Taking the Next Step: Collaborative Partnerships, Faculty Mentors and Students Bring QSEN - PowerPoint Presentation

Taking the Next Step: Collaborative Partnerships, Faculty Mentors and Students Bring QSEN to Capstone Course in Nursing 2016 QSEN National Forum May 25-27, 2016 Ellen Moore, DNP, RN, FNP Purdue University Calumet College of Nursing Hammond, IN 46323

AIM:To describe a pre-licensure Capstone course in Nursing that moves away from the traditional preceptor model and integrates QSEN Core Competencies.To emphasize student-centered learning and the role of Faculty Mentors and Collaborative partnerships. To demonstrate the “flow ” in the curriculum-- Quality and Safety for Professional Nursing Practice through Capstone Course in Nursing. To engage students in real-world quality improvement and safety initiatives.

Overview of PresentationRationale for redesigning courseFrameworks that guided redesignEngaging community partnerships Team-driven EBP projects Types of projects Dissemination of projects Lessons learned

Rationale for Course RedesignCall for educational transformation Complexities of nursing practice Competition for clinical sites EBP knowledge transfer and implementation science QSEN integration Experiential learning The need for balance!

Transforming the Capstone Course Frameworks Used

Capstone Course in Nursing

EBP Capstone Project Goals Communicate and collaborate with healthcare professionals to improve patient outcomes through EBP and QSEN competency development. Emphasize quality improvement and patient safety. Disseminate knowledge related to knowledge transfer and implementation science. Expand competencies of BSN graduates as future EBP champions.

How Projects are SelectedRequest form sent to healthcare agencies two months prior to start of semester Agencies identify projects and activities that are currently impacting organization (usually quality improvement and safety initiatives) First day of class students form teams and choose up to 5 projects from final project list Course coordinators assign projects (and make every attempt to be fair)!

The Course Blueprint over 16 weeks! Week 1 Course Overview and Project Start-Up Finalize teams; Prioritize project selection; Assign EBP faculty mentor; Meet with project director Week 2 Project Analysis Project management principle review; EBP review; PICO question; Database search mentor/library scientist; RAPID Appraisal; Teamwork and collaboration; Status reports; Guided reflection via journaling Week 3 Project Design Engaging in self-directed study; Faculty Mentor and Project Director collaboration; Develop PICO Question

The Course Blueprint over 16 Weeks! Week 4 Project Design Engaging in self-directed study; Develop Search Strategy; Faculty EBP Mentor meetings Week 5 Project Design/Intervention Development Applying best available evidence; peer and Faculty Mentor feedback; Critical appraisal; Evidence table; Narrative summary Week 6 I ntervention Development Poster presentation review; Reflective Journal; Status Reports; Teamwork/collaboration review; EBP Plan for Implementation; Plan for Evaluation

THE COURSE BLUEPRINT OVER 16 WEEKS!Week 7 Intervention Development Finalize presentations and posters; peer/Mentor/Project Director feedback Week 8 Summarizing and Integrating QSEN Core Competencies; Week 9-15—EBP Project continuation meetings with Faculty Mentor/Project Director. EBP Showcase/Poster Presentation; Post-Project Review; Final reflective journal; EBP Capstone paper (final paper submitted to SafeAssign )

Course Activities:EBP Process: Ask, Acquire, Appraise, Apply, Asses ( The 5 A’s) Self-Directed Learning; Reflective Assignments; Problem-based learning Peer and Faculty Mentor Meetings; Status Reports QSEN integrationStudent team-led presentations/discussionsMeetings with Project Directors/ Presentations Professional poster developmentSeelio Professional Portfolio SafeAssign requirement Completing the final EBP paper—all sections completed EBP Showcase of posters

Examples of ProjectsQI projects related to harms: CAUTI, ClABSI, Falls, VTE, HAPU, VAP; 30-day readmissions Enhance handoff communication Infant Mortality Increase physician compliance to hand washing; Infection ControlDevelop and implement plan for a stroke prevention unitPolicy/protocol for horizontal violence“Condition H” evidence review/implementation

QSEN—Quality and Safety for Professional Nursing Practice Course Course Objectives:Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making it achieve quality patient care. Minimizes risk of harm to patients and providers through both system effectiveness and individual performance. Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

