Today’s Nursing Practice
It’s as if a quiet revolution is taking hold. On every front—from high-level policy discussions to day-to-day bedside practice—nurses are becoming a more vocal and instrumental component in improving the complex healthcare puzzle. For nurses, it means more leadership opportunities and greater professional satisfaction. For healthcare institutions, it means more widespread use of evidence-based practices and improved work flow. And for patients, it means improved access to safer, more family-centered care and better health outcomes. But it doesn’t come easily.
Changing the way nurses practice involves engagement on multiple levels, beginning with how nursing students are taught. From technology that allows independent manipulation of simulated patients to in-depth research projects that require identifying a problem and making a solid case for its solution, Johns Hopkins University School of Nursing students are learning to become leaders in nursing practice. For examples of nurses already pioneering these important practice trends, they don’t have to look far.
Influencing health policy
Consider Deborah Trautman, PhD, RN. There’s no doubt that she is serious about getting nurses involved in shaping healthcare policy. For almost three years, as a Robert Wood Johnson Health Policy Fellow, Trautman worked on the health policy team of the Honorable Nancy Pelosi, Speaker of the House, United States House of Representatives. Now, as executive director of the Johns Hopkins Medicine Center for Health Policy and Healthcare Transformation, Trautman hopes to continue to build on the concept of nurses as an integral voice in shaping future health policy.
“This is about determining how we can extend collaborations between folks in medicine, nursing and public health to do more to inform policy makers,” she says.
Nurses are a logical choice to contribute ideas that will shape health policy, Trautman believes.
“We are this trusted voice,” she says. Case in point: the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation conducted a survey of opinion leaders, asking which professionals will be most influential in shaping health policy; survey respondents answered “nurses” 13 percent of the time.
And in the current political climate, roiled by partisanship that has stymied efforts at healthcare reform, Trautman sees nurses as a potential voice of reason. “If we can come together and present information in a non-partisan way, it would be pretty compelling,” she says.
This shift will require nurses to make their voices heard beyond boundaries in which they typically operate. “I don’t think everyone needs to knock on the door of the senator,” Trautman says. “But nurses can begin by participating on advisory boards, coupling our content expertise with stories and data…I view it [involvement in healthcare policy] as an extension and an amplification of what nurses have been taught.”
Taking on greater autonomy at the bedside
Oftentimes, handing over greater authority to nurses just makes more sense.
“Because of nurses’ constant presence at the bedside, they’re more likely to monitor patients,” says Deborah Dang, PhD, RN, director of nursing practice, education, and research for The Johns Hopkins Hospital (JHH). This logical approach has led to an increase in nurses managing aspects of patient care that were previously handled by physicians.
One example is the nurse-managed heparin protocol, recently implemented at JHH. Heparin, an injectable blood thinner, had until two years ago been managed by physicians throughout most units of the Hospital. When Peggy Kraus, PharmD, CACP, clinical pharmacy specialist in anticoagulation management, and Dana Moore, former assistant director of regulatory affairs for JHH, introduced the idea to the Hospital’s Standards-of-Care Committee, which comprises nurses, the initial response was cool. “There was resistance, initially. They didn’t know how they’d incorporate it into their workload,” Kraus says.
But with adequate training consisting of a train-the-trainer approach, whereby a nurse is trained on the protocol and then trains other nurses, plus a 24/7 beeper contact that the nurses could rely on for support, the transition went more smoothly than anyone anticipated.
After some hesitation, the JHH nurses embraced their new responsibility. In return, they saw a decrease in patients’ waiting time to receive therapy, an increase in patient safety, and the nurses reported feelings of greater empowerment. “The outcome was overwhelmingly positive,” Kraus says.
Teaching nurses to be agents of change
The School of Nursing’s doctorate of nursing practice (DNP) program acts on the advice of Dang and Trautman, cultivating future nurse leaders to implement healthcare innovations and influence policy.
Students who enter the DNP program come with several years’ worth of nursing experience. Familiar with current nursing practice and eager to apply their problem-solving skills and analytical nature to improving it, DNP students look to the program for a framework in which to pursue their professional interests.
