Accountability And Nursing Practice

Accountability and Nursing Practice

Accountability and Nursing Practice Program Transcript

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NARRATOR: Personal accountability.

KENNETH REMPHER: I think there’s a direct relationship between holding nurses accountable and their own perceptions of what they contribute to the overall health care process in an organization. And I think one of my greatest epiphanies as an administrator was when one of the nurses looked at me, and she said, if you expect more from us, you’re going to get it. And I was like, what do you mean. And she said, if you expect us to produce a higher level, you give us the tools that we need to do it, we’re not going to disappoint you.

NARRATOR: This week, Miss Nitza Santiago, Miss Diane Johnson, Dr. Kenneth Rempher, and Miss Maria Manna share strategies for improving nursing practice and promoting patient’s rights.

NITZA SANTIAGO: Involving patients in their care has a very direct impact on safety and quality and partly because having them fully knowledgeable of what is expected during that patient’s stay, what is that treatment plan, really allows them to look at what’s happening around them and to confirm that if the doctor said you’re going to have some blood work done later today, that if it doesn’t happen, that they’re questioning the health care team.

FEMALE SPEAKER: I just want to talk to you about what they did today. What Dr. Herval found.

NITZA SANTIAGO: The more involved the patient is in their care, it’s going to lead to a more positive outcome at the point of discharge. And yes, you know, the patient should have to be worried about everything that’s going on, are we doing the right thing. But as we all know, unfortunately, errors do occur. So it’s important that everybody is involved in the care and attentive to what needs to happen.

And I also believe that if they know their treatment plan, if they have a good understanding of their diagnosis, they can take an active role in knowing how to prevent signs and symptoms or to catch signs and symptoms early on and call the nurse, and say, I’m feeling really lightheaded, dizzy. All of that helps us to intervene earlier.

DIANE JOHNSON: The changes that occurred in our organization, when I think of previous times to what’s happening, is being less focused on what’s convenient for hospital staff. OK? And looking, as part of our patient-centered

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Accountability and Nursing Practice

care, looking at what is best for the patient and family and engaging them in a partnership.

And so that right now was a big focus area for me is to realize that, again, we’re here for the patient, but we need to make sure that while we may have the expert knowledge in terms of the science, et cetera, the patient knows themselves best. OK? And it is our responsibility to make sure we’re collaborating with them. That we’re not simply telling them this is what’s going to happen.

We ask them about their preferences. We plan the time, the schedule. Some things we can’t do that, but there are lots of opportunities where we could say, would you like to eat at this time versus this time, or you have these three tests today, we might be able to change the order of the tests. Is there a preference that you would have for one versus the other. They’re in a foreign environment, away from a lot of things that are familiar to them. And anything that we can do to ease that, I think it’s our duty and our responsibility.

KENNETH REMPHER: The NDNQI, which is the National Database of Nursing Quality Indicators, is a database that’s been around probably since the mid ’90s. 1994, I think, was the original version that was developed in collaboration with the American Nurses Association. What the NDNQI allowed was for nurses to take those components of clinical practice that were as nurse-sensitive as possible, pull those out, find a way to assess those, to measure those, and to present those in some form that would be meaningful to nurses that would require– and I honestly do believe that the NDNQI is probably the soul or one of the strongest contributors to this movement that holds nurses accountable for their practice. Because for the first time, nurses have been given data that say, we know that you’re there 12 hours a day, every day, and then you’ve got a counterpart that comes on to replace you, but we’ve never had a way to really quantify what it is that you do to tell you how good you are at what you’re doing as a discipline or as a profession.

NDNQI does that. In our organization, at Sinai Hospital Baltimore, there are a series of local councils called outcomes and practice councils. The data for each service line are presented to the local councils, the outcomes and practice councils, and they’re presented on a consistent quarterly basis, where we have been using this dashboard process.

And the dashboard process is a mechanism whereby we record not only our own scores, but we record benchmarks that are provided to us through NDNQI, because they provide you with various percentile rankings for hospitals like your hospital in cities like your city that provide services like your unit. So that’s the other important thing about NDNQI, is that it presents unit-based data. Now, the bottom line is that once it comes to these local practice councils, we now have the mechanism in place to hold nurses accountable for their practice.

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Accountability and Nursing Practice

MARIA MANNA: The NDNQI set benchmarks for indicators that are key to a specific practice area in most instances. So if you have no benchmarks or no measurements to look at, sometimes your interventions or what actions you are employing don’t hold a lot of significance for you. Making nurses aware of the key indicators in their practice areas and where they are in reference to a national benchmark gives them an idea of where they need to go and how they need to move. And they develop action plans in order to meet those benchmarks that the action plans being developed by them gives them buy-in.

It makes them feel supported that they actually have the authority to create the action plans. It’s not something that’s handed down to them and saying, OK. Now you need to do this. They’re actually telling leadership. As direct care nurses, we do this every day, and this is what we believe needs to be done in order to achieve this result.

