are competent and confident to provide care in our NICU.
(Source of Evidence 11.4)
Description and Evidence of Mentoring Activities at all Levels of the Organization for both Clinical and Leadership Roles
Mentoring, formal and informal, is essential to the professional growth of our direct care nurses and those in leadership positions. The following examples describe a range of mentoring activities across our organization.
Mentoring to Ensure a Successful, Multidisciplinary Unit Board
Mentoring has been defined as an active and personal relationship where the mentor intentionally initiates development of another toward personal and professional goals. Mentoring is one of the critical qualities required of direct care nurses who advance to the RN 4, expert level, in our professional practice program. The VPNPP program defines the mentor as someone who is:
• a teacher-coach
• role model
• nurturing
• fosters independence and self-actualization
• provides feedback
Since the initiation of our VPNPP program four years ago we have seen a true culture change related to peer mentoring among direct care nurses, making this practice not only accepted, but also valued.
Example Focus on Unit Board
Elaine Atteberry, RN 4, MSN, Unit Board chair took the concept of mentoring to a new level, using it to promote a multidisciplinary unit board in the Department of Radiology.
Initially, Radiology’s Unit Board was comprised of nursing staff only, even though many of the issues in radiology involved more than nursing. Technologists, radiologists and other ancillary staff were needed to create effective solutions. Elaine used the process of mentoring to develop and implement the concept of a multidisciplinary unit board. She began by seeking out individuals with dynamic personalities who wanted to work toward change and improvement. By simply taking five minutes of a person’s time she would educate the team member on the concept of shared governance and how interdisciplinary participation could help improve their department. Elaine’s mentoring has proved successful and radiology now has a multidisciplinary unit board which handles issues that cross disciplines. One of the recommendations for change that was implemented was education using their IDXRAD email system.
Elaine has also used what she learned to develop and co-facilitate a Board Basics program, an educational program designed to provide basic information on how to start a unit/clinic board. This forum allows her to teach, coach and further mentor others on the principles of shared governance and how to implement them in their clinical areas. Elaine spoke at The Middle TN Magnetic Resonance Society meeting in June 2005 about developing a multidisciplinary board and will speak again in June 2006 at the American Radiological Nurses Association on Shared Governance: Past Concepts with Current Applications.
Elaine’s mentoring and Radiology’s multidisciplinary unit board has seen positive outcomes. Documentation has improved; educational opportunities have increased with a more global approach to education of the hospital staff related to equipment, procedures, and patient requirements. Nursing turnover is essentially nil, and staff are satisfied.
Formal Mentoring in the Pediatric Nurse Residency Program
The VCH Pediatric Nurse Residency Program (PNRP), as distinguished from the VUH Nurse Residency Program, was originally developed in July 2002 to improve VCH nurse recruitment and retention. Mentoring is foundation to our PNRP program. Thus, we began this focus by having a training class to introduce the concept of mentoring to the mentors and mentees in our 1st PNRP program. At our first PNRP we assigned each PNR a mentor with whom they met biweekly for lunch as well as other informal times. Each mentor had 2-3 mentees and met with their mentee throughout their program. In the spring 2005, we revised our curriculum. Now, our PNRP coordinators serve as mentors while the PNR’s are in their initial core classes. Doing this allowed greater standardization. Scheduled roundtables allow the PNR’s to discuss their questions and concerns with other nurse residents and their coordinator/mentors. Coordinators send letters of appreciation and encouragement to each PNR during the program. Once core classes are complete at the end of 10 weeks, a mentor from their home unit is assigned to each PNR. The mentor/mentee relationship is celebrated throughout the program with mentors attending their mentee’s program completion celebration and mentee’s giving an award for the mentor who made the biggest impact on the class.
Mentoring Through a Difficult Patient Situation
Death of a patient is never easy, however, for new nursing staff and students, supporting a patient and their family through the dying process and death can be very challenging. In dealing with death and other difficult situations, our more experienced direct care nurses serve as mentors for other nurses and students as they seek to develop skills needed to support families in this crisis. Two examples of nurses serving as mentors in difficult times are highlighted.
Margaret Hayes, RN, MSN works in our VUH Medical Intensive Care Unit. Recently, Margaret had the opportunity to mentor a new MICU nurse through a difficult patient care experience. The patient had coded and the family was upset and had even become abusive. While this new nurse had completed orientation, this was her first code and resultant death. Margaret noticed the new nurse was tearful and seemed at a loss to know what to do next. Margaret identified this as an opportunity to mentor her through this situation, so that she would be better equipped to manage similar situations in the future. She coached the nurse to identify two key components: (a) the families need to be supported and (b) the appropriate people to contact when a death occurs (Tennessee Donor Service, bereavement). Rather than taking over, Margaret coached the new nurse through each step so that she would learn and feel empowered to handle similar events in the future.
Connie Ford, RN, BSN, CPON, is currently manager of the Pediatric Hematology Oncology Clinic, and is frequently involved with families who are losing a child. We have new nurses as well as nursing students from area hospitals working in the inpatient and outpatient units. In her own words, Connie writes:
“We lose a child about every 2 weeks on the pediatric hematology/oncology service so it is very important to provide resources for our direct care nurses. Many times the nurses have cared for the children for several months to years, developing a close relationship with the child and family. We recognized a need to help new nurses and students develop skills to work with families and cope with death. We have a psychosocial team who rounds every Wednesday to discuss cases. The team has meetings for direct care nurses after the death of a child to support sharing and venting. This provides continued mentoring and problem solving. In addition, the senior nurses mentor younger nurses when patient die. Direct care nurses are involved in our annual “Time for Remembering” event, which is a memorial for all the children who had died during the year.
Mentoring Managers in Finance
In her own words:
“As the director of nursing finance, I (Anne Underhill, RN, MSN, CPA) have identified a need for further training, support, nurturing and structure in working with our nurse managers and their staff in regards to planning and monitoring budgets. To better meet these needs, I have made mentoring managers a priority. The mentoring provides structure with the creation of the bi-weekly summaries and monthly manager meetings to guide and direct managers in the appropriate direction. I also meet with managers individually using this as an opportunity to mentor and educate them about HPPD, staffing matrix and running their units more efficiently. The managers have learned to budget appropriately, flex staff as needed and use tools to provide data for our models of care and to benchmark with other institutions. This is an ongoing process whereby I meet with them every two weeks providing data and helping to develop their skills. Managers then take the knowledge and skills they learn in these sessions and share with the staff they serve in their areas. Feedback goes both ways as managers educate charge nurses, assistant managers and direct care nurses. In turn, these same staff provides critical feedback about fiscal matters from a very practical, front line point of view.”
(Source of Evidence 11.5)
Examples of Organizational Incentives which Promote the Nurse Teaching Role
We have numerous programs and policies in place which support the nurse’s role in patient education. For example, our clinical pathways, which provide the basic plan of care for patients with a specific diagnosis or procedure, clearly define the patient and family teaching to be completed prior to discharge. These teaching tools are available electronically through E-Docs to provide easy access at the time they are needed. Our Clinical Practice Guidelines also clearly defines teaching as one of the roles of the professional nurse. The strongest incentive, however, for patient and family teaching is our professional practice program (VPNPP).
VPNPP
Patient and family education is identified as a key function of our direct care nurse’s role regardless of whether they are functioning in an inpatient, outpatient or procedural setting. Job Descriptions for RN 1-4 are exhibited in Force 4. While all nurses are responsible for providing patient education, RN 3 and 4’s are expected to intentionally share their expertise with others/nurses as they function as role models, resources, coaches and mentors. This is an integral part of the criteria for advancement in the VPNPP program. Evaluations of the VPNPP indicate that nurses at the RN 3 and 4 levels not only teach their patients and families, but also develop teaching materials that can be used by all nurses in their patient care areas. The defined expectations in our RN 1-4 job descriptions and the accountability obtained from our performance evaluation system have successfully promoted the nurse teaching role.
Nursing Case Managers
In addition, teaching is incorporated into other RN job descriptions. The Nurse Case Manager (NCM) job descriptions include a key function which requires Case Managers to continuously improve the knowledge/skills of self and others. Specifically, NCMs are expected to read/review new information, analyze and apply to practice as well as develop skills though committee work and participation in professional activities. In fulfilling this responsibility our case managers have participated in teaching at various levels, giving internal and external presentations.
(Source of Evidence 11.6)
Staff Involvement as Faculty/Adjunct Faculty
VUMC serves as a clinical site for VUSN as well as other nursing schools in our community and the southeast. Nursing students represent programs offering associate, baccalaureate and master degrees in nursing and participate in clinical rotations in all areas of the Medical Center, experiencing all levels of nursing from direct care to administration. Nursing staff participate as clinical preceptors on the unit and/or provide lecturers in the classroom. The volume of VUSN students alone who complete clinical rotations at Vanderbilt indicates the degree of involvement of the nursing staff in clinical teaching. In the last academic year, VUSN clinical rotations included:
• 150 1st year (pre-specialty bridge year) students who worked on approximately 13 units in the Medical Center. Each student completed 750 clinical hours over 3 semesters.
