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February 2008

Center for Nursing Excellence Newsletter February 2008 (pdf)

In This Issue...

CKHS Holds First Nursing Leadership Retreat

For the first time, nursing leaders throughout Crozer-Keystone Health System gathered to discuss and make joint decisions surrounding the practice of nursing at the CKHS Nursing Leadership Retreat held on January 8, 2008. Topics ranged from best practices at CKHS to the recent climate survey of nursing excellence results.  Performance measurement and nursing philosophy and theories were also on the agenda.

In Pursuit of Magnet™

CKHS Chief Nursing Officer Nancy Bucher, RN, MSN, CNAA-BC, welcomed the 110 nursing leaders in attendance and led a discussion about Crozer’s journey to Magnet™ hospital designation by the American Nurses Credentialing Center (ANCC) Magnet Recognition Program®. 

 “While achieving Magnet Recognition is a goal, our overarching mission is to further nursing excellence within Crozer-Keystone,” Bucher emphasized. “The pursuit of Magnet will enable us to fulfill that mission. Numerous research articles attest to better patient outcomes and increased nurse satisfaction in hospitals who have achieved Magnet designation.” Bucher presented the timeline for Crozer-Keystone’s application for Magnet Recognition; the final application will be submitted in June 2009.

Nursing Philosophy and Theories

Nursing philosophy is a key driver of the journey toward nursing excellence and Magnet Recognition. Jerri LaRocco, RN, MSN, CNAA-BC, assistant vice president for Patient Services at Delaware County Memorial Hospital (DCMH) led a discussion about Crozer-Keystone’s philosophy of nursing (see “Executive Endings” for more information).

Closely tied to nursing philosophy is nursing theory. During the retreat, JoZetta Shawl, RN, MHA, CNAA-BC, director of Nursing and Clinical Support Services at Springfield Hospital, presented the theories of four expert nurses who have developed various models of nursing care over the past 45 years. They included Joyce Travelbee’s model which focuses on the establishment of a caring human to human relationship in which the purpose of nursing is to assist an individual, family or community in preventing or coping with the experience of illness and suffering.  

Nursing theorist Virginia Henderson defined nursing as the unique function of helping the well or sick individual perform activities that contribute to health, recovery or death. She believed that the nurse is a part of the medical team and functions independently of the physician. Henderson espoused 14 components of nursing care that encompass all possible functions of nursing.

Faye Abdellah promoted the theory that nursing is both an art and a science that molds attitude, intellectual competencies and technical skills into the desire and ability to help people cope with their health needs. She outlined 21 nursing problems to be used as a guide for excellence in nursing care.

Patricia Benner defined five stages of nursing practice – novice, advanced-beginner, competent, proficient and expert – and seven domains or key responsibilities of nursing to be mastered.

Retreat participants considered which nursing theory might best reflect Crozer-Keystone’s mission and vision of nursing care. “Nursing philosophy and theory are important yardsticks for Magnet designation,” noted Zanet Lester, RN, MHSA, coordinator of the CKHS Center for Nursing Excellence. “The Magnet Recognition Program considers how effectively the philosophy and theory espoused by a health system have been put into practice.”

Best Practices 

During the retreat, several patient care nurses presented best practices that have been implemented successfully in their areas, another critical measure of nursing excellence.

DCMH’s 5 East Surgical and Orthopedic Unit discussed the collaborative effort behind the creation of their unit council. The council’s accomplishments include improved communication among staff and management with staff empowerment, improvements in daily flow of the unit, patient/nurse ratio, supplies and equipment, all of which are contributing to increased employee and patient satisfaction. 

The development of best practice for Foley catheter utilization was outlined by Sharon Mulato, RN, MSN, CNS, CRRN, nurse educator for Taylor Hospital. Research was initiated in 2003 to determine the best practice for preventing the inappropriate use of Foley catheters and catheter-associated urinary tract infections (CAUTI). As a result of this research and staff education, Taylor has experienced a significant decrease in the percentage of patients with a Foley and a dramatic increase in documented reasons and physician’s orders when a Foley is used.  In addition, the number of CAUTIs has trended downward.

