The Patient Comes First

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April Rufus, a clinical associate on Osler 8, helped develop a protocol and visual aid for novices learning how to suction patients.

New programs empower clinical associates, improve collaboration with nurses

By Stephanie Shapiro

Over the years, Osler 8 nurse manager Sandra Garlic, BSN, grew weary of losing reliable clinical associates because they felt undervalued and overworked. “I’ve seen some excellent CAs come and go on my unit because of their frustrations and not having enough of a voice in decisions,” Garlic says.

As Johns Hopkins nurses increasingly manage computerized records and medication administration, clinical associates have taken on more responsibility at the bedside. It is the CAs who place and remove straight catheters, change dressings, draw blood, take vital signs, administer EKGs and glucometer finger sticks, and frequently are the first to note changes in a patient’s baseline status.

What’s more, experienced CAs stand ready to help new nurses. “I may not be an RN, but I’ve been in codes,” says Theresa Toppin, a CA in Weinberg. “I will be at your back when a code happens, even if you don’t know what’s going on or this is the first code you participate in. I’m strong enough to be behind you so that your patient won’t know that this is the first code you ever participated in.”

Despite the wealth of experience and support Toppin and other clinical associates contributed to a unit, they were often left out of daily reports and their opinions were frequently ignored. Nor were CAs equipped to lobby on their own behalf.

Through a host of initiatives, nurse managers and their colleagues throughout Johns Hopkins have enlisted the clinical associates in a campaign to boost their confidence and stature in the workplace. It is a continuing effort that demands new protocols, as well as mutual respect, essential to teamwork. The solution is not “just putting tools in place that mandate what’s going to happen,” stresses Pat Sullivan, MS, RN ’77, a nurse manager on Meyer 3. “It’s changing the culture.”

When CAs from Osler 8, Meyer 8, and Nelson 7 gather for meetings of the SOARING program, the proceedings begin with I Believe I Can Fly, the group’s theme song. In 2002, Garlic established SOARING, based on the principles of Success, Ownership, Accountability, Respect/Responsibility, Independence, Integrity, and Growth. At these meetings, Garlic and hospital nurse educator Margo Preston Scott, MSN, RN, cover the basics of conflict resolution, communication strategies, prioritizing, how to avoid chronic absenteeism, and other skills. Once SOARING launched, Scott took the lead, preparing lesson plans, giving presentations and inviting guest speakers. Increasingly, Garlic and Scott have given CAs the floor to make presentations as well. “Sandra and I want this to be their meeting and to feel good they’ve been at SOARING even if there’s tough stuff to talk about,” Scott says.

Garlic, who will receive her MSN from Johns Hopkins University School of Nursing in December, and Scott advocate on the behalf of CAs with nursing staff, while also urging them to solve problems on their own. Program participants recognize that “they’re the best advocates for themselves,” Garlic says. “Now, nurses respect their opinions, because they’ve learned what a CA can do and listen to them.”

Motivated by new-found confidence, Christine Wilson and April Rufus, both CAs on Osler 8, developed a protocol and visual aid for novices learning how to suction patients. After approval by Garlic, the protocol was introduced to the unit during an in-service training by Wilson and Rufus. Without SOARING, “We probably would have discussed the suction protocol among ourselves [and left it at that],” says Wilson, who is enrolled in an RN program at the Community College of Baltimore County.

Though skeptical at first, Phyllis Oseni, another CA on Osler 8, found that participation in SOARING paid off in very practical ways. “We did a skit one time about how your tone is if you ask somebody to help you,” Oseni says. “A week later, I really needed some help moving a patient, and another CA said she was busy. I thought about the skit, and I didn’t get mad, even though that person could have helped.”

Recently, a second SOARING program launched for CAs on CMSC 9, Nelson 8 and Osler 5. “I would love to see it go hospital-wide,” Garlic says.

Meanwhile, a systems analysis told Sullivan, Meyer 3 nurse manager, that poor communication between nurses and CAs assigned to observe high-risk patients jeopardized everyone’s safety.

Clinical associates on Meyer 3 often spend most of their shift observing and interacting with patients at risk for suicide. And yet, Sullivan says, “They’re not used to contributing in rounds, because they have felt like nobody’s listening to them. Some of it is self-perception, not believing they’re important. We try to bring them in and support their efforts.”

Sheila T. Johnson, a CA for 21 years, helped to revise a patient report sheet to en-sure critical information is updated shift to shift based on behavioral observations made by CAs. Johnson contributed to the effort as a member of a multidisciplinary task force that included Sullivan, nurse clinicians Karin Taylor, PMHCNS-BC and Elizabeth Scala, IIE- PACE, as well as a PI team leader and attending physician.

Designated by her peers as one of the unit’s “lead CAs,” Johnson now works hand in hand with the charge nurse, participating in daily milieu rounds and reports. “To know you’re being heard and something’s being done about what you’re saying makes you feel like you’re really part of the team,” she says.

Marian Richardson, MSN, RN, AOCN, a nurse manager in the Department of Radiation Oncology, has always valued the role played by the CAs throughout Weinberg and sought ways to build upon their enthusiasm.

When communication faltered between nurses and clinical associates in various Weinberg departments, experienced CA Roslyn Watson approached Richardson with a plan to hold educational seminars for her peers.

“I just saw what was needed on the floors,” Watson says. “Talking to Marian, I knew the nurses and CAs needed to be a team and that’s my goal, to make all of us a team.”

Richardson readily agreed to support Watson’s efforts, which began with building morale among her peers. “The CAs play a vital role in the functioning of our clinics,” Richardson says. “We wanted to recognize their contribution and provide educational meetings to enhance their skills.”

In less than a year, Watson and a committee of other experienced clinical associates have established a monthly series of seminars where CAs learn communication and coping skills, participate in training programs and receive information about educational opportunities. Last October, Weinberg clinician associates also held the first “CA Week,” complete with health screenings, massages, and guest speakers.

“Basically, our whole idea for this program is that the patient comes first,” Watson says. “No matter how hard the job is, the patient comes first. And everyone’s going to be a patient one day.”

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