• 105 2nd year (specialty focus) students who completed between 56 and 420 clinical hours during the semester. The clinical experiences during the 2nd year focus on advanced practice and typically use APNs as preceptors. [11.6, Book 10, Exhibit A: Specialty 2nd Year Student Clinical 2004-05]
Not only does VUMC provide numerous, innovative practicums to VUSN students, VUMC served students and their instructors from 10 separate schools over the southeast in spring of 2005, including Auburn University and the University of TN at Knoxville. These students worked across the medical center including VUH, VCH, Operative Services and PHV.
In addition to teaching through clinical experiences, many nurses at Vanderbilt teach in nursing programs throughout the middle Tennessee area. We provide several examples of these activities:
• Ann Simons, RN, MSN, CPON in the department of Pediatric Hematology Oncology lectures annually at Aquinas College and VUSON.
• Connie Ford, RN, BSN, CPON in the department of Pediatric Hematology Oncology lectures annually at Belmont College, Motlow College, and VUSON. Connie also lectures 1st year medical students in a Clinical Oncology class for Dr. Mike Freeman.
• Randee White, RN, MSN, Renal Case Manager and a national leader in the care of renal patients teaches a 3 hour class every spring at VUSON on venous access for hemodialysis. She has taught in the past on peritoneal dialysis as well. Randee participates in audio conferences as well. This past year the audio conference dealt with anemia in dialysis patients and was broadcast on 12 occasions. Randee has also written a chapter on Circulatory Access for the textbook, Contemporary Nephrology Nursing, which is to be published in early 2006; additionally, Randee has published an article in the Jan-Feb 2005 Nephrology Nursing Journal titled, “Functional Ability of Patients on Dialysis.” She has another journal article on vascular access due to be published in early 2006.
• Susan Moore, RN, MSN, Case Manager for BMT/HEM serves as a Clinical Instructor for Belmont University School of Nursing.
• Gail Herrmann, RN, MSN, Case Manager for BMT/HEM serves as a Clinical Instructor for Belmont University School of Nursing.
• Virginia Turner, RN, MSN, Case Manager for Palliative Care, has given several lectures to VUSON nursing students and has spoken at a conference sponsored by VUSON re: hospice care and communication with the dying patient and their families.
• Becky Keck, RN, MSN, Assistant Hospital Administrator, lectures annually at Belmont University on “Budget Planning”, Columbia State University on “Budget and Fiscal Planning” and VUSON on “Leadership in Professional Nursing” and “Emergency Preparedness.”
• Nancy Feistritzer, RN, MSN, Assistant Hospital Administrator (Perioperative Services) lectures annually at Lipscomb University. She teaches a “Leadership and Management Course” to MBA students.
Many of the members of the Nursing Administrative Board serve as adjunct facility at VUSN. As adjunct faculty members, many other nurse administrators lecture in the health systems and administration and management courses taught in the school of nursing. The director of nursing research holds a joint faculty position and is a member of the Doctoral Program Committee in the school of nursing and a member of the Graduate Faculty in the university. She teaches masters and bridge level classes to VUSON nursing students on evidence-based practice and classes at the doctoral level on the concept of pain. In addition, the director of nursing research is a member or chair of a number of doctoral student dissertation committees. The majority of Advanced Practice Nurses in the Medical Center (70%) hold adjunct faculty positions with either the school of nursing or medicine. [11.6, Book 10, Exhibit B: List of Adjunct Faculty at VUSN]
Other schools/areas that VUMC nurses serve as adjunct faculty and lecturers are provided in the table below:
|Austin-Peay State University |Motlow State Community College |
|Columbia State Community College |Nashville Community College |
|Cumberland University School of Nursing |Tennessee State University |
|David Lipscomb University |American Heart Association – Training Center Faculty |
|Middle Tennessee School of Anesthesia | |
(Source of Evidence 11.7)
Innovative and Creative Academic Practicum Experiences which are in Place
With the high demand for clinical experiences at Vanderbilt and the number of nurses who teach and precept students, it’s essential that innovative strategies for education be developed.
VUSN student and faculty involvement in VUMC
Here are a few examples of faculty and student involvement in projects at VUMC during this past academic year:
• Nursing students acted as research assistants with Dr. Mary Jo Gilmer (faculty) to gather data at Children’s Hospital for a pediatric palliative care program. That initiative has thus far generated 1 published paper, and 2 international presentations.
• Dr. Linda Norman, Professor of Nursing and Senior Associate Dean of VUSON led students who participated in the ACT II project, a national initiative focused on quality improvement, specifically multidisciplinary safety efforts in hospitals. There were five projects in the ACT II collaborative, a RWJ sponsored project, designed to improve various processes at VUMC. These were geared primarily toward advanced practice nurses and residents working collaboratively to improve patient care. Eleven nursing students and 5 residents were involved in these teams in our medical center. Work was completed in the Spring, 2005 and presented at the national meeting in Boston in June.
• Dr. Karen D’Apolito, Neonatal nurse practitioner program director, is Co-PI on a grant for substance abuse in pregnant women. These women are being cared for during pregnancy and will be delivered by the faculty nurse midwives at VUH. Karen also teamed up with Nancy Kraft, APRN, in the NICU, to help her with a Hi Flow O2 study.
• Dr. Joan King assisted the VUH Transplant service with their February 2005 symposium and will be assisting with another one later this year.
Practicums with Vanderbilt CNS/Case Manager II’s
VUSN has 2 Case Management courses which require 70 hours of clinical practicums. Each year VUMC case managers have the opportunity to work with some of these students in their clinical rotations. Several 2005 practicums included:
• Marsha Kedigh, RN, MSN, formerly Nurse Case Manager II for General Medicine, worked with Jeanne Jackson, VUSON NP student, during spring 2005. Jeanne had the opportunity to participate in learning the key functions for the VUH Case Manager, specifically managing the coordination of care across the continuum as well as working with our evidenced based practice pathways/order sets. Jeanne experienced first hand our nationally known collaborative case management model, understanding the unique responsibilities contributed by each discipline as well as the shared functions.
• Susan Moore, RN, MSN, CM II, BMT/HEM, and Gail Herrmann, RN, MSN, CM II, BMT/HEM CM had two Air Force Nurses who completed this practicum. In addition to managing patients across the care continuum, these students, Laurel and Sarah, worked with Gail and Susan to set up and implement an Excel spreadsheet to track quality data on home health and infusion companies used with their BMT and leukemia patients. This tracking of quality and patient satisfaction with continuum of care services we arrange for our Cancer patients is one of the requirements for being designated a National Cancer Institute. In addition, this data has been presented at one of BMT’s monthly QA meetings with the MD’s.
Practicums with Nursing Administrative Leaders
All members of our Nursing Administrative Board serve in VUSON adjunct faculty positions. Advanced practice nursing students have the opportunity to participate in a wide variety of innovative clinical practicums with our nursing leaders. Several examples from this past academic year:
• Nancy Feistritizer, RN, MSN , Assistant Hospital Director, Perioperative Services, had two MSN students precept with her. These students were involved in many of the projects Nancy oversees as well as were able to interact with a wide variety of physicians, staff and other hospital leaders. In addition, Nancy partnered with the Associate Director of Perioperative Quality to precept another MSN student for the summer practicum in Patient Safety. This student had the opportunity to work with Vanderbilt’s innovative Crew Resource Management in the VUH Operating Room.
• Karen Hughart, RN, MSN, Director of Systems Support Services and Nursing Informatics had Melissa Travis, RN, work with her in the Spring, 2005. Currently, Missy is a nurse in our Infection Control Dept. and was going to school full-time as well. Missy had the opportunity to combine an interest in nursing informatics with the need to address an infectious disease problem for her practicum project. Missy worked on a way to provide more timely information on patients with Vancomycin Resistant Enterococcus (VRE) so that non-clinical staff checking these patients in for clinic visits can make sure they are not placed in the same waiting room in the Pediatric Oncology Clinic as myelosuppressed patients without VRE. She did a pre-intervention survey, worked with staff in the clinic on details for the education, and worked with Infection Control and the StarPanel programming staff to craft changes to the StarPanel Alerts capability to better meet their needs. This innovative practicum proved to be an excellent way for Missy to learn how nursing informatics professionals interface between clinical users and technical development staff to develop and implement technology that addresses clinical needs.
• Ann Cross, RN, MSN Administrator for Psychiatric Hospital had the pleasure of working with a Psychiatric NP student who was interested in a leadership experience with a strong business focus. This student had the opportunity to lead a project related to our VITA Intensive Outpatient Program (IOP). We knew that our reimbursement was not covering our PHV costs, but we also believed a financial benefit might exist related to reduction of readmissions within 30 days among patients for whom we received a case rate. The student examined patient by patient the impact of the VITA Intensive Outpatient Program on readmissions and reimbursement. The student spent a month at PHV, attending the IOP so she would have a better understanding of the clinical issues. Following this, the she spent several hours with Ann to design the process to obtain and analyze the data. Through study of the data, PHV found very few of the patients being targeted for readmission reduction actually attended the program. While the findings were not what we had hoped, the student's input was very beneficial in making an unemotional decision, based on data, to close the IOP program on June 30, 2005.