The framework is intensive and research-based, as evidenced by the program’s capstone experience. Designed as a scientific project that draws from existing medical literature and observation, it dovetails with the curriculum and allows the students to shape a project based on their interests and practice. The capstone project is an opportunity to provide structure to an organic way of thinking that comes naturally for critically thinking nurses.
“I knew to think that way, but I didn’t know how to use evidence to make a point and influence care,” says Suzanne Rubin, DNP, MPH, CRNP-P, a 2011 graduate of the DNP program and a pediatric nurse practitioner specializing in newborn health at The Johns Hopkins Hospital. Through her rigorous capstone project, Rubin learned how to quantify her observations and, ultimately, influenced practice.
Her project aimed to reduce the negative outcomes for which late preterm infants (34-36 weeks gestation) are at risk, including hyperbilirubinemia, prolonged length of hospital stay, feeding difficulties and associated weight loss, feeding inadequacy and subsequent unplanned cessation, and increased readmission rate.
To address this range of potential adverse effects Rubin introduced a “late preterm, specialized-care order set” consisting of five specific, practical and research-proven interventions. They included, but weren’t limited to: an increased use of isolette and skin-to-skin or kangaroo care, to reduce bilirubin clearance; early feeding and lactation support; and early monitoring and treatment with phototherapy for infants with hyperbilirubinemia.
Rubin’s project, along with five others, was reviewed by the Perinatal Collaborative (which has since merged with a neonatal network to become the Perinatal-Neonatal Learning Network) and Maryland’s Department of Health and Hygiene. Ultimately, it was chosen as a primary goal to institute in hospitals throughout Maryland.
“The best way to change care is by knowing how to present your measurements clinically, and to change practice at the bedside. To me, that’s where it’s at,” Rubin says.
Although the project is now complete and Rubin has graduated and continues her work as a nurse practitioner, her zeal for identifying opportunities for improvements in nursing practice hasn’t waned. She describes jotting down notes on the infants she cares for in the Hospital. “Then, when I get enough data, I look at the literature to see if my findings are comparable. Then, I get IRB [institutional review board] approval to start looking deeper,” Rubin explains.
Driven to improve patient outcomes and armed with the tools to do so, it’s likely that over her professional lifetime Rubin will support the implementation of many more healthcare innovations. “It becomes really enveloping. And it helps inspire us as change agents.”
Choosing to remain in the trenches while influencing practice
DNP student Sue Kim-Saechao considered getting her PhD in nursing, yet ultimately chose a different route. Many DNP students, herself included, enjoy the in-the-trenches work that nursing practice offers and want to stay in that arena. But they want to be able to effect change in their practice environment. That made the DNP a perfect fit. “With a DNP we’re active clinicians, using research to bring about change,” she says.
It didn’t take long for Kim-Saechao, a full-time nurse practitioner in UCLA Medical Center’s division of Interventional Radiology, to choose the topic of her DNP capstone project. “As a nurse practitioner, you notice certain trends,” she says.
Kim-Saechao observed that PICCs (peripherally inserted central catheters) where she works were being removed prior to completion of therapy in up to 20 percent of patients. “People sometimes forget that PICCs are central lines and with these lines comes a risk. Possibly due to increased vigilance for bloodstream infections or for other reasons, clinicians may request removing PICCs prematurely, despite clear CDC guidelines on the management of intravascular infections,” Kim-Saechao says.
It’s not surprising, then, that Kim-Saechao chose “Inappropriate PICC Removals: A Reason for Change” for her capstone project. The project, which is currently underway, allows Kim-Saechao to work with the Hospital’s infection control team and nurse leadership to decrease inappropriate or unnecessary PICC removals.
It’s an opportunity that Kim-Saechao welcomes. “Sometimes we notice a pattern but don’t really track it. Without that, you can’t make changes,” she says.
Working with interdisciplinary teams for better outcomes
Gail Pietrzyk, a DNP student and director of perioperative services at Crittenton Medical Center in Michigan, isn’t tracking patterns alone. For her capstone project, Pietrzyk is studying the impact of individual variables within hospitals—leadership, demographics, education, and culture—and how they relate to a hospital’s ability to implement quality initiatives.