Assignments and EvaluationParticipation in all in-class activitiesCompletion of Institute of Healthcare Improvement Open School (IHI) Basic CertificationTeam Quality Improvement (QI) written report of projectTeam QI PowerPoint presentationPeer Evaluation of Presentation

An Example of a QI Project--HAPUOur HAPU rates on Unit A have risen significantly over the past 6 months. We have a Wound and Skin Care Nurse (WSCN) who has training in wound care. This nurse does not have a Master’s degree or specialty certification in this area. The Wound and Skin Care Nurse is scheduled to work from Monday through Friday, 8a-5p. The nurse visits every unit and asks about each of our patients. If we identify someone as having a red spot or a potential area of breakdown, we let her know during the rounds.   The WSCN visits patients daily if they are on a computer-generated list of patients at risk for skin breakdown. The list is created when a box is checked in the computerized charting skin assessment area that asks if the patient is on bed rest or is unable to move independently. If a ‘yes’ is checked then the patients name is automatically placed on the list.   The WSCN spends a lot of time on the unit with the biggest problem with HAPU’s, our medical-surgical unit. We sometimes have a problem when a patient needs to be seen by the WSCN but is not on the list. Our current process is to perform the Braden Scale upon initial admission assessment, then once a day, usually during the midnight shifts. The information is entered into the electronic chart (documentation system). We can track the patients’ progress and see what treatments are given to the patient. For the most part, the WSCN does all the treatments unless we are given specific instructions about an individual patient. Because we have a WSCN, the direct care nurses are not familiar with how to care for the patient with skin breakdown unless the WSCN provides specific directions. We need to know what the best practices are for caring for a patient with a HAPU, including nurse driven care versus what the WSCN does for the patient .    

Group Members Amma Afriyie-Bonsu Tiffany Bennett Ranisha Brown-Simpson Janea Edwards Stephanie Norvil Aisha DailyJulia ParkerHospital Acquired Pressure Ulcers

Background of Problem Over the years, hospital acquired pressure ulcers (HAPU) have been a major concern in hospitalized patients . “ More than 2.5 million patients in the United States suffer from pressure ulcers in acute care facilities annually; sixty thousand of those patients die related to the complications of pressure ulcers” (Paul, Hanson, Hasenau & Dunn, 2013, p. 32). HAPU’s are more prevalent amongst patients with restricted/impaired mobility. Because patients are often very ill once admitted to an acute care setting, skin assessments and prevention measures are often delayed after admission. It is stated that “pressure ulcers contribute to extended length of hospital stay, infections, amputations, increased need for specialty consults, increased nursing time, and to the potential for hospital readmission”(Paul et al., 2013, p.32) .

Defining Stages of Pressure Ulcers Stage 1 An area that has non-blanchable redness in intact skin Stage 2 Partial thickness loss of dermis Stage 3 Full thickness tissue loss that may evolve the subcutaneous tissue only Stage 4 Full thickness tissue loss that evolves exposure of muscle, bone, or tendons Unstageable Full thickness loss where ulcer cannot be staged because of eschar or slough Definition According to Swafford et al (2016), pressure ulcers are defined as “any area of skin or been damaged by unrelieved pressure or pressure in combination with friction and shear, typically over a bony prominences in immobilized patients”(p.153 ). Hospital Acquired Pressure Ulcers are acquired within 48 to 72 hours post admission. I.S.K.I.N Bundle I Identifying patients at risk S Surface Selection K Keeping patients turning and moving I Increased moisture and incontinence management N Nutrition and fluid intake

Pico QuestionIn hospitalized patients with restricted mobility, what is the effectiveness of using the I.S.K.I. N. bundles compared to current practices to reduce the rate of hospital acquired pressure ulcers.

Analysis of Current ConditionsAccording to the case study, HAPU rates on Unit B have risen significantly over the past 6 months.There is one Wound and Skin Care Nurse (WSCN), servicing the entire facility Monday-Friday from 8a-5p. The WSCN visits patients based on a computer generated list of patients at risk for skin breakdown. A problem arises when patients that need to be seen do not populate onto the daily list. The WSCN provides all the treatments due to the fact that direct care nurses state that they are not familiar with how to care for the patient with skin breakdown unless the WSCN provides specific directions. Missed Opportunities Floor nurses don’t know the best available evidence for prevention of skin breakdown.Patients are only assessed once during the midnight shift.In order for patients to be seen by the WSCN they must appear on a computer-generated list.