Observational Program for students exploring Nursing as career
One of our “out of the box” practicums is providing observational experiences for students exploring nursing as a potential career. Providing nursing experiences to high school and post secondary students helps fulfill our academic mission and introduce nursing as a career early to high school students. From Jan 2005-March 31, 2005, the Medical Center provided 59 high school and college students some type of observational experience. Students had a wide variety of experiences in our VUH, VCH, the OR and TVC, being paired with nurses and other health care personnel, from two 8-hour shifts up to 12 weeks. Work continues as we seek to improve our program. Currently, we are drafting guiding principles, goals, and content for these observation experiences to improve our coordination, consistency and adherence to regulatory and privacy regulations. [11.7, Book 10, Exhibit A: High School OBS Experience]
Marilyn Dubree, RN, MSN, CNO, Becky Keck, RN, MSN Assistant Hospital Director, Betsy Bond, RN, BSN, Clinical Learning Consultant and other nurse leaders are working to formalize this program by creating a “Nurse Ambassador” position that would serve as an ambassador to high schools, colleges and others to coordinate appropriate observational experiences for students at the Medical Center. A budget proposal for this position was presented to Norman Urmy, then VUH CEO. The formal position has not yet been budgeted; however, the provision of observational experiences has continued to occur and we hope to formally actualize the role of Vanderbilt Nurse Ambassador.
Student nursing practicums, VUMC Nurse Externships, and VCH Nurse Residency Program: A personal story
Amanda Layne, RN direct care nurse in NICU, has personally experienced a wide variety of practicum based experiences at Vanderbilt. It was her experience with our NICU nurses that led Amanda to choose nursing as her profession and gave her the solid foundation she needed to begin her career as a Vanderbilt nurse. This is Amanda’s story…volunteer, nursing student, nursing extern, nurse resident and now NICU staff nurse…as told to Karen Robinson, RN, MSN.
Amanda grew up in Mobile, Alabama with the dream of being a nurse. The only problem…Amanda did not think she was “smart enough” to be a nurse. After all, everyone had told her, “If you want to be a nurse, you have to be good in math and science”…and, in Amanda’s estimation, she was only mediocre in math and science. When it came time for Amanda to choose a career path, she chose her other passion….music. Music brought Amanda to Belmont University in Nashville where she became a Music/Voice major. Amanda, however, could not let go of her first love to become a nurse and so in her sophomore year (1999), Amanda chose what seemed to her to be the next best thing: she became a volunteer in our NICU. Amanda loved holding the babies and after the first week extended her weekly time as a volunteer, describing it as the highlight of her week. As she held the babies she closely watched the NICU staff nurses. As she observed their practice, her desire to be a nurse intensified. Our NICU nurses began to anticipate and even look forward to Amanda’s visits and were glad to see her come each week. Relationships were formed between volunteer and nurses. And, the more Amanda sat and rocked the babies, the more she thought “I have to do this…I want to be a nurse too.” However, that nagging fear that she just wasn’t smart enough in math and science kept her from making the decision.
In the fall of 2000 Amanda decided to take a year off from Belmont to participate in a one year church music internship program. All during this experience her mind kept returning to nursing and her experiences in our NICU. Finally though, resigning herself to the belief that she could not be a nurse she decided she would become a Medical Social Worker. Returning to Belmont, Amanda began pursuing Social Work. Just as quickly as she could, Amanda also returned to her beloved NICU volunteer job… rocking and loving on babies as well as observing and talking with our staff nurses. It was one of those days when NICU nurses, Debbie Swint, RN, and Rochelle Driver, RN, asked her what she had missed the most while she was away. Without hesitation, Amanda said, “Being here in the NICU.” Amanda then shared her dream about becoming a nurse to which Debbie very simply asked, “If you want to be a nurse, why don’t you go to nursing school?” Amanda responded, “I’m scared I could not do it.” Without hesitation Debbie and Rochelle encouraged Amanda to pursue her passion saying she would never really know unless she tried. Amanda states “these nurses seemed to have more faith in me that I did.” Amanda pondered this for a week and finally decided to go for her dream. Amanda was accepted to Belmont’s Nursing School in January, 2002. Amanda shifted from volunteer to nursing student doing many of her experiences at VUMC. Over the course of her Belmont student nursing practicums Amanda had the opportunity to have a wide variety of practicums at Vanderbilt including caring for patients on 10N VUH Trauma, 8S VUH General Medicine, and 8A VCH General Pediatrics.
In January, 2004, Amanda, now a Belmont Senior, decided she would take advantage of another practicum, VUMC’s Nurse Externship. Amanda was hired as a NICU Nurse Extern. Our Nursing Externship program is offered to nursing students who have completed their first clinical rotation. Nurse Externs have a separate job description and essentially work as care partners. What makes this a unique experience are the practical learning opportunities with VUMC nurses and other members of the health care team. Amanda said the nurses/others in the NICU knew she was in school and they would pull her into clinical situations where she could observe and learn. Amanda says about her time as a Nurse Extern and the NICU nurses, “Everyone was so great at using those teachable moments. I learned so much, plus it built my confidence by giving me more experience.” [11.7, Book 10 , Exhibit B: Nurse Extern Job Description]
Amanda states “I appreciated the opportunity to work in a variety of clinical settings during my school practicums. But, none of those experiences took away my desire to work in the NICU.” It was during her senior year, Amanda heard of another practicum experience offered by VUMC…. the Nurse Residency Program. The Nurse Residency Program is offered to graduate nurses. There are 137 nurses who began the summer 2005 Nurse Residency Program (96 in the post baccalaureate residency and 41 in the AD program). There are 34 nurses in the winter cohort of the residency program. Their program is one year long and ends February 2006. In VCH, there are 50 nurses who began the summer Residency Program which began July 11, 2005. There were 25 in the winter program. The VCH residency program lasts 16-22 weeks depending on the area staff will be working. [11.7, Book 10, Exhibit C: Pediatric Nurse Residency Program]
Amanda was accepted into the Pediatric Nurse Residency Program. Amanda said about her experiences in the Nurse Residency Program, “The program was well organized and thorough. I got to hear many health care team members we work with in the NICU talk …the lactation consultant, child life, chaplains, etc. It gave me the big picture I needed. Doctors came, too, and talked about different diagnoses we treat, as well as the difference between interns, residents, fellows and attending physicians. They made learning fun using games and other interesting things. It was not at all boring going to classes in this program.” While a nurse resident, Amanda got to rotate through each area of the VCH for 2 weeks each. Of this, Amanda said, “My knowledge of nursing is so much richer because of the Nurse Residency Program. I feel so blessed to have been a part of this program.”
Amanda graduated from the Nurse Residency Program on Friday, June 24th, 2005. Her lifelong dream is a reality. Amanda is now a full fledged Vanderbilt NICU nurse. The Nurse Manager of NICU, Marlee Crankshaw, RN, MSN, had this to say about Amanda, “I am happy to have Amanda. She is bright, eager, enthusiastic, caring, and kind. She had all the qualities we want in a nurse. Plus, she knew she wanted to be a nurse and she wanted to be in our NICU.”
In addition to the Nurse Extern position that is available year round for nurses who have completed at least their first clinical rotation in nursing school, VUMC offers an 8 week Summer Extern Program. In summer of 2005, VUMC had 42 summer VUH and VCH externs. Summer externs also have a separate job description. VUMC had approximately the same number in the summer of 2004. Each of the eight week externship has three four hour learning events in which variety of topics are discussed.
We currently work with 25 schools to provide a learning environment for their students. These are in addition to VUSN. The programs include; 7 associate degree programs and 19 bachelor’s degree programs. [11.7, Book 10, Exhibit D: Schools of Nursing Affiliations]
(Source of Evidence 11.8)
Process of Assessing, Planning, Organizing, Implementing, and Evaluating the Educational Needs, Reflecting Concern for Cultural Differences and Language, of Patient Populations at all Levels of the Organization
Assessment of education, cultural and language needs of all patients begins at the point of entry into our Medical Center. While the documentation tools vary slightly among VUH, VCH, PHV and TVC/VMG, all assess the same basic information at the point of entry:
• patient’s ability to read, write
• primary language
• education level
• how they prefer instructions (written, spoken, demo, video/TV)
• learning challenges
A teaching record is initiated on admission within the first 8 hours of hospitalization. In addition, there are specific teaching records available to individualize education for certain disease processes or procedures. [11.8, Book 10, Exhibit A: VCH Admission/Discharge Tool]
Meeting patient language needs
When patients whose first language is not English come to VUMC for health care, there are many resources available to the nurse, patient and family. Interpreter Services has a staff of 4 to meet the needs of patients and families with limited English proficiency. Oral and document translation are available from Interpreter Services. Spanish is the most commonly requested language, but there are a wide variety of languages requested. Therefore, Vanderbilt also has 13 contract interpreters available. Contract interpretive services may be accessed via phone to Interpreter Services or via an established web site. In addition to these interpreter services, nurses in the Medical Center can use the Language Line which expands our interpretive service to cover 160 languages with 24/7 coverage.
