You Can t Change Practice Without Changing the Culture First A Strategy to Get Nurses to Own It Christine Thomas MSN RN CNP VA-BC Jane Hartman MSN RN PNP-BC CE Code (Attendee Use Only):
Financial Disclosures Financial relationships to disclose: Christine Thomas is on the Speaker s Bureau for: Genentech Biopatch Jane Hartman has no financial relationships to disclose. We will not discuss off label use and/or investigational use in our presentation.
LEARNING OBJECTIVES Identify barriers impeding significant changes in nursing practice using standard educational strategies and inservices. Describe strategies to improve vascular access nursing practice and engagement by development of vascular access champions. Describe the strategies of empowerment to augment learning and engagement in nursing behavior.
Telling of a Story
INTRODUCTION Healthcare Facilities Held Accountable 2008 CMS (Centers for Medicare and Medicaid) concluded that HAI s including CLABSI s are preventable and ceased reimbursement 2010 The Joint Commission mandate finally identifies lack of knowledge of CLABSI prevention and vascular access as a problem Required all healthcare personnel to receive education on prevention of CLABSI
Previous Nursing Education on Vascular Access Multiple strategies consisting of: Orientation classes with specific section on care and maintenance of lines and PIV practice skill stations Manager meetings with in-services on new policies R/T vascular access In-services given by manufacturer clinicians with new products Newly created Mandatory module on Prevention Of CLABSI
Results of Episodic Education and Modular Learning No significant change in nursing practice or CLABSI Rates
Modular Learning
Vascular Access Specialist was appointed as Chair of CLABSI Prevention Education for Nursing
Multidisciplinary Team Vascular Access Specialist Nursing Education Department Nursing Administration Pharmacy Physician Champion Infectious Control Practitioners
Identified Problems Vascular access audit developed with results of poor compliance Modular learning created no engagement Lack of vascular access knowledge or standards Inconsistent or outdated policies throughout system (poor resources available to staff) No leaders to champion best practice and monitor improvement
How Can We Make a Difference? More in-services and education? How can we get them to own it?
You Can Make a Difference!!! Lets Give the Challenge to Decrease CLABSI Rates to the Nurses
Barriers to Learning & Engagement In a published 2012 Nursing Staff Study Barriers include: Lack of time Lack of support of organization Lack of educational resources *Suggest development of role models or champions (Melnyk et al, 2012)
PRIMARY OBJECTIVES BY TEAM Review and revise all vascular access policies according to current standards, guidelines and evidence-based research. All vascular access products must be consistent Increase knowledge of evidenced-based practice and provide resources Empower nurses to become engaged
Primary Strategy Development of the Vascular Access Champion (VACh) program for staff nurses Evidence-based education on Vascular Access Nurse empowerment & engagement
Nothing will change until you change the culture Dr. Dennis Maki 3M Symposium, 2010
Involvement of staff nurses facilitates recognition of both the nurses clinical expertise as well as their ability to influence and guide clinical practice (Gawlinski, 2008). Engagement
Empowerment Knowledge plus empowerment equals a change in culture. Culture will not change in the presence of knowledge alone, empowerment must accompany it. Modular Education (knowledge alone) Click Slide Answer Phenomenon Revealed no retention of information and no engagement
Hands-On Learning Hands-on learning study Perception of self-efficacy for practice of nursing student Increased satisfaction, confidence and consistent retention of theory Andrusyszyn, 2012
Steps in Development Obtaining full support of Nursing and Medical Administration Given empowerment to be the leaders on their units to teach and monitor best practice Can stop procedure if standards are not followed especially with aseptic technique Given recognition by Manager and staff as the expert in their units Contributed to Career Ladder
VACh Responsibilities To co-workers: Collaborate with manager: In-services and educational posters. Monthly audits & review for quality and areas of improvement Communicate changes of VA policies and new products/equipment Be resource on unit for troubleshooting
Course Pre-requisites Reading selected evidence-based article on Vascular Access Completion of module on Central line Bundle **Pretest prior to class to assess baseline vascular access knowledge
Didactic Section 4 hour didactic section included specific vascular access evidenced-based knowledge, current national standards, guidelines, policies and research Topics included types of lines, indications, extravasation, complications and legal implications Focused on principles of empowerment Enforcing standards to staff
One-on-One Hands-on Workshops Instructors developed own script consistent with Policies and Vascular Access Specialist guidance Five 30 minute workshops Central line dressing change Central line blood draws Implanted port access & de-access, DC lines Central line total occlusions Extravasation assessment and treatment.
One-on-One Hands-on Workshops During hands-on skill stations where each nurse was instructed and individually monitored for competence of skills.
