Massachusetts Department of Higher Education. Nursing Education Redesign Grant Program. Final Project Implementation Report

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1 Massachusetts Department of Higher Education Nursing Education Redesign Grant Program Final Project Implementation Report Submitted by: Berkshire Community College November 30, 2012

2 Executive Summary Overview of Project Accomplishments Redesigning the curriculum in both the practical nursing certificate program and the associate in science in nursing program to incorporate gerontological concepts, increase quality of care, and further develop critical thinking skills, has led to the following curricular changes: In NUR-202 (Physical & Mental Health IV), students who have not had a long-term care experience will have a three week rotation in a long term care facility and address four of five Gerontology Clinical Objectives in their clinical journal. The summer workshop, Advanced Clinical Concepts in Geriatric Care, resulted in students expressing significantly more confidence applying gerontological concepts after the workshop. Acute Care Nursing Student Educational Forums (twelve scheduled for winter/spring 2013) for both the A.S. degree in nursing students and the practical nursing students provide expert information on topics ranging from medication safety to coordination of care along the continuum. In addition, the collaboration between the two programs (A.S. in Nursing and Practical Nursing) has increased the awareness of each program to the other s role in preparing practitioners and working as a team to teach quality care and safety. Professional development workshops for faculty from both programs provided an opportunity for faculty to learn from each other and discuss future directions for curriculum to ensure a seamless path for LPN students to bridge into the degree program, and develop faculty expertise in gerontological quality and safety education. A faculty retreat provided an opportunity to reflect on the accomplishments thus far, and plan for continuation of programmatic changes for the future. The department chair for the practical nursing program has served as the liaison between the programs and will provide ongoing leadership for the gerontological clinical rotations, further strengthening the links between the two programs. Research Findings to Date Gerontology Workshop Outcomes To measure the outcomes of student confidence in applying gerontological concepts, a survey of ten items was administered to 13 participants before and after the workshop. An unpaired-samples t test indicated that the mean Gerontology pre-workshop scores (M = 2.96, SD 1 P a g e

3 = 0.45) were significantly greater than the mean post-workshop scores (M =1.82, SD = 0.27), t (17) = 6.45, p=.001. Therefore, students expressed significantly more confidence applying gerontological concepts presented after the workshop s presentation. Table 1 shows specific content area pre and post workshop student scores. The one content area that did not show a significant difference between the pre and post scores was student confidence, knowing what clients need when they are discharged from the hospital to be admitted to extended care facility or go home. It may be that this concept is too broad for the recent nursing graduate to begin to feel confident clinically. Focusing on a specific health condition, for instance, the patient with heart failure being treated across health care systems, allows students to identify critical signs and symptoms requiring interventions prior to discharge from the acute care setting and/or extended care setting. Because item 6 Beginning to see what clients need in care transitions may capture more accurately a new graduate s level of confidence faculty may consider presenting patient movement though care transitions within the nursing curriculum. Table 1 Gerontology Workshop Pre and Post Mean Scores Measuring Participant s Level of Confidence on Specific Content 1 (N = 13) 1. Teaching client medications & self-care to avoid rehospitalization 2. Handoff to other staff during shift or discharge transitions Pre Workshop M Post Workshop M p* Knowing client s needs when discharged from hospital to extended care facility or home na 4. Respecting other nurses across care settings to share responsibilities and accountability Beginning to coordinate and collaborate Beginning to see clients transitional needs Assessing client s level of functioning Practicing in a long-term care facility Using geriatric nursing resources like consultgerirn.org Using evidence-based practices On a scale of being extremely confident (1) to being not at all confident (5), rate your level of confidence in the following clinical areas. Note. * 2- tailed 2 P a g e