Staffs have used other resources to address language needs. Babelfish translation allows our nurses to type in English and be translated to any of a dozen languages. Babelfish is used frequently in our Emergency Departments to type and then print discharge instructions for patients/family members going home from our ED. Since Spanish is our most frequently requested language for translation, Vanderbilt’s Human Resources department regularly offers a Spanish class to help nurses and caregivers speak the language and build rapport with Spanish-speaking patients. Our most recent class began Jan 31, 2006. Our goal this year is to develop a successful volunteer ambassadors program in interpreter services for VUH and VCH following the model of the advocacy ambassador serving to provide proactive advocacy and additional comfort to our patients/families with limited English proficiency (LEP).
Patient education delivery mechanisms
E-Docs, a searchable database which contains all patient education sheets developed at Vanderbilt, along with order forms for multi-page booklets. Below are examples of patient education documents that are translated into Spanish and available on E-Docs. The requests for translations come from individual nurses, nursing committees and other departments such as Nutrition Services who recognize a growing trend in their LEP patient population. Note that the list includes instructions in Spanish for asking for interpreter and translation, creating a true bridge between the languages.
• Instructions for requesting Interpreters for Limited English Proficient patients and Translations of Documents
• Wired Jaw Instructions
• Passive Smoke and Your Lungs
• High Calorie, High Protein Diet
[11.8, Book 1 ,Exhibit B: Website for E-docs Directory] ]
EZTV, the in-house television system, delivers on-demand educational videos, with telephone-controlled monitors at all non-ICU beds. Many of these videos are in Spanish and English. [11.8, Book 10, Exhibit C: Website for EZTV Educational Materials]
]
The new patient education software package Discharge 1 2 3, used in both the pediatric and adult Emergency Departments, provides a tool for staff to search and download evidence-based discharge instructions in English. Approximately 50% of the documents are available in Spanish as well. This system helps our nurses customize the documents to be consistent with Vanderbilt’s practices. This system has replaced hand written discharge instruction sheets and prescriptions in the ED. This improvement has resulted in a decrease in the number of pharmacies calling the ED due to illegible handwriting and has decreased the number of return visits because patients understand what they are to do when they go home. [11.8, Book 10, Exhibit D: After Care Instructions for Bronchiolitis-Peds in English & Spanish]
Identifying religious and cultural preferences
When patients are admitted to VUH, a nurse completes the following questions on the Admission History/Discharge Plan:
• Do you have religious, cultural or ethnic practices that we should consider while you are in the hospital?
• Religious preference?
• Should clergy be requested to visit you in the hospital?
• Pastoral Care Consult ordered?
Our nursing staff is oriented to religious and cultural resources during their initial orientation. This information is built into the core curriculum for our Nurse Residency program. In addition, the Religious and Cultural guidelines are available online for staff access. Our Pastoral Services representatives are also available via consult to assist staff in care of patients with religious and cultural needs. The Medical Center has access to the services of several Hispanic priests, Korean and Chinese-speaking pastors in the community. They readily respond to requests for clergy visits. The Office of Pastoral Care keeps a list of other volunteers in the community who make themselves available to our patients as needed.
Other work around issues of cultural diversity has been conducted. For example, a “Faith Based Guidelines Committee” developed guidelines for working with patients who are Jehovah’s Witness and others with special needs related to religious beliefs and medical treatment. This committee included Rev. Ray Nell Dyer (Pastoral Care) Brent Lemmonds RN, MS, Administrative Director in the ED, Mary Murray, MSW, VCH Social Worker and Pat Givens RN, MEd., Assistant Hospital Administrator VCH. As part of this work, Mary Murray gave an inservice on Understanding Issues of Jehovah Witnesses in June 2004.
2 Clinical examples from a VUH and VCH Case Manager
From the words of Cindy Fink, RN, Pulmonary Hypertension Case Manager as told to Karen Robinson, RN, MSN
Mrs. B from Bosnia was admitted to our service with class 4 heart failure and for induction to Flolan treatment. We encountered a number of language and cultural issues in the care of Mrs. B. First, Mrs. B’s only family were a 16 year old daughter and a 19 year old son, who both spoke English. To bridge the language barrier, our Pulmonary Hypertension team sought to enlist the help of the patient’s two children. The daughter was present and engaged with the care of her Mom, the son was not. Because the daughter was in school, we also enlisted a female volunteer from the community who was Bosnian by background and who spoke fluent English. Both helped translate during Mrs. B’s hospitalization, after discharge with the home health nurses and in our follow up clinic appointments.
While she was in the hospital we encountered ethnic dietary restrictions along with certain dietary restrictions needed for Mrs. B’s disease. Using our community volunteer, we educated the family about dietary restrictions based on her disease and then had the family to supplement Mrs. B’s nutrition by bringing some meals from home that met her own dietary restrictions and those needed for her condition.
When it came time to prepare for discharge, the case manager sought to educate Mrs. B., but also needed to educate a family member. The team felt some concern about the responsibility being placed on the young shoulders of Mrs. B’s 16 year old daughter and, therefore, hoped to engage the 19 year old son in learning as well. However, according to Bosnian culture females are responsible to care for the ill/elderly. The son was opposed to learning the care for his mother, feeling it was not “man’s work.”
Thus, the team educated the 16 year old daughter to help with the mixing and administration of the necessary home medications. With the help of the daughter, the community volunteer, patient instructions by the case manager and the home health nurse, Mrs. B has been able to learn to mix and administer her own medications. At last report Mrs. B was doing well at home supported by Flolan and the careful attention of her daughter, a community volunteer and her health care team.
From the words of Lorraine Patterson, RN, VCH Case Manager as told to Karen Robinson, RN, MSN
Lorraine and the staff of the Pediatric Intensive Care Unit had the opportunity to care for the child of a Chinese speaking couple who were in the USA on a visa. Their child was admitted to our VCH with Tetrology of Fallot. The child required surgical correction, complex discharge teaching and intense follow-up home care. We encountered language and cultural issues. The parents were highly educated (the Dad had his PhD); however, they spoke limited English.
While the child was in the hospital, our PICU team engaged the services of The Language Line to ensure the family clearly understood their child’s diagnosis, treatment and follow up care. In addition, we used one of our own HEM/ONC fellows who spoke fluent Chinese and English. The team noted that the child’s parents would not make any decisions about the child’s care, but always deferred to the grandmother who was in attendance as well. In China, those who are the eldest always guide decision-making. Our team was careful to include the grandmother along with the mother and father in all discussions and decisions.
In spite of our best efforts to communicate, however, the nursing staff began to interpret some of the family’s behavior as being “hostile”. Staff nurses requested the help of the PCCU Nursing Case Manager. Using the interpreters, Lorraine, our Nurse Case Manager (NCM), spent considerable time with the family and learned their behavior was not “hostile” as originally interpreted, but they were very fearful. The NCM developed a plan of care with the family and staff in the PICU to meet the parents’ need for understanding and reassurance. To ensure greater trust, build rapport, and support the continuity of care, the NCM asked the family which nurses they were most comfortable with delivering care to them and their child. Based on this, and in collaboration with the PICU charge nurse, 2 experienced nurses were assigned as primary nurse care givers to this child.
The NCM worked very closely with these two nurses, the family and the interpreters to give careful, step by step instructions so that the family could learn the care of the tracheostomy and the G-tube. The child’s Mom was very fearful at first and was convinced she could not learn to provide the care that was going to be required at home. But, with patient, clear, daily instructions, many supervised practice sessions, and return demonstrations the Mom did demonstrate that she learned the care and the child was safely discharged to the care of the Mom and family.
(Source of Evidence 11.9)
Examples of Specialty or Population-based Patient Education Initiatives conducted, Implemented, and Evaluated by Nurses
Patient education initiatives frequently are developed for populations with common learning needs. Examples have been selected that highlight initiatives that address simple and complex teaching needs.
Bringing Childbirth Education to the Clinic
Nurses in the obstetric (PGP) clinic, where many of the patients are insured by TennCare, identified a need for better access to childbirth and parenting education for this clinic population. Despite availability of childbirth education, many of these patients do not sign up for the scheduled classes because of the cost. If a woman does sign up, she often misses several classes. These absences may be related to the time commitment required or to the fact that she comes from a different background from the other participants. The nurses in the clinic, labor and delivery, postpartum and nursery have recognized a need for more education for this segment of our population prior to their arrival at the hospital for delivery. This project, which is in the early stages, is led by two direct care nurses from the clinic and a perinatal educator.
Two educational strategies were identified to better meet the needs of our PGP clinic patients. The first strategy is the use of videotapes to teach patients about newborn care and parenting. The team decided to play these videotapes in the waiting rooms to expose all patients to this material as they waited. Televisions and VCR’s were placed in the clinic. The second strategy is a class, held monthly, that includes an overview of labor and delivery, postpartum and baby care as well as a tour of the hospital. The content of the class is currently being developed through discussion and survey with staff from labor and delivery, postpartum and the clinic. This class will be provided at no charge to the patients. These classes will be held one afternoon each month and nurses in the clinic will urge their patients to attend one class before their delivery.