In Crozer’s Cardio-Vascular Unit, the implementation of a Rapid Response Team has resulted in a dramatic decrease in Code 99 calls, according to Kathy Poole, RN. “The Rapid Response Team is activated when the patient’s condition is deteriorating but he or she is still breathing,” explained Poole. “We have seen a positive correlation between the use of the Rapid Response Team and patient recovery and earlier discharge.” 

Springfield Hospital’s Acute Care Center implemented daily evidence-based medicine (EBM) multidisciplinary rounds to improve results for EBM indicators such as pneumonia, acute myocardial infarction, stroke and congestive heart failure, reported Lisa Schmidt, RN, nurse manager. Rounds include an EBM Department representative, a pharmacist, case manager, house physician and patient care nurse. Since the nursing staff initiated this practice eight months ago, the Acute Care Center has exceeded its goals on nearly every indicator.

Measuring Performance 

Performance measurement is essential to the journey toward excellence. DCMH Director of Nursing Helene Burns, RN, MSN, CNAA-BC, presented the “nursing dashboard” that will be used to track nursing performance at Crozer-Keystone. It includes four key indicators: patient care, patient safety, patient satisfaction and resource management. “Sharing this data encourages feedback and accountability as well as benchmarking among our hospitals and like hospitals,” explained Burns.

Responding to the Climate Survey  

In November 2007, Crozer-Keystone patient care nurses had the opportunity to evaluate nursing excellence in their hospitals in 10 areas, including clinical competence, nurse autonomy and accountability, and visibility of the Chief Nurse Executive, among others. Results of the climate survey indicated that the Unit Councils, which are comprised of patient care nurses, should be empowered to make more practice decisions, and nurse managers need to ensure that the councils have the necessary tools and information to do so.

Retreat participants also discussed the importance of increasing the visibility of CKHS Chief Nursing Officer Nancy Bucher.  

Bucher announced plans to increase her visits and rounding on the units, among other initiatives. She also announced plans for monthly town hall forums where nurses can raise questions and offer comments.

Spotlight On: Award-Winning Nurses

Elizabeth “B.J.” Pearsall, RN, BSN, CNOR, loves the OR. A 31-year veteran of Taylor Hospital, she has always welcomed the challenge of the “unexpected” that is characteristic of the OR, and she finds it rewarding to provide care and comfort to patients who may be frightened or stressed both in the OR and PACU.  A 10-year breast cancer survivor, she is especially proud of her efforts to reassure and encourage patients who are undergoing surgery for that disease. “My personal experience has enabled me to help a lot of patients,” she relates. “I tell them, ‘Here I am, 10 years later, and I’m doing fine.’ It gives them comfort and confidence.”

Pearsall shares her gift for patient care by teaching and mentoring new OR nurses as well as nursing students at Delaware County Community College where she is a clinical instructor of perioperative nursing and surgical technology.

Last year, Pearsall was recognized for her outstanding contributions with Taylor Hospital’s first annual Nurse Excellence Award. Nominated by her co-workers, she was praised for her dedication to her profession and her patients and for serving as a role model for younger nurses.

A 1976 graduate of Philadelphia General Hospital School of Nursing, Pearsall received her bachelor’s degree in nursing from Eastern University. A certified nurse of the operating room, she is a member of the Education Council at Taylor Hospital. She is also a member of the Association of Operating Room Nurses (AORN) and Sigma Theta Tau.

Linda DeGothseir, RN, MSN, OCN, is a patient advocate and nurse educator at heart.  As a patient care nurse on Delaware County Memorial Hospital’s Oncology Unit, she is known for the kind and compassionate care she provides, particularly to end of life patients and their families.  “Linda goes out of her way to see that their needs are met,” says Nurse Manager Kathy Manuel, RN, MSN, OCN.

A 29-year DCMH veteran, DeGothseir also goes above and beyond to share knowledge gained from her experience as a nurse and as a representative on DCMH’s Education Council. “Linda is always eager to share the latest information with her colleagues on the Oncology Unit,” notes Manuel.  DeGothsier also serves as a clinical instructor of oncology and a mentor to nursing students at Delaware County Community College.  

In recognition of her dedication, Linda was nominated by her peers for the Nursing Spectrum Nurse Excellence Awards and the Pennsylvania Nightingale Awards in 2007. An oncology-certified nurse, DeGothseir received her bachelor’s degree in nursing from Villanova University and her master’s in nursing from Widener University. She is a member of the Oncology Nursing Society, Sigma Theta Tau and the National League of Nursing.