In my practice area, we look at seclusion and restraint. That’s one of the key indicators. And we look at ways to perhaps reduce the number of seclusion episodes. So nurses were involved in an action plan where we would request a peer review and have a consultation with the physician involved in the case and have an interdisciplinary meeting to resolve issues that we believe would potentially reduce the amount of time any particular patient might spend in a seclusion situation.

We would look to see if that has an impact on reducing our seclusion episodes. And if we’re effective, we would continue that. If not, the nurses have an opportunity to modify their action plan. We have an outcomes and practice committee where nurses attend, and that is where that work is done, and then it’s presented to the entire nursing staff on a particular unit. So those benchmarks that NDNQI drives actually focus the nurses on key indicators that they need to work towards for the betterment of the patient. It’s improved quality.

KENNETH REMPHER: So the NDNQI, overall, has gone from a database that just collects data to something that we can enforce at the unit level that really holds nurses accountable for providing the optimum patient experience. We’re very proud of one particular unit. In our organization there’s an intermediate care unit that has a relatively high acuity in terms of patients. Where the acuity increases, there tends to be an alignment with increase in nosocomial or even community-acquired pressure ulcers.

This particular unit had a pretty significant rate. Up to 40% of its patients during their stay on this unit were acquiring pressure ulcers, which is an abysmal rate. It’s something that needed to be addressed immediately. Through the use of the NDNQI, we were able to track that data. The nurse manager and the clinical specialist for that service line met with the direct care staff to say, this is not how we practice. This is not who we are. We are much better than this. What can we do to turn this around?

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Accountability and Nursing Practice

Through a lot of creative thinking and through multidisciplinary collaboration, they developed a magnificent program that has resulted in no nosocomial pressure ulcers for 26 months. There was a gradual trend downward. But the important point here is that using this data allowed them to see how poorly they were doing.

It caused them to become creative and to develop through an interdisciplinary process of plan. Implement that plan. Reevaluate the data. Submit it. Come back now, for 26 months, or actually for almost eight quarters, we’ve had absolutely no acquired nosocomial ulcers.

We’ve had the opportunity to influence practice literally around the world. And by doing that, we have been able to, as I said, we’ve consulted with other hospitals, we have presented at international, national, local, and regional poster competitions. We have articles in line for publication at this point. So there’s been a true opportunity, and this has been important for direct care nurses to see that what they thought was mundane and routine can really be construed as something powerful and allows them to see the presence of nursing at the bedside by qualified people can make a big difference.

MARIA MANNA: Traditionally in psychiatry, we don’t see a lot of pressure ulcers. The majority of our patients are up walking around. They’re generally well hydrated. And so we identify that we really needed to make sure that our patients were receiving the appropriate skin assessments, that we were able to recognize wounds that need to be staged, et cetera.

So the nurse felt empowered enough to attend an eight-hour workshop. She initiated that attendance. And then what she did was she created a poster board. A three-part poster board. It’s absolutely beautiful, with pictures of wounds, directions about how to stage, what’s important to look at far as assessment.

And she presented that to her peers so that she could share her knowledge with them. And that in the end, it would go to improving the quality of care that the psychiatric patients would receive. And this again goes to dementia patients who are more debilitated, who do need that additional treatment, perhaps, and may need to have a wound assessed. Now, because she felt empowered to take advantage of education provided and empowered to pass that education along to her peers, the patients can benefit from that. And the other nurses feel that they have the tools that they need to do their job effectively.

In psychiatry, we have not only the patient’s bill of rights that every other patient has, we have a specific patient bill of rights for psychiatric patients. And nurses are responsible for making patients aware of those rights when they’re admitted. Every patient admitted to a psychiatric unit is apprised of those individual psychiatric patient’s bill of rights.

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This is a very vulnerable population. They feel that because of their illness, they, of course, can’t trust people. They have generally struggled with many psychosocial issues. They may not have a lot of family support. So oftentimes, nursing is the identified party that’s going to advocate for that patient when it comes to their right. And a right to refuse medication belongs to that patient.

That’s one of the areas of advocacy. We had a patient admitted to our unit who was certified. That means they were committed against their will because they are considered to be incompetent at the time of their admission. In psychiatry, once treatment commences, people can improve pretty quickly. And so her cognitive state changed.

When this woman was admitted, she had breast [INAUDIBLE] with metastasis and was refusing treatment. She was refusing any diagnostic testing as well. So in order to help her, the treatment team determined that guardianship was probably necessary so that she could take advantage of testing and treatment. And that’s exactly what happened.

Guardianship was pursued. We accomplished that. But in the meantime, the patient’s mental state improved. She was no longer incapacitated. Nursing staff really felt an ethical dilemma existed there because now she had the capacity to make decisions. She had the capacity to understand due to the improvement of her symptoms, yet she no longer had the ability to make her own decisions.

So nurses advocated for her. They called an ethics consult. The ethics committee person met with our physicians and then met with nursing staff to try to resolve the ethical conflicts that they felt on behalf of the patient. So they were advocating again for her right to refuse the treatment. And the result of that, I think, was very gratifying for the nursing staff, and I think the patient felt very supported.

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