Using technology to improve discharge teaching for NICU parents
KidVid is an innovative video program created and launched in July 2005 by our technologically savvy NICU nurses. Using KidVid, NICU pre-discharge teaching moments and other special moments are captured on CD for review by patients and families after discharge. Marlee Crankshaw, RN, MSN NICU Manager, and Keith Massey, RN, NICU direct care nurse, are two of the primary originators of the KidVid concept. Marlee and Keith submitted a proposal and received a $10,000 grant to create KidVid. Keith is serving as the project manager for KidVid. The grant allows Keith to come in one day a week, to film teaching sessions and other special times. Keith adds background music to each CD as an extra special touch.
Our NICU serves hundreds of families each year who have stated they learn best from hands on experiences supplemented by a variety of visual/technological aids. Most of our families are knowledgeable about DVD’s, CDs and CD-ROMS. KidVid teachable moments include such tasks as bathing, feeding the premie and sessions with physical therapy. A bath for a baby on oxygen weighing less than 4 pounds can be challenging. Timing is critically important due to the premie’s rapidly falling body temperature. Knowing how to check the formula, use equipment properly and helping “pace” the baby, makes feeding more successful and less stressful for all. Being able to review not just what was said, but how it was done is helpful to families. KidVid also films special moments in the life of our NICU babies: Mom getting to hold her premie for the first time or a baby’s first visit with Santa Claus. In December, 2005 sixty eight KidVids were created as Santa visited each infant and parent in the NICU. Parents express delight and appreciation for these CD’s and teaching tools.
The Asthma Initiative
Our VCH asthma initiatives have grown from our early beginnings with a 1995 Institute of Health Care Improvement (IHI) Breakthrough series. One aspect of our asthma improvement project was a targeted effort to streamline inpatient and outpatient asthma education. Early data suggested the important relationship between education and positive outcomes. Thus, our focus concentrated on educating internal and external health care professionals, physicians and nurses and other members of the health care team as well as patients and families. The asthma initiatives in VCH are interdisciplinary and interdepartmental. Currently, the VCH Asthma Steering Committee consists of direct care nurses, nurse case managers, physicians from the ED, PCCU, general care units and Pulmonary service, respiratory therapists, pharmacists and a member from VCH quality department (PM&I).
Our collaborative asthma initiative has accomplished a wide variety of improvements since its inception, but education of providers as well as patients/families remains a dominant theme. Provider education includes:
• a yearly asthma week offered to our physician residents
• an asthma buddy program that pairs medical students to serve as mentors to high risk asthma patients in our pulmonary clinic
• a drug education card which provides a stepwise approach to pharmacological aids based on the NHLBI guidelines.
Nurses have worked collaboratively with RT, Pharmacists, and MD’s to develop each of the educational tools. Patient and family education has also been the product of collaborative efforts led by nursing. Asthma educational materials, created through this work, are used throughout our children’s hospital and in many clinics, extending even into our non-VCH medical community. Educational materials are available in color, paper copy/packets for newly diagnosed patients and for use in some of the outlying community clinics.
They are also available on-line through E-Docs, providing easier access within our system. On-line availability has helped in maintaining and using the most current version of our educational materials. Our tools are updated every other year, or as practice changes, to ensure the most current research is incorporated. Tools can be customized for specific patient needs, such as language; our asthma education materials are available in Spanish for our patients with limited English proficiency. [11.9, Book 10, Exhibit A: Sample Asthma Education Sheet]
While many factors influence the positive outcomes we have with our asthma population, we believe that our education program has impacted our LOS and readmissions to VCH by teaching proper use of relievers and thereby preventing re-admissions. Asthma readmissions to the hospital within 30 days have been consistently low for 6 years. Among hospitals participating in the Child Health Corporation of America (CHCA), VCH ranks among top hospital performers with respect to asthma readmissions within 30 days (0%), LOS (2.17 days) and use of relievers (100%). (The CHCA is a collaborative group of nationally recognized, free standing pediatric hospitals that compare data.)
[11.9, Book 10, Exhibit B: Graph Pediatric Re-admit Rates] is a graph of the pediatric readmit rates within 30 days by month.
Diabetes Self-management
The Vanderbilt Children’s Hospital offers our patients and families a comprehensive Diabetes Self-Management Education Program which is nationally recognized by the American Diabetes Association (ADA). Cindy Lybarger, RN, NP coordinates our diabetes team and oversees our program development and compliance with ADA education standards. Our program, which originally began in 1996, is conducted now by an interdisciplinary team which includes:
• nurse practitioners
• nurse educators
• pediatric endocrinologists,
• registered dieticians,
• child life specialists
• pediatric social workers.
The goal of our program is to promote initial survival skills for children/families facing a new diagnosis of diabetes as well as to provide ongoing education and support to children and families. The hope is that as the child reaches a greater level of understanding of the disease and tools available to manage diabetes, they will be able to care for themselves independently. Education begins as soon as possible following diagnosis. Nurse educators and nurse practitioners, working with VCH nursing staff, meet with families in whatever setting they are diagnosed: the emergency room, intensive care unit, hospital room, or clinic setting. The aim is to provide support and introduce the skills that must be mastered by the caregivers prior to going home. Upon discharge patients/families are placed on a diabetes education pathway. We communicate this plan for follow-up education prior to discharge. The one-on-one education pathway for new patients encompasses the following:
• Initial teaching visit with the nurse educator and physician
• Two visits at 1-2 weeks intervals with the NP and dietician
• One transition visit with the nurse educator, dietician and physician
• Four weeks after transition visit: a post-assessment visit to review and evaluate education with the nurse educator, dietician and physician.
• Routine follow-up then begins with the patient seeing the physician or nurse practitioner every three months.
Additional special teaching is provided for annual education updates, pre-pump decision making, pump teaching, and post pump evaluation. Nurse educators and nurse practitioners manage the telephone calls to guide patient’s decision making, to provide ongoing education and support, to provide assistance with sick day management and/or for insulin dose adjustments. Patients with frequent hospitalizations and those who are noncompliant are seen for additional education in the clinic.
In addition to our individual teaching sessions with children and families, the diabetes education team initiated group classes for new onset diabetes patients in November with improvements during 2005. Group classes have helped to promote a fun environment in which to learn, allows us to use a wider variety of teaching methods, addresses different learning styles and provides and avenue for children and families to meet others who are adapting well to life with diabetes. Many of our diabetes educators also work at diabetes camps and have seen the benefits of children getting to know others facing similar issues. They have observed children sometimes helping to teach other children new ways of doing things.
Our diabetes education classes were designed, and are taught weekly, by our nurse educators, dieticians, social worker and child life specialists. The content is standardized and the educators are cross trained to cover for each other when needed. The group classes are often discussed and evaluated for their effectiveness by the team in our weekly diabetes education team meetings. Our NP’s use screening criteria in an initial one-on-one session to determine which patients are most suitable for the group learning environment. Children/families with language or education barriers, special needs, age constraints (very young) or parents with scheduling issues are educated in individual sessions throughout the program. The majority of patients and their families, however, attend the two group classes. Families are encouraged to invite siblings, babysitters, friends, teachers and/or coaches. The program’s educational content includes:
• hypoglycemia management
• counting carbohydrates
• checking blood sugars
• insulin dosing and calculation
• preventing complications
• physical activity
• managing children with diabetes during illness
In total, most patients receive five or six individual and group teaching sessions following initial diagnosis. At the completion of the educational program within about four months from diagnosis, there is a post-assessment visit where the nurse educator, dietician and physician each see the child and family to formally evaluate the achievement of learning objectives. A standardized teaching checklist serves as the means to document education progress as well as the learning post assessment. [11.9, Book 10, Exhibit C: Pediatric Diabetic Teaching Tools]
Our Adult Diabetes Clinic has similar programs. They also work to meet the needs of patients and families.
Nurses work to prevent PHV re-admissions using education
Staff at the Psychiatric Hospital at Vanderbilt (PHV), Adult II program, implemented a relapse prevention program in April, 2005 to try to help stem higher than desired readmission rates of 7-16%. The project was initiated by Chris Robertson, RN, direct car PHV. Chris worked with 2 other staff nurses, Tom Rine, RN and Nicole Carter, RN, the Nurse Manager, Lori Harris, RN, along with several mental health specialists, the physician clinical director and the social worker. Some of the topics developed to be shared in group sessions offered 3 times per week included:
• Group meditations related to AA’s 12 steps, with primary focus on the first 3 steps
• Information regarding recognizing and dealing with depression
• Education on interactions of illicit drugs
• Medications used to treat various diagnoses
Patients are given handouts and encouraged to participate in the group as each subject is addressed. We continue to evaluate our program and are working to collect outcome data. Initial patient feedback and satisfaction has been positive. Readmission rate prior to this educational effort averaged 13% for a three month period. In the first two months of this program the readmission rate dropped to 4.5%.