“There are about 85,000 elective surgeries every day. And 50 percent of hospitals’ adverse events are linked to surgery,” Pietrzyk says. “These are big public health issues.”
Working with the state of Michigan’s Keystone Surgery Collaborative, Pietrzyk aims to identify how these variables promote or impede a hospital’s ability to implement surgical safety and quality goals, and then disseminate her findings among anesthesiologists, nurses, and surgeons who work together.
“The potential to improve patient care and safety through improved performance in quality collaboratives is tremendous,” Pietrzyk says.
Embracing patient- and family-centered care
“In today’s world, it’s no longer enough to be a good clinical nurse. Frankly, clinical skills are only one piece we look at when we hire nurses,” says Sharon Hadsell, senior vice president of patient care services at Howard County General Hospital in Maryland.
Hadsell strongly believes that nurses need to be capable of interacting effectively with a number of players: physicians and other clinicians, colleagues, and—last but not least—patients and their families. “We’re looking more now at the family’s needs—not the provider’s needs,” she says.
Practical changes throughout the hospital, such as rearranging the patients’ rooms to have a “family” side and a “provider” side so that nurses and families each have adequate space in which to work and visit, respectively, improves nurses’ work flow and sets up family members and nurses as partners, rather than adversaries, explains Hadsell.
“All you have to do is think ‘How would you like to have the room set up if it were your mom and dad?’” Hadsell says.
Providing tomorrow’s nurses with practical preparation
Nurses are known for being practical thinkers. It makes sense, then, that nurse educators are applying practical measures to ensure that nursing graduates are better prepared than ever to enter the workforce.
Consider the School of Nursing’s bachelor of science program, which offers as a clinical academic practice partnership (CAPP), an innovative clinical experience with one of four local hospitals. During this clinical practice option, students are paired with a preceptor to acquire specific clinical experience.
“In traditional nursing programs, students will have one or two patients and are on the clinical unit for an abbreviated work day of four to six hours,” Hadsell says. With CAPP nursing students care for between four and five patients for a regular, twelve-hour shift. “We’re trying to more accurately mimic the environment in which students will work,” Hadsell adds.
That doesn’t mean nursing students are left to fend for themselves. “Preceptors have the role of facilitating students in their clinical education,” says Pamela Jeffries, PhD, RN, associate dean of academic affairs at the School of Nursing. “Faculty serve as mentors to the clinical preceptors and as liaisons between clinical practice and nursing education.” She calls it a ‘win-win’ situation, as students get a taste of real-world nursing experience and preceptors take on the role of helping the next generation of nurses.
Evidence Shows Advance Practice Nurse Care Comparable to Physician Care
by Teddi Fine
Writing in Nursing Economics, Johns Hopkins University School of Nursing associate professors Julie Stanik-Hutt, PhD, ANCP/GNP, CCNS, Kathleen M. White, PhD, RN, and colleagues present what Stanik-Hutt calls “the stuff of which new health policy is made.” Their analysis of 18 years of U.S. studies (1990-2008) found care by advanced practice nurses to be of comparable quality, safety, and effectiveness to that of physicians. Stanik-Hutt likens the study to research comparing the relative capacity of two different medications to treat the same illness; here the study compares advanced practice nurse and physician effectiveness when treating people with the same illnesses. The study, conducted by a multidisciplinary team and funded, in part, by the Tri-Council for Nursing, specifically found care by nurse practitioners and nurse midwives is as good as, and in some ways better than, that of physicians. Clinical nurse specialists not only enhanced the quality of care for hospitalized patients, but also reduced unnecessary hospital days, stays, and readmissions.
According to Stanik-Hutt, the findings reflect the distinct but complementary prisms through which nurses and physicians view patients. Physicians treat and cure disease; advance practice nurses see patients, not pathology. Both provide effective interventions, but for different reasons. She says, “The study isn’t about who is a better health provider. Rather, the study suggests the value of enabling both doctors and advanced practice nurses each to do what they do best in a collaborative but autonomous environment. When each profession works to its strengths, without the fetters of current regulatory restrictions, the unique contributions of both shine through. And that’s what I call a win-win for patient care and for providers alike.”