FEBRUARY Introduction. Framework for Practice vs. Model of Care Delivery

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1 FEBRUARY 2009 Introduction This month s issue of enursingnow focuses on Models of Care. Models of care serve as the basis of nursing practice and as an essential element of success for any Magnet organization. At NMH, we use both a Framework for Nursing Practice based on the work of theorist Virginia Henderson and models of care delivery which are based on a patient centered approach. Framework for Practice vs. Model of Care Delivery Understanding the difference between a framework for practice and a model of care delivery can be confusing. Sometimes the terms model and framework are used interchangeably. In reality however, they are very different from one another. A care delivery model provides nurses with guidance regarding how to deliver patient care within a specific healthcare setting. Thus, care delivery models typically focus on nursing practice at the point of the delivery of care (i.e., at the nursing unit level). Below are examples of care delivery models often used in hospitals. Here at NMH, we use a patient centered model of care in most practice settings. Team or Functional Nursing Care A model using the RN as a team leader and LPNs/unlicensed assistive personnel (UAPs) to perform activities such as bathing, feeding, and other duties; it can also divide the work by function such as "medication nurse" and "treatment nurse." Primary or Total Nursing Care A model that generally uses an all-rn staff to provide all direct care and allows the RN to care for the same patient throughout the patient's stay; UAPs are not used. Patient Focused Care A model that uses RNs as care managers and UAPs in expanded roles that include drawing blood, performing EKGs, and performing certain assessment activities. Patient Centered Care Model (PCCM) This is the care delivery model used in many areas at NMH. It is an evidence based approach to providing nursing care. The model is focused on creating a healing environment centered on trust, compassion and the incorporation of the patient s personal values into the plan of care. Individual patients clinical and safety needs are addressed through monitoring, interventions, and staffing adjustments. The PCCM also uses in the moment critical thinking to create a culture of seamless team collaboration. Source:

2 A theoretical framework for nursing care guides daily practice and clinical decision making. NMH uses a Framework for Nursing Practice which identifies both the physiological and psychological aspects of care delivery. The framework is based on the work of Virginia Henderson. Henderson believed that both a physiological assessment and an assessment of basic human needs are important aspects of nursing practice. The Henderson Framework for Nursing Practice is discussed in the following article. The Henderson Framework for Nursing Practice The Henderson Framework for Nursing Practice is shown on page 3 of this issue. Our framework serves as a road map to guide the daily practice of nurses at NMH. It is comprised of five components: the nurse, nursing excellence, the patient, the family/ significant other, and the patient care team. Each of these components is described below: The Nurse At the top of the triangle is the NMH Nurse. NMH Nurses demonstrate nursing s unique and essential function through Seven Attributes (i.e., advocate, autonomous, collaborative, compassionate, dynamic, knowledgeable and professional). The Attributes are derived from Henderson s nursing framework. Henderson views the nurse as accountable for his/her practice and for adherence to professional standards. Nursing Excellence The left side of the triangle depicts nursing excellence which is demonstrated through a Magnet environment that fosters shared leadership, continuous learning and professional contribution. Excellence also is one of NMH s Core Values. We continuously strive for excellence. We are always learning and improving our skills, programs and services. Henderson views nursing as an art and a science. She states that the nurses must get inside the skin of each patient through listening, being sensitive to the patient s non-verbal communication and through encouraging patients to express their feelings. Patient Care Team The right side of the triangle represents the patient care team of which the nurse is a key member. Henderson emphasizes that patient care should be multidisciplinary with all members working together to carry out the plan of care. At NMH, the team is committed to integrity, teamwork and providing safe and effective care. Integrity and Teamwork are NMH Core Values. Integrity entails adhering to an uncompromising code of ethics that emphasizes complete honesty and sincerity. Through our words and actions, we earn the complete trust of our patients and their families, our community and our coworkers. We do the right thing.

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4 Teamwork means working collaboratively with others. At NMH, we achieve our mission and goals through the collective and coordinated efforts of our employees. We use our diverse talents, backgrounds, ideas and experiences to benefit patients and create solutions. We value team success over personal success. Safe and Effective Care is one of the core components of the hospital s quality strategic plan. NMH is committed to providing patients with care that is evidence-based and error free. Patient and Family/Significant Other The center of the triangle represents the patient and family/significant other. Henderson views the patient as the center of care delivery. NMH s Core Value of Patients First states: We put the patient first in all we do. Caring for the individual patient and his or her family is the heart of our mission and our philosophy. In summary, the Henderson Framework for Nursing Practice is consistent with our NMH core values and our Patients First philosophy. The framework serves as a road map to guide nurses in their daily practice and decision making. It helps us stay focused on those things that are consistent with our organizational values and essential to providing the Best Patient Experience. Care of the Critically Ill Oncology Patient DMAIC Project Approximately five patients per week, more than 200 NMH patients per year, have been transferred from the medical oncology units to an ICU. In 2008, the preventable code rate on the oncology units was 0.60 codes per 100 discharges or one code for every ten patients transferred to the ICU. When the hematology oncology units moved to Prentice Women s Hospital last year, the travel time to an ICU from the oncology units increased from about two minutes to minutes. The increased distance along with other barriers to a safe and effective transfer created the need for proactive identification of critically ill patients. The DMAIC team identified the primary indicator for a safe and effective ICU transfer as a low preventable code rate. They set a project goal to reduce the preventable code rate by one-third. Multidisciplinary team members included Pat Murphy, RN, MSN, MBA, Director of Oncology Nursing; Barbara Gobel, RN, MS, AOCN, Oncology Clinical Nurse Specialist; physicians from both oncology and internal medicine; Semico Miller, RN, Rapid Response Team; Tarrah Merjudio, RN, MICU; Sara Witt, RN, OCN, Staff Educator, 15 PWH; Deb Mast, RN, OCN, Clinical Coordinator, 16 PWH; and Annaliza Rodriguez, RN, MSN, OCN, former manager of 15 Prentice. Mark Schumacher supported the project as the quality improvement leader.