Broad based outreach programs for underserved ethnic groups in the community
In addition to reaching out to patients with cultural and language needs on an individual basis, VUMC is committed to ongoing and meaningful involvement in grassroots coalitions which target ethnic minority and underserved populations. Some of these include:
• National Association for Advancement of Colored People-Health Committee
• National Black Leadership Initiative on Cancer
• Meharry Medical College East Nashville Breast Health Study Consortium
• Vanderbilt University-North Nashville Community Outreach Partnership Center Health Promotion committee
Tonya Micah, Manager of Vanderbilt Ingram Cancer Center (VICC) Minority Outreach Program works collaboratively with nurses at VUMC and throughout the community (Tennessee State University, Fisk University and Meharry Medical College) to assess educational needs of ethnic minorities, plan, organize and implement at least one major cancer educational intervention program targeting minority/underserved populations each year.
In July 2005, Vanderbilt Ingram Cancer Center hosted a health disparities workshop, “Delivering Healthcare to Your Community” that included clergy from minority-based churches and other community leaders. The goal of this program was to discuss health disparities issues and ideas on how VICC may outreach to this community via the church congregations. A follow-up program will be held which will assist clergy in the implementation of cancer educational programs amongst their congregations.
(Source of Evidence 11.10)
Examples of community Collaborative Educational Endeavors
Vanderbilt nurses partner with many community agencies to provide education to health care providers and the public. Examples are provided to illustrate some of our initiatives that provide education to our community.
EMS Night Out: Educating Fellow Emergency Service Providers
EMS Night Out is an educational event begun in 1997 to meet the educational needs of the local EMS community and EMS personnel within Life Flight’s referral area. EMS Night Out was started by two of our Life Flight staff nurses (at that time), Jeanne Yeatman, RN and Kevin High, RN. VUH Life Flight nurses continue to plan and implement these educational events, working collaboratively with many other departments and health care professionals. EMS Night Out consists of a two hour educational session that includes two lectures and offers continuing education credit to attendees. While this event initially was held on a bimonthly basis at the Vanderbilt School of Nursing, due to increasing popularity and community demand are now offered monthly in 2001. At that time the decision was made to hold events on site at our area EMS agencies. []
EMS Night Out is widely recognized and respected within the EMS and air medical transport community as a model for outreach education. VUMC’s EMS Night Out program is now nationally recognized and has served as the model for other EMS Night Out programs such as those developed in Charlotte, NC, Redding, CA, and Atlanta, GA. Articles regarding our program have appeared in periodicals such as the Journal of Emergency Nursing, Air Med, Journal of EMS and in local print/TV media. A “how to” session on EMS Night Out was presented at the 2002 Air Medical Transport Conference by J. Yeatman and K. High. [11.10, Book 10, Exhibit A: EMS Night out]
Screening the Public for Depression: A Collaborative Effort
The Middle Tennessee Mental Health Association approached The Psychiatric Hospital at Vanderbilt (PHV) in mid-2004 to help sponsor a community event focusing on depression. The event, entitled Go On And Live (GOAL), was offered free to the general public and was held at the Loews Vanderbilt Plaza Hotel. The goal of this event was to help break the stigma associated with depression, encourage people to seek professional mental health treatment and heighten awareness of at risk individuals. The PHV staff who participated in this collaborative effort included direct care nurses, nursing administrator, a nurse manager, and a social worker. Vanderbilt marketing department supported this event.
Delta Burke was the guest, a celebrity speaker who shared her moving, personal story of depression. This was followed by a discussion of treatment modalities by VUMC’s Dr. Ron Salomon. [11.10, Book 10, Exhibit B:GOAL flyer] Approximately 750 people attended this event. After the formal program PHV staff hosted free depression screening. Approximately 30 people remained for the screening and, of those, 1 person was actually admitted urgently to an inpatient psychiatric unit.
Educating the Public and Health Care Professionals about Eating Disorders
Eating disorders are illnesses with serious emotional and physical problems which can have life-threatening consequences. Because of the complexity of eating disorders, they cannot be treated in isolation and professional and community education about this disorder is critical. Vanderbilt’s comprehensive Eating Disorder Program was developed through the collaborative efforts of Susan Beightol, RN, MSN, CNS/Case Manager for Pediatric Medicine and Dr. Bermudez and other members of the interdisciplinary health care team.
Recently, The Vanderbilt Eating Disorders program joined forces with the Eating Disorders Coalition of Tennessee, a non-profit organization in an effort to obtain additional resources and support for eating disorders as well as to educate patients, families, professionals, and communities about eating disorders. Susan has been the point person to speak on Vanderbilt’s behalf on the medical complications and treatment of eating disorders. She presented information to a wide variety of audiences locally and beyond. Each educational opportunity was tailored to fit the audience. For instance, when Susan spoke to students at a grade school or high school level, prevention is spoken of in terms of promoting healthy development and the unrealistic expectations that society has placed on individuals rather than in terms of eating disorders. Group presentations have included:
• Nashville District Dietetic Association
• Williamson County faculty and staff inservice
• Battle Ground Academy Parents Association and Health Fair
• K-12 Educational Television program broadcast via Middle Tennessee State University (MTSU) Satellite Video Conference
• MTSU Faculty, Staff and Athletes, Greek Life and Nutrition Students
• Donelson YCMA
• Davidson County Metro School Nurses
• Let it Shine Gymnastics Club of Nashville
• Girl Force, Adolescent Outreach and Prevention Training program
• Image: Vanderbilt Undergraduate and Graduate Student Organization
• Nursing Grand Rounds, VCH
• National Eating Disorders Association in St. Charles, Il
Community Training in Basic Life Support
The Vanderbilt Resuscitation Program, composed of 2 RNs, a respiratory therapist and an administrative assistant, have been holding community Basic Life Support (BLS) courses three times a year for many years. These courses are designed for non-heath care groups and are open to University and Medical Center non-healthcare employees and the community at-large. Vanderbilt currently serves our community as one of the American Heart Association’s training agencies. Many nurses at VUMC serve as BLS Instructors. Over the past two years, approximately 22 nurses have helped to educate more than 550 community students in BLS. This year our Resuscitation Program will be expanding to include First Aid as well.
For each course offering, advertisements go out to targeted areas across the medical center, university campus and other locations throughout the community. Our courses are posted on our publicly available website as well. In the past couple of years we have trained a variety of individuals from all walks of like, including the Vanderbilt Naval ROTC, the Children’s Hospital Junior League Family Resource Center, and teenagers applying for Lifeguard positions at local pools. In November 2005 a community wide mass CPR training at the football stadium was held and 5 Vanderbilt nurses who are BLS Instructors assisted with this community educational program.
Stroke Prevention Education
As a JCAHO-credentialed primary stroke center, VUMC is actively involved in stroke prevention and education. Our involvement dates back to the late 1990’s when physicians who specialize in stroke care met with community leaders about how we could improve community education regarding strokes. This led to our involvement in a variety of community education events over the years. One such community volunteer educator is Vicki Stalmasek, RN, MSN, Neurosciences Case Manager. Vicki is an avid supporter of the American Stroke Association (ASA) and partners with them on a regular basis to promote stroke (and healthy heart) education. Vicki has presented 1-2 hours sessions to American General (AIG) leadership, a group of music industry executives, a number of different nursing homes in our area and others. Vicki also serves on the ASA’s Stroke Systems Care Task Force for the state of TN. Their purpose is to align systems of stroke care so area providers across the continuum are providing comprehensive, efficient, standardized according to research approach to stroke care.
In addition to Vicki’s strong involvement with stroke education and screening, many of our direct care nurses participate in our yearly stroke screenings available to all VUMC employees. Our last screening was in 2004 and our next will be in 2006. (The 2005 screening was not held as we were undergoing our JCAHO visit to obtain stroke certification.) [11.10, Book 10, Exhibit C: Stroke Community Education Flyer]
In addition, our doctors and nurses participate in educating outlying healthcare professionals through our annual Stroke Symposium. Our ninth symposium was November 11, 2005. About 10 direct care nurses attended this event; this also served to help meet our JCAHO stroke certification requirement for these nurses. (To maintain our JCAHO stroke certification, every direct care nurse in our neurosciences PCC is required to meet eight hours of continuing education per year.)
Women’s Health Education
Community education about heart healthy lifestyles takes a variety of forms. Two recent events included VUMC’s hosting the 6th annual Ann F. Eisenstein Symposium on April 11, 2005 and All About Women Convention Sept 30-Oct 1, 2005.
• This Eisenstein symposium consisted of 3 breakout sessions led by our physicians, a breakfast and a health screening. The breakout sessions were on heart disease, nutrition and our new hybrid OR. The screening included height, weight, body mass, glucose and cholesterol checks. VUMC nurses screened and helped to educate 150 nurses of the 400 who attended the symposium.
• Our 3rd annual All About Women Convention, was held at the Opryland Hotel and Convention Center and was attended by over 5000 women. Approximately 30 VUMC nurses participated in screening over 1000 women over the course of 2 days. Screening included BP, height, weight, bone density, flexibility, glucose, and cholesterol. After our screenings were completed 3 VUSON Nurse Practitioner students served as health advisors to discuss the women’s results and suggest next steps for health improvement.