For more than 20 years, Gerarda Bozinko, RN, has been the public face of The Nathan Speare Regional Burn Treatment Center at Crozer-Chester Medical Center.

In her role as coordinator of the Center’s Burn Outreach Program, she educates the local community about burn prevention and burn injuries and offers professional training in the assessment and treatment of burns to Emergency Department physicians, nurses and nursing students as well as pre-hospital personnel. Last year, the breadth and success of her efforts were recognized when she was a finalist in the Nursing Spectrum Nurse Excellence Awards.

Bozinko offers outreach programs that address concerns across a broad range of ages from infants through senior citizens. She is particularly proud of the Juvenile Firesetter Program which focuses on the problem of fireplay and firesetting among children. She coordinates efforts with juvenile fire detectives who identify children from age 3 to 18 for whom this is an issue. “I talk with the children and their parents to raise their awareness and understanding of the possible consequences of their actions,” she explains. 

Bozinko has also helped many pediatric burn victims through the Center’s School Re-Entry Program which is designed to provide a young burn patient with an easier transition into the school community. 

A graduate of Wilkes University with a bachelor’s degree in nursing, Bozinko was recently appointed to the American Burn Association’s Education Committee. She is also an instructor for the association’s Advanced Burn Life Support course and a member of the American Association of Critical Care Nurses. Last year, she directed the first Northeast Regional Burn Conference for professionals from Maine to Washington D.C.

Best Practices:  Teamwork Reduces Cardiac Door-to-Balloon Time

The situation:

The American College of Cardiology (ACC) and the American Heart Association recommend that patients suffering from a specific kind of heart attack known as an ST-segment elevation myocardial infarction (STEMI) have their arteries opened directly within 90 minutes of arriving at the hospital. A STEMI is identified by a major elevation of the tracing in the ST portion of an EKG study. Time is critical because the sooner the patient’s arteries are opened, the greater the chance of saving heart muscle and, therefore, the patient surviving. The national average for door-to-balloon (angioplasty) time is about 100 minutes, according to researchers at Duke University. In March 2007, median time at Crozer-Chester Medical Center exceeded 100 minutes.

The response:

In March 2007, members of the Crozer Emergency Department and Cardiology Department’s Cardiac Catheterization Lab formed a team to develop best practices for reducing door-to-balloon time to 90 minutes or less. As of November 2007, Crozer’s median time had dropped to 59.4 minutes, more than 30 percent better than the ACC benchmark.

“Through this initiative, we’ve developed a great working relationship between the ED and Cardiac Cath Lab,” notes Michele Gillespie, administrative director of Cardiology at Crozer. “Our patients are reaping the benefits of the best practices that have resulted.” 

Best practices:  

The Cardiology Department released the right to activate the call team to Emergency Department physicians, thus eliminating the need for a series of phone calls between the ED and Cardiac Cath Lab which took a significant amount of time.

Members of the ED and Cardiac Cath Lab worked together as a team, conducting a case by case review, discussing what they were doing and why, and considering actions that could be taken to remove obstacles and reduce time. Through this effort, the two departments developed a strong, collaborative working relationship that led to significant improvement. “For example, instead of splitting the 90 minutes in half -- 45 for the ED and 45 for Cardiac Cath – they looked at the 90 minutes as a whole and figured out the best way to use it as a team,” notes Joan Marino, director of Performance Improvement at Crozer. The team continues to meet monthly for case reviews with the goal of making additional process improvements that will further reduce the time.

Steps were taken to facilitate quick recognition of a STEMI. “Whether the patient comes into the ER via EMS or as a walk-in, we have a system in place to recognize and act on a STEMI very quickly,” says Victor Heresniak, DO, chairman of the Department of Emergency Medicine at Crozer. “Walk-in patients suffering chest pain immediately receive an EKG at the front entrance. If a STEMI is indicated, we begin treatment immediately. If the patient is coming in via EMS and an EKG performed en route indicates a STEMI, the EMT relays that information to us and we activate the call team so they are ready and waiting when the patient arrives.”