Unit AUnit B Quarter 1 4.3 .66 Quarter 2 2 3.6 Quarter 3.332.33Quarter 4 .332Average Hospital-Acquired Pressure Ulcers on Units

Root Cause Analysis

Fishbone

Action Plan: Target

Who What When Reporting Collaborative approach from all healthcare professionals in the hospital setting such as: WCSN Unit Nurses Patient Care Technicians Registered Dietitian Physicians Unit Managers Nurse Educator PT/OT Work together to assess the patients with HAPUs or at risk for HAPUs. Implementation of the I.S.K.I.N. bundle (as listed above in the Action Plan) Communication is essential to implementation of the I.S.K.I.N. Patients will be educated prior to discharge from the hospital on ways to prevent further skin breakdown This should begin at admission and ongoing until discharge from the hospital The I.S.K.I.N. bundle must be performed every shift and as needed as part of the plan of care During every shift change To nurses at monthly unit meetings Posting data on bulletin boards in employee lounges/breakrooms of data and also weekly newsletters Quarterly meetings with the collaborative healthcare team (as listed under Who) to evaluate the effectiveness of I.S.K.I.N. bundle Evaluation and Benchmark To reduce the occurrence of HAPUs within the facility on all units by 50 % with a targeted timeframe of within six months of implementation and 100% within one year of implementation .

Best Available Evidence Action Plan Frequent position changes (at least every two hours) Avoid friction and shear when repositioning. When repositioning, use proper technique.Implement pressure relieving mattresses or surfaces.Avoid turning patient on an area that is already reddened related to pressure. For pressure ulcer prevention, do not rub or massage area. Emollients can be used to hydrate the skin. Barrier creams to protect skin from increased moisture. Frequent skin assessments per protocol. Nutritional risk assessments with interventions. Additional protein supplements in additional to their regular diet    Alderden et al (2011) list the following best practices in preventing HAPU’s.

Alderden, J., Whitney, J. D., Taylor, S. M., & Zaratkiewicz, S. (2011). Risk profile characteristics associated with outcomes of hospital-acquired pressure ulcers: A retrospective review. Critical Care Nurse, 31 (4), 30-43 14p. doi:10.4037/ccn2011806 Fabbruzzo-Cota , C., Frecea, M., Kozell, K., Pere, K. Thompson, T., Thomas, J. & Wong, A. ( 2016). A clinical nurse specialist-led interprofessional quality improvement project to reduce hospital-acquired pressure ulcers. Clinical Nurse Specialist Journal. doi: 10.1097/NUR.0000000000000191 Joanna Briggs Institute. (2016). Pressure area care. The Joanna Briggs Institute, 1-6. Retrieved from http://ovidsp.tx.ovid.com/sp- 3.19.0a/ovidweb.cgi?&S=GJJCFPJOKFDDGOPENCIKMCGCBHLNAA00&Complete+Reference=S.sh.21%7c2%7c1Spetz, J., Aydin, C., Brown, D. & Donaldson, N. (2013). The value of reducing hospital-acquired pressure ulcer prevalence. The Journal of Nursing Administration, 43 (4), 235-241. doi: 10.1097/NNA.0b013e3182895a3cSwafford, K., Culpepper, R., Dunn, C. (2016). Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit.  American Journal of Critical Care , 25 (2), 152-155 4p. doi:10.4037/ajcc2016963 References

Now TO Capstone Course in Nursing ….EBP Project Example

Capstone Project—Phase IIEvidence-Based Implementation of Baby Boxes as a Preventive Measure to Decrease Pregnant Teen Infant Mortality In Lake County, IN.

BackgroundLake County is ranked in the top 10 counties for having the highest infant mortality rate (IMR) in the state of Indiana with an IMR of 8.5 [per 1,000 infants] between the years of 2009-2013. Within Lake County, the area zip code 46312, East Chicago, has the highest infant mortality with an IMR of 15.1. Infant mortality is defined as, “the death of an infant before his or her first birthday” (Indiana State Department of Health, 2012). Top causes of infant mortality include perinatal complications, congenital malformations, Sudden Unexpected Infant Death (SUID). An unsafe sleep environment is directly