Education of Insurance Companies re Stem Cell Transplants
Our Stem Cell Transplant Center is part of the Alliance Transplant Network, which is comprised of all nationwide stem cell transplant centers. Initially, many of the transplant protocols, which are considered the standard of care by the nation-wide transplant network, were being considered experimental by some of our local insurance companies that had contracts with VUMC to perform stem cell transplants. Also, when we opened our outpatient stem cell transplant unit, it was discovered that many of these same insurance contracts did not include care on an outpatient basis. This resulted in many of our transplant candidates being denied initially. Much of our transplant coordinators time was being spent appealing these denials.
During this appeal process the transplant coordinators found themselves teaching the insurance case managers about disease processes, the different transplant protocols and the rationale behind the transplants. They also began to see denials being overturned when our stem cell transplant physicians wrote letters and sent supporting articles to insurance company medical directors.
Our stem cell transplant team wanted to facilitate our patients moving through this approval process; in some cases we knew that we could actually improve patient outcomes by the timeliness of the approval and resulting procedure. In addition, we knew much valuable time was being spent trying to overturn insurance company denials. Thus, our team sought to provide education to some of these insurance company case managers through offering a stem cell transplant conference.
The following team convened to develop this conference: Janice Tracy, the administrative officer of the stem cell transplant team; Susan Moore and Gail Herrmann, nursing case managers from the hematology and stem cell transplant; Paulette Smith and Kris Atkinson, the stem cell transplant coordinators and Pam Williams, the Program Coordinator. This group got additional input from our stem cell physicians, Drs. Greer, Schuening, Jagasia, Kassim and Ruffner.
A two day conference was held and included, transplant principles, the disease processes and the transplant protocols including what was considered standard of care among the Alliance Network. A pharmaceutical representative helped to cover the costs of our conference. The stem cell transplant physicians acted as presenters.
Ten case managers from insurance companies attended the first conference. The first day of the conference focused on an overview of the stem cell transplant program and the importance of our program being part of the Alliance Network. The first day also included the stem cell transplant principles and disease processes as well as a tour of the inpatient stem cell unit, the outpatient unit and the bone marrow processing lab. The second day of the conference included the transplant protocols with emphasis on the nationally recognized alliance transplant network’s standards of care.
Feedback from the attendees was positive and over the next year our number of denials decreased. The following year, the insurance companies asked VUMC to provide another conference for other case managers who were not able to attend the first conference. The conference has become an annual event with the latest information regarding stem cell transplant being presented. This year, there have been a couple of supervisors that have expressed interest in attending as well as several medical directors.
Community Education: Cancer
Cancer patient education and community outreach activities are planned and implemented through Vanderbilt Ingram Cancer Center’s (VICC) Office of Patient and Community Education (OPACE) which has developed programming that now reaches more than 70,000 people each year. The goal of OPACE is to empower health care consumers to make informed decisions along the cancer care continuum through communication, education, and outreach initiatives.
VICC commits approximately $1.2 million to outreach/education which includes staffing and numerous program initiatives. The staff is comprised of the director, 3 oncology nurses, 3 outreach/education managers (including one focused specifically on minority outreach), a patient advocacy manager, a patient education coordinator, a webmaster and graphic designer.
Cancer Information Program
Established in 1997, the Cancer Information Program is designed to provide accurate and timely information, primarily by telephone, about cancer prevention, diagnosis and treatment services and clinical trials at VICC to consumers, health care professionals and others. Staffed by three full-time oncology nurses and two part-time assistants, the program receives approximately 3,000 inquiries per year. The program works closely with the regional office of the NCI’s Cancer Information Service to make appropriate referrals and avoid duplication of services.
Cancer Patient Education
Approximately $250,000 has been allocated to implement a comprehensive cancer patient education program targeted to cancer survivors and caregivers. Led by OPACE director, Anne Washburn, this initiative is based on the NCI Guidelines for establishing comprehensive education and includes:
• the development of a patient education committee comprised of nurses, doctors, social workers, support staff and cancer survivors
• implementation of patient focus groups to assess the educational/support needs
• the redesign of the Patient/Family Resource Center
• hiring a patient education resources coordinator
• development of patient handbooks
• implementation of cancer education programs focusing on issues patients face from time to diagnosis throughout their care and post-treatment.
Survivorship Programs
The VICC coordinates several cancer survivor programs each year in partnership with community agencies like the American Cancer Society, Gilda’s Club Nashville, The Susan G. Komen Foundation and The Leukemia and Lymphoma Society. Vanderbilt nurses are involved in most of these survivor programs. For example, Gina Turner, RN, MSN, Nurse Case Manager for Palliative Care has led Gilda’s Club for several years, ending in December, 2005. The Middle Tennessee Cancer Survivors Celebration, spearheaded by VICC, is a joint effort of all area hospitals, cancer centers and support agencies that reaches more than 500 survivors and their families each year. In June 2005, OPACE implemented “Living the Moment”, a cancer survivor conference that focused on a variety of topics of concern to cancer survivors, including fatigue, nutrition, care for the caregiver, financial concerns, use of the Internet for survivors, and complementary therapies. This program was planned by a committee of VICC staff members (nurses, social workers, health educators), cancer survivors, and community collaborators from Gilda’s Club, American Cancer Society, Leukemia and Lymphoma Society. Evaluations stated that survivors/caregivers would like additional programming on these survivorship topics.
The Childhood Cancer Conference, with programs for parents and children, is a collaboration of the VICC, the Leukemia and Lymphoma Society (LLS) and Gilda’s Club Nashville. In the past, VICC has co-hosted an LLS Keys to Survivorship educational program for parents and offered a simultaneous Gilda’s “Noogiefest” Celebration for the children. The VICC continues to provide staffing for the American Cancer Society’s Camp Horizon for children with cancer and their siblings and Easter Seal’s Camp Bluebird for adult cancer survivors.
The following table highlights other examples of community collaborative education endeavors which VUMC nurses are involved with.
|Collaborative Education Endeavors |
|4-H groups |
|American Cancer Society Smoking Cessation Volunteer |
|American Heart Association Regional Faculty |
|American Heart Association Speaker’s Bureau; Instructor Trainer; Training Center Manager |
|Belmont University Physical Therapy School – tobacco prevention and cessation |
|Boy Scouts and Girl Scouts – First Aid and Safety courses |
|Career Day presentations on the profession of nursing – elementary, middle, and high schools |
|Children’s Hope International – speaker for parents who are adopting children |
|Church presentations on health related issues |
|Co-facilitated workshop for Hospital Hospitality House |
|College presentation on Experiencing culture in nursing |
|Community First Aid and CPR classes |
|CPR – American Hear Association, Fire Department |
|Developed content for community diabetes education program |
|Elementary school presentation on Hand washing importance |
|Grand Rounds for the psychiatry department – addiction of nicotine |
|Guest Lecturer Lipscomb University MBA program |
|Guest lecturer Vanderbilt Fraternities on Alcohol awareness |
|Health Fairs |
|Helped teach the Arrhythmia class and heart and lung sounds for the Critical Care Program Critical Care Course – Center for |
|Lifelong Learning Vanderbilt University School of Nursing |
|Lectures at other hospitals: |
|Middle Tennessee Medical Center |
|Southern Hills |
|St. Thomas |
|Outlying hospitals in rural Mississippi and Arkansas |
|Bedford County Hospital |
|Nursing Explorers speakers |
|Peabody College – Aging lectures and smoking/tobacco lectures |
|Presentation at Holistic Nursing Seminar |
|Presentation Heart Disease risk factors for African Americans |
|Robertson County Health Council |
|School presentation – First Responder program; cardiology educational seminar and health clinic for Grassland Middle School |
|Senior exposition – Nashville – healthy aging presentation |
|Speaker with visiting hospital groups on collaborative approach used to build Children’s hospital: |
|Johns Hopkins |
|Boston Children’s |
|University of Chicago |
|Summer Students at Meharry Medical Center – Tobacco use and cessation |
|Taught g-tube care to employees at Merci Home |
|Tennessee State University – graduate level psychology class – tobacco use and cessation |
|Vanderbilt University School of Medicine – smoking and tobacco use |
|YMCA lecturer |
|Home Health Workshop – participated as experts at skills check off stations |
|Strategic Institute for Continuing Healthcare Education - lectures |
|Meharry Medical College – co-taught classes on quality of life and symptom management to the medical fellows |
|Emphasis Mentor – mentor a VUMC medical student project in the community |
(Source of Evidence 11.11)
Evidence of Broad Participation in Professional Development Programs Designed to Develop, Refine, and Enhance Teaching of Expertise
Vanderbilt has a wide variety of programs that enhance nurses teaching skills. Our preceptor program is a good example of a broad-based program that cuts across many areas of the Medical Center. We provide examples of some of the broader educational opportunities that have been developed and attended by many of our nurses. Some of these are discussed briefly or in detail in Forces 1-11. Finally, we highlight a comprehensive program that is educating our nurses and other health care providers about the special needs of the elderly.