4 Nursing Implications: Focusing on specific health conditions,( i.e., patient with heart failure being treated across health care systems), allows students to identify critical signs and symptoms requiring interventions prior to discharge from the acute care setting and/or extended care setting. Faculty should consider presenting patient movement through care transitions within the nursing curriculum either in clinical settings or through patient simulation in a controlled environment. This workshop demonstrates areas of graduate student confidence in working in a long term facility and a need for faculty to focus on core curriculum use of geriatric nursing resources and evidence based practices. The outcomes demonstrate that students level of confidence increases after a gerontological workshop offered after graduation. A similar survey instrument (pre and post-professional development) was administered to all faculty (A.S. degree in nursing and practical nursing) to assess confidence in teaching gerontological concepts. The results will be analyzed and disseminated to faculty and staff during the spring 2013 semester. Changes implemented and plan for sustainability Berkshire Community College (BCC) partnered with Berkshire Health Systems (Berkshire Medical Center-BMC) to present multidisciplinary forums for students early in spring semester, Benefit was found for both the College and BMC and another series of twelve acute care nursing student forums will be presented in spring, The multidisciplinary teams of presenters modeled current practice and raised expectations for students in practice to begin to develop relationships among interdisciplinary staff in the hospital and other healthcare agencies. Simulation was focused on increasing critical thinking and reasoning skills using a progressively complex scenario involving hypoglycemia. Scenarios were developed by faculty to progress students through a patient s emerging signs and symptoms and have students determine when these signs and symptoms begin to impact patient safety or reflect the need for immediate intervention. Additional scenarios are being developed and will be used during the fall 2012 for the LPN students, and spring 2013 for the first year associate degree nursing students. Simple tools such as SBAR (situation- background-assessment-recommendation), and hand-offs between shifts provide evidence-based structure for patient information exchanges and scenarios can be modified to reflect different situations. Debriefing provides the opportunity 3 P a g e

5 for both self-reflection by the student, and peer and faculty review. The afternoon simulations reinforced prior learning and development of interdisciplinary teamwork. Second year associate degree nursing students who have not had a long-term care experience will have a three week rotation in a long term care facility and address four of five Gerontology Clinical Objectives in their clinical journal. This will be piloted spring 2013 and incorporated into the associate degree nursing program for the future. BCC faculty will continue to incorporate gerontological concepts and patient quality and safety methods into the curriculum as well as Nurse of the Future Core competencies. The summer workshop, Advanced Clinical Concepts in Geriatric Care, will be offered again in summer An additional week will be added to the course to provide additional time for simulation and an expansion of the observation at Fairview Commons. Students will have a mini-clinical experience to apply new skills. The two week workshop will incorporate the Quality and Safety Education for Nurses Education Consortium Institute (QSEN) approach to enhance the ability of nursing faculty to reinforce quality and safety competencies with an expansion of the hands-on clinical component of the workshop. Barriers encountered, addressed, worked around It was originally projected that participants would be ready to take the gerontology certification through the National Federation of Licensed Practical Nurses. It was later discovered that the National Federation of Licensed Practical Nurses (NFLPN) requires six months of employment history in addition to a current license. Students were comfortable with the requirement however, and welcomed the opportunity to hone their skills and reinforce their knowledge base before applying for the certification. The faculty will follow up with all students to encourage them to work toward this goal. In addition, while the evaluation of the observation at Fairview Commons was overwhelmingly positive, many students expressed disappointment at not being able to have a hands-on experience. In summer 2013 plans are to meet with Fairview Commons and other agencies to provide mini-clinical experiences in future workshops. 4 P a g e