In the future, Crozer plans to acquire 12-lead EKG technology that will enable EMTs to transmit the actual EKG from the field to the ED.

The team developed a pre-assembled STEMI box that contains all supplies and medication protocols needed to treat STEMI patients.

The Cardiac Cath team conducts mock STEMI codes at least every six months to keep their skills sharp and response time down. In the future, ED staff members may also participate in these mock codes.

A new STEMI team will be implemented within the next six weeks. Similar in function to a trauma team, it will include a nursing supervisor, radiology technician and security officer. The team will be activated when a STEMI patient is identified.

Magnet™ FAQ

What are “Forces of Magnetism?” 

Forces of Magnetism are key factors, identified by the American Nurses Credentialing Center (ANCC), that contribute to the successful recruitment and retention of nurses. These forces include quality of nursing leadership and patient care, nurses as teachers, interdisciplinary relationships, professional development, autonomy, and community outreach, among others.

The Forces of Magnetism are used to:

  • Shape the vision of nursing service.
  • Direct the operations of the nursing department.
  • Attract staff that welcomes responsibility and accountability for their nursing practice.
  • Model service excellence.
  • Demonstrate evidence of highly successful leadership.

Executive Endings

Jerri LaRocco, RN, MSN, CNAA-BC, Assistant Vice President for Patient Services, Delaware County Memorial Hospital 

What is a philosophy of nursing and why is it important to Crozer-Keystone nurses? At our recent CKHS Nursing Leadership Retreat, we discussed the idea that a philosophy statement is our “Super Bowl commercial.” It conveys the values and beliefs of the Crozer-Keystone Department of Nursing, and it guides us in our practice.  

During the retreat, we adopted a statement that combines two very similar philosophies that have been in place for several years, one at DCMH and the other at Crozer, Springfield and Taylor. Now we must take what we wrote on paper and put it into practice every day. We must live it and breathe it. Our goal is to help each of you to enrich your nursing practice by becoming completely familiar with it, starting right now.

Based on the Patient’s Bill of Rights and the American Nurses Association Code of Ethics, our philosophy statement recognizes that nursing is both an art and a science. The art brings in the importance of respecting the individual patient’s feelings as well as cultural, spiritual and ethnic beliefs in planning for the patient’s care. The science involves actual care of the patient.

In addition to patient care, our philosophy emphasizes the importance of nursing research and learning. Nursing is not a stagnant science . . . it is always moving forward. Only through continued learning and research activities will we be able to provide the excellent healthcare that we want to give to our patients. We put this into practice every day in our evidence-based medicine activities, which involve many nursing indicators. We teach our patients about certain medications, we make sure that they undergo certain tests, and we see that they receive preventive health measures like the pneumonia and influenza vaccines.  

This links to another key element that has always been part of the Crozer-Keystone philosophy:   We don’t just take care of the people in our hospitals; we take care of our community. We make our nursing philosophy real by routinely providing health screening and health maintenance services throughout the communities we serve. 

Our philosophy statement also emphasizes the importance of mentoring our new nurses as well as our responsibility to develop future nurse leaders. During the past year, Crozer-Keystone has been developing mentorship programs for new nurses. This is exciting for our patient care nurses who will participate as mentors, as well as for our new nursing graduates who will benefit from this support as they embark on their careers.

Last year, Crozer-Keystone put this into practice by starting an Emergency Department fellowship. This very successful six-month program gave new nurses the professional development they needed to function in the challenging ED environment while meeting the community’s need for more staff to handle the increased volume of patients. This fellowship represents a considerable investment in education which Crozer-Keystone will repeat again this year. It is making our philosophy real.

We also plan to provide mentoring to nurses who are a few years out of school and moving into new positions in areas such as the Emergency Department or Cardiac Care Unit. Having a mentor to support them after their orientation will be a great asset to their professional development.

In addition to guiding our daily practice, our nursing philosophy is essential in our journey to Magnet™ hospital designation. When Magnet representatives visit our facilities, they may ask you, “What do you base your practice on?   What do you value?” Your response will reflect how well our philosophy statement is understood and practiced throughout our system. You can find this statement in its entirety in the nurse practice manual available at every Crozer-Keystone site. Living and breathing it every day will help each one of us to provide excellent care and find even greater reward in the noble profession we have chosen.