Partial summary showing broad participation in professional development programs
There are a wide variety of programs designed to develop, refine and enhance the expertise of our nurses. A comprehensive list of programs and attendees would require volumes. The information below is shared to provide a snapshot of the programs offered and participation of our nurses in the same.
|PROFESSIONAL DEVELOPMENT PROGRAM |WHO PARTICIPATED |WHERE PARTICIPATION IS DOCUMENTED IN SYSTEM |
|VUMC Annual requirements: Universal Safety |ALL DIRECT CARE NURSES | Staff files, learning center records |
|courses, Blood and Body Fluid/patient contact, | | |
|Airborne precautions, point of care testing | | |
|[11.11, Book 10, Exhibit A: VUMC Annual Staff | | |
|Requirements 2005] | | |
|Mock codes, defibrillation and advanced airway |ALL ICU AND STEPDOWN DIRECT CARE NURSES |Staff files, learning center records |
|On-line training modules: there are over 100 |Some modules, such as restraints were required |Participation for each module may be obtained |
|listed that have been posted for staff to read |for all staff; others were focused on a smaller|by each administrator, director, manager, etc |
|and sign off |cohort of staff. |for their staff. Reports are available at a |
| | |summary level for each of the 100 reports. One|
| | |example is attached for the module “Admission |
| | |History Updates and Falls Prevention” [11.11, |
| | |Book 10, Exhibit B: Example Assigned Module |
| | |Summary Report] |
| | | |
|Over 2005 our Learning Center has provided 283 |There were a total of 4,995 participants in 283|Report Exhibited as Exhibit B in 11.1 |
|courses for which contact hours were awarded. |programs. (Note: the totals represent all, not| |
| |just nurses) | |
|At least 26 workshops were provided by |These 26 workshops were given on inpatient and |Attendance record listing number of nursing |
|professionals in our Employee Assistant Program|clinic areas to direct care nurses. |staff is attached. [11.11, Book 10, Exhibit C: |
|on subjects ranging from Stress Resilience, | |Workshops given by EAP for staff from July |
|Encountering Hostile Patients and Families, | |04-June 05] Note this attachment has other |
|NICU Grief, etc | |presentations listed as well. |
|Eloise Cathcart Conference: Nov 2, 2004. This |100 direct care nurses and leadership from |Roster Available |
|all day conference was designed to introduce |inpatient, outpatient, procedural areas, | |
|the nursing narrative, build a common |clinic, from VUH, VCH, TVC/VMG and PHV | |
|understanding of describing expertise in |attended | |
|nursing practice and engage clinical leaders | | |
|and staff in exploring applications of this | | |
|Diversity in Action Workshop |39 nurses (mostly leadership) attended from |Referenced on the 2005 TNA exhibit above |
| |VUH, VCH, Operative Services, Clinic/VMG. | |
|1 hour Presentation to Shared Governance user |11 participants | |
|Group on “Collaborative Problem Solving: 6 | | |
|thinking hats” | | |
|The Shared Governance User group has had many |Attendance ranged from 10-12 to as many as 40 |Minutes are available for each session that |
|educational sessions to develop expertise of |in each session |shows participants who attended. |
|our unit board leaders and other leaders on | | |
|titles such as “Evidenced Based Practice”, | | |
|“Knowing and Using Your Personality to improve | | |
|Communication”, “Nurse Wellness”, “Magnet | | |
|Awareness”. | | |
|Legal Issues (specific to Mental Health |19 Registered Nurses from PHV | |
|Subutex Use by Michael Baron, M.D. |10 RNs from PHV | |
|Changes in TN Care related to Mental Health by |8 RNs from Adult (population most affected) | |
|Michael Cull, RN | | |
|During Nurses Week 2005 we provided 20 |Almost 200 nurses attended these sessions |Attendance records available from Rachael |
|presentations in way of continuing education | |Hamilton for these. [Also, referenced on the |
|events [Exhibit: Nurses Week 2005 Educational | |2005 TNA exhibit above] |
|offerings} | | |
There are other examples we mentioned showing broad participation in professional development programs. Please refer back to these for other evidence provided:
In 11.1 we provided evidence of:
• The Nursing Continuing Education Committee’s programs
• Critical care education and nurses completing this program
• Nursing leadership education sessions
In 11.2 we provided evidence of:
• The Post Baccalaureate Nurse Residency Program
• Preceptor Program
Improving Care for Elders: A Coordinated Approach
Nurses Improving Care for Health Systems Elders (NICHE) is a nation-wide initiative aimed at improving nursing knowledge, attitudes and practice regarding geriatric care. The program was developed by New York University and the Education Development Center for Health Care Practice with funding from the John Hartford Foundation.
Vanderbilt’s adaptation of this program, V-NICHE, was borne out of the consultative services provided by two advanced practice nurses on our Geriatric Service. Sarah White, RN, GNP and Jamie Spicer, RN, GNP,, Nurse Practitioners on our inpatient Geriatric Service, noted recurring issues such as incontinence resulting from extended use of Foley catheters, delirium not diagnosed, reduced mobility and pressure ulcers because of restrictive orders related to bed rest and nutrition. Published research refers to these conditions as “common geriatric syndromes” and they have been determined to lead to an overall decline in function and health for hospitalized elderly patients. In addition, we knew that conditions like these, resulted in a less than optimal quality of care, extended length of stays, higher health care costs related to avoidable resource utilization and patient/family dissatisfaction. Furthermore, we knew the need was likely to continue since individuals age 65 and over represented 20% of Vanderbilt’s inpatient adult admissions, 25% of our inpatient days with an average length of stay one day greater than the adults aged18-64. Based on demographic trends we knew these statistics were likely to increase significantly over the next decade.
From these experiences and others, we believed there was a necessity to recognize the special needs of our elderly patients and establish them as a separate cohort within our adult hospital population. Furthermore, knowing the importance of the nurses’ role in recognizing and meeting these special needs, we recognized the need for intense nurse education about the special needs of our elder population. This desire fueled us to seek to develop a program that would improve the knowledge level of nurses across the medical center and embrace evidenced-based approaches to the nursing care of geriatric patients to minimize the negative effects of hospitalization.
Because our hospital based Skilled Nursing Facility is often the recipient of these elderly patients experiencing one or more of the common geriatric syndromes, Sarah White and Jamie Spicer, the nurse practitioner members on our inpatient Geriatric Service, partnered with Vickie Harris, NHA, MBA, our Subacute Unit Administrative Director to brainstorm about challenges of elderly patients in the hospital environment and how to respond to their special needs. As part of this work, the two practitioners conducted a two-week prevalence study in August, 2004 on three general medicine units that validated their observations. Simultaneously, research was completed to determine how other institutions were responding to the special needs of the hospitalized elderly. Various strategies and scenarios were developed and considered by the team of three, one of which was Vanderbilt’s participation in the John Hartford Foundation’s Geriatric Institute of Nursing NICHE initiative. The NICHE program was determined to offer the best fit and most comprehensive research based approach. This work has progressed at a steady pace since this first prevalence study. This is outlined below:
• In November, 2004 a proposal was developed and submitted to our CNO highlighting the observations of our two nurse practitioners, the results of our prevalence study with the supporting research along with an approval request to partner with the NICHE program offered through the Geriatric Institute of Nursing.
• In December, 2004 the CNO approved Vanderbilt’s participation in the national NICHE initiative, giving birth to V-NICHE.
• In January 2005 three Vanderbilt representatives (geriatric NP, VUSN faculty and hospital administrative director) attended an introductory NICHE Leadership conference at New York University.
• In February, 2005 a V-NICHE Steering Committee was established consisting of the following:
o Advanced Practice Geriatric Nurse Practitioners
o Inpatient Staff Nurses – General Medicine and Orthopedics
o Nurse Educator, General Medicine
o Inpatient Nurse Managers and Assistant Managers – General Medicine, MICU, Subacute and Surgery
o Faculty – School of Nursing
o Administrative Director – Subacute Care Unit
• In March and April, 2005 our steering committee meet to review the materials available in the NICHE toolkit, which consists of a self evaluation tool (the Geriatric Institutional Assessment Profile-GIAP), geriatric clinical protocols, educational materials such as an online tutorial for the ANCC gerontological nurse certification exam, and field-tested nursing care models. The group decided to begin with a broad assessment/comparison of our volumes and ALOS for patients age 65 and older compared to patients age 18 to 64. Ten inpatient units, 5 with high volume geriatric patients and 5 with a low geriatric patient volume were selected and surveyed in May 2005.
• In June, 2005 a presentation to our Nursing Leadership Board was held. This was followed by discussion and selection by the steering committee of 8 units to participate in our initial V-NICHE efforts. RNs, LPNs and Care Partners job classes were selected to take the GIAP.
• In August – September, 2005 GIAP unit coordinators were selected for each of the 8 units.
• In October – November, 2005 information sessions were held and the GIAP surveys were distributed to our RNs, LPNs and Care Partners on our 8 selected units.
• In December 2005 - Chief of Staff approved the designation of the 3RW, an inpatient non-teaching acute unit to be designated as an Acute Care for the Elderly (ACE) unit. ACE is one of the four nursing models of care developed in conjunction with and endorsed by the NICHE program.
• In January, 2005 GIAP surveys were sent to NY University for data analysis, preparation of aggregate reports and benchmarking of our data with our institutions.
• Next steps: When our results are returned the data and benchmarks will be shared with each of the 8 units, issues will be prioritized and improvement programs will be developed.
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