5 The team identified three primary factors that served as barriers to safe and effective transfer: (1) difficulty in differentiating the symptoms of neutropenic fevers from critical conditions that require critical care transfer, (2) difficulty in using established thresholds or indicators of acuity or clinical deterioration because of the overall acuity of illness in this patient population, and (3) the common view that these patients are best cared for on the oncology units by Oncologists and oncology trained nurses. The team built a protocol to identify and proactively intervene with critically ill patients. The protocol uses both a serum lactate level and the Modified Early Warning Score (MEWS) at a lower threshold than that used by the Rapid Response Team (RRT) to identify patients at risk for clinical deterioration. Since the implementation of the new protocol in March, 2008, the preventable code rate on the oncology units has dropped 75% from 0.60 per 100 discharges to 0.15 pr 100 discharges. There have been only four preventable codes in the ten months since the protocol has been implemented. The total code rate has also dropped dramatically. This improvement is being maintained through a control plan that emphasizes ongoing data tracking, ad-hoc code review meetings, and ongoing education and support for the staff. The most important factor in achieving and exceeding the goal was the collaboration among RNs, MDs, and the RRT. Condition Help Program Effective February 16, 2009, all inpatient units will participate in a new program called Condition Help. This program will assist NMH to provide The Best Patient Experience and supports our Patient s First philosophy, a key component of the Henderson Framework for Nursing Practice. The Condition Help program also meets one of The Joint Commission s new National Patient Safety Goals. The Condition Help program provides hospital patients and their family members an additional resource to call when there is a sudden change in the patient s medical condition and nursing staff are not present to assist, or when the patient and/or family member has already spoken with a staff member, but still have urgent concerns. The program has been piloted on 12 West in Feinberg since October The admitting nurse educates the patient and family about the program and there is a placard placed in each patient room to display instructions and the activation phone number.

6 Patients and/or family members are instructed to use their call light for medical emergencies or urgent concerns first. However if they experience a delay in Response, they are encouraged to use Condition Help by dialing from the phone in the patient room. The call is answered by an operator who dispatches a page to the Charge Nurse who addresses the call and escalates the issue, as appropriate, to the necessary personnel. The success of the program has already been demonstrated on the pilot unit when a patient activated the system. This patient was trached and required suctioning, but was unable to reach his nurse by using the nurse call system because it had been accidentally disconnected from the wall. Condition Help was activated and the process worked beautifully. Staff on 12 West intervened quickly to prevent a possible respiratory arrest. Rebekkah has been a nurse since 2005, and has worked at NMH since she graduated from nursing school. Rebekkah also serves as a nurse liaison this year. Rebekkah s future educational plans include enrolling in an Adult Nurse Practitioner Program in the Fall of Her career goal is to become a Heart Failure Transplant Coordinator or work in a Heart Failure Clinic. Currently, Rebekkah is focusing on the continued development of her leadership skills and nursing knowledge through serving as Clinical Coordinator, Nurse Liaison and by being involved in committees. To assist with the roll-out of Condition Help, nurses are being asked to complete a Computer Based Training Module (CBT). This module is currently available and may be accessed via NM Connect. For additional questions on the Condition Help program please contact Ashley Currier at or Katie Erickson at Nurse Leaders Rebekkah Beil, RN, BSN, Clinical Coordinator, 11 West, CVT Stepdown Unit, is Chair of the Nursing Professional Practice Committee. She has been a committee member since September Pictured: Rebekkah Beil, RN, BSN Given her experience as the Chair of the Nursing Professional Practice Committee, Rebekkah believes that the shared leadership committees positively impact nursing care by developing and modifying policies and protocols that guide nursing practice on a daily basis.

7 Note: In last month s Nurse Leaders column, we stated that Sarah Buenaventura BSN, CMS RN, had been the chair of the Nursing Best People and Professional Excellence for the past three years. Actually, Sarah became the chair in May of Prior to Sarah s tenure, Blanche G. Calomarde, BSN, RN, CNRN Clinical Coordinator 10SE Neuro/Ortho Spine/Plastics, served as the chair of the NBP/PE Committee. We apologize for the error. Accolades Melanie Shepley, SICU Critical Care Nursing Certification

8 Poll Question Hand Hygiene Compliance 20% 35% 2% 3% 11% 9% 20% Place more signs and more gel dispensers in patient care areas to remind staff members to wash their hands Have the Infection Control team provide in-services to educate staff on proper hand hygiene compliance Have each member of the unit's quality committee rotate in a "sheriff" role to identify and address non-compliance with colleagues "in the moment" Hold staff member who don't wash their hands accountable for their actions Both the first and second choice Both the third and fourth choice All of the above

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