Outcomes Monthly VA unit audits After VACh training: majority of units revealed 100% compliance Pre-test and Post-test scores Mean Score prior to class = 40 to 55% Mean Score after completion = 85 to 100%
Delayed subjective follow-up surveys completed by VACh participants Affirmed significant engagement, feelings of empowerment and Culture Change Letter was sent to each participant asking them to share a recent experience that occurred after they attended the VACh program. These are some of the comments from our VACh nurses
I carry my information sheet with me while on my regular unit or when I float to another, just incase an opportunity to teach or correct should arise I am orienting a new nurse and taught her the correct way to change a central line dressing I even made her stop after breaking sterile technique and start over I shared much of the info with colleagues. I m sure that they would like to tell me to Be Quiet Already! I just want to tell everyone what I have learned.
"...there is a buzz about the hospital from all the nurses who completed the VACh class. They all feel empowered, it's in the air". "The class really motivated me to come back and teach my peers and be a VACh advocate and to save patient lives! It has enabled me to be more of a leader and I now feel more inclined to speak up as an advocate for patients concerning IV access and the necessary precautions. I also feel more empowered to hold physicians accountable during procedures (central line placements).
Indications of Success Unprecedented response to Course Registration Waiting list for to get into Program Its easier to win the lottery than to get into the course CNO s requests for more classes to open Extended to all hospitals in system including distance learning sessions Safety Champion of the Year Requests by other healthcare systems to replicate
Indications of Success Quality Report of Magnet application The Vascular Access program results exceeded expectations Including: Significant reduction in CLABSI Significant improvement of compliance Notable Nursing Article Empowerment can be felt within The course is infectious. It continues to educate and empower nurses caring for all patients with vascular access and SAVE lives.
Implications for Practice Modular education is not successful in changing clinical practice or culture. Programs created with multidisciplinary involvement and focus on individualized handson training and empowerment yield changes in clinical practice and culture. Nurses have support and tools to OWN IT
Patricia Benner: Novice to Expert Theory Sound background in the theoretical underpinnings of nursing is necessary for nurses to advance their clinical expertise. Competency lies midway between the novice level and the expert level on this continuum. Role of the nurse educator to create learning experiences that tie the theoretical underpinnings of nursing to clinical experience. Only when the nurse is able to make the connection between the didactic information and clinical experience, will a nurse reach the level of competence.
Learning Styles Visual Learners: images techniques Kinesthetic Learners: need to move around and work manually with ideas Smells and textures are important The more activity they experience while doing a skill, the better they learn it Auditory Learners: Hearing Speaking
Discrepancy Between Adult & Pediatric Vascular Access Education Volumes: In & Out Heparin: To use or not to use! Doses Sizes: Dressings, Syringes, Biopatches Stopcocks Cathflo dosing Alcohol impregnated caps CHG: Preemies PICU/NICU
Differences Peds VARN: It s not just for Champions Smaller pediatric nurse population Need everyone to be an expert in pediatric vascular access practices Information important for ALL nurses New Class in Nursing Residency Program NICU nurses added to the mix in March of 2015 with same reviews
PEDS VARN October 10, 2014 Hospital Unit Pre-Test Pre % Post-Test Post % Main M40-9 40-4 73 Main M40-8 47-3 80 Main PICU -8 47-6 60 Main M40-9 40-4 73 Main M33-5 67-3 80 Main PACU -9 40-2 87 Main M33-9 40-5 67 Main PICU -8 47-5 67 Main M33-6 60-2 87 Main M40-8 47-3 80 Hillcrest Peds ED -10 33-3 80 Main M40-10 33-3 80 Fairview Peds -9 40-1 93 Main M33-8 47-2 87 Main M33-3 80-2 87 Main M33-5 67-4 73 Main M50-7 53-1 93 Main M50-6 60-2 87 Home Care Peds Infusion -3 80-3 80 Fairview Peds -10 33-1 93 Homecare Peds Infusion -4 73-4 73 A111 Care Coordinator -11 27-1 93 Main M33-5 67-2 87 Hillcrest Peds ED -5 67-3 80 Main M40-7 53-8 47 Main PICU -8 47-6 60 Hillcrest Peds ED -7 53-5 67 Main M33-8 47-5 67-205 -93-7.321428571-3.321428571 53% 80% Pre/Post Test Scores
CLABSI Rates as of August 13 th 2015 PICU: CLABSI free 354 days NICU: CLABSI free 665 days Overall Children s Hospital ~ 1.1 past 3 years
Thank You
References Andrusyszyn, M. et al. Curriculum Development in Nursing Education, 2009. Benner, P. From novice to expert: Excellence and power in clinical nursing practice. New Jersey: Prentice Hall. Interprofessional Health Collaborative. (2007, June 6). Benner, P. Using the dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of Science, Technology & Society 2004;24(3)188-199. Gawlinski, A. The power of clinical research: Engage clinicians, improve patients lives, and forge a professional legacy. American Journal of Critical Care 2008,17(4) 315-326. Gentile, D. Applying the novice to expert model to infusion nursing. J Infusion Nursing 2012;35(2) 101-107. Melnyk, B. et al. The state of evidence-based practice in US nurses: Critical implications for nurse Leaders and educators. Journal of Nursing Administration 2012;42(9) 410-417.
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