6 Ongoing project dissemination Information regarding the project has been disseminated through faculty meetings, curriculum discussions (which have included Nurse of the Future Competencies and QSEN) and at a nursing faculty retreat where faculty in both programs shared information regarding the project implementation and future directions. On January 9, 2013, the results of this project will be presented at the Nursing and Allied health Initiative Advisory Council (N&AHI-AC). Opportunities for scale up projects/dissemination As we have seen, baby boomers have multiple diagnosis and chronic health conditions requiring care across a variety of health care settings. Nurses at all levels must be prepared to function effectively in the healthcare system including long term care. Practicing nurses must respond to patient emerging health needs regardless of health care setting or educational program preparation. This project is an important step in providing an additional skill set for students in the associate degree in nursing program at BCC and for the new graduate LPN to develop more acutely, critical thinking skills in patient assessment. It also provides an opportunity for development of interdisciplinary teamwork skills and analysis of the unique health care needs of the older adult. This project was designed to strengthen nursing education and career pathways through enhancing nursing curriculum and developing faculty expertise and student proficiencies in gerontology. The project activities included: 1) redesigning nursing curriculum to incorporate gerontological concepts, patient quality and safety methods into the curriculum; 2) developing faculty expertise in gerontological quality and safety education through professional development workshops; and 3) providing a transition into Practice course for LPN graduates and incumbent nurses to prepare the LPN and registered nurse (A.S. degree level) for employment in long-term care. Key lessons learned Patients within care transitions require nursing skills linking knowledge, clinical reasoning and practice that belong in practical nursing education as well as in the RN curriculum. The LPN student as well as the RN student, uses evidence based practice to determine 5 P a g e

7 assessments and interventions for effective efficient outcomes based on the science of nursing. All students found evidence-based nursing tools useful in the objective assessment of the elderly patient. As with any nursing resource, faculty must select appropriate tools (case studies, simulation scenarios, analyses of research) for the educational level of the student. Three assessment tools found useful are: Try This: and How to Try This series which present geriatric syndromes with several assessment tools in a variety of media. INTERACT Tool Kit (Interventions to Reduce Acute Care Transfers), which can be used to help nursing home staff identify when a residents care changes, what to further assess, and when to communicate changes. ACES (Advancing Care Excellences for Seniors NLN, 2010a) provides a framework acknowledging the complexities of care and patients vulnerabilities during transitions. This nursing resource provides unfolding case studies and teaching strategies for the older adult client. Recommendations for DHE It is important to recognize that nursing program outcomes build on core values and integrate concepts across all levels of nursing education, starting with Practical Nurse and ending with Doctoral prepared nurse. Teamwork and collaboration is a core nursing competency and underscores the value of involving students in interdisciplinary clinical health care forums and simulations scenarios as a way to have students participate in interdisciplinary teamwork. As the long term care continuum evolves, nursing students are presented with challenging and complex learning environments. It is critical for the LPN to acquire the advanced skills necessary to ensure patient safety, become increasing aware of patients worsening symptoms and conditions, and respond appropriately to such situations critical to long-term care nursing. Improving skills helps reduce patient complications preventing unnecessary hospital admissions. Establishing an education career ladder for LPN to RN to NP or Nurse Educator is a critical component to keep in the forefront of nursing education. With the evolution of nursing education, it is important to have multiple entry levels and make room in healthcare for all levels of practitioners. 6 P a g e

8 Development of faculty expertise through professional development workshops and onsite training with technology helped to build confidence and provided additional assessment tools that included best practices. Having an interdisciplinary approach to both training and teaching, models the teamwork that is important for students to incorporate in their own practice. In addition, the multidisciplinary forums allowed students to appreciate the interventions of the different areas presented. They could see immediately the interactions among healthcare professions as the various disciplines presented clinical management issues related to nutrition, cardiac failure, diabetes mellitus, oral health, patient care navigation, and other topics related to acute care nursing. It became clear to students that there was a cumulative effect on patient outcomes with each discipline s intervention. Findings from the student evaluations are providing direction for future consideration for the summer workshop. From comments made by participants, it was noted that there was great value in having both first year nursing students and practical nursing graduates in the workshop. They were able to work together and each student was able to see their role within the team. In addition, the faculty represented both programs, again modeling the teamwork approach to healthcare. In closing, it is essential to have highly educated, skilled nurses to provide a competent workforce. Competencies and clinical objectives should be specific to the older adult, and student learning outcomes assessed. Students as well as practicing nurses working with older adults should be confident in identifying the scope and complexity of gerontological nursing. 7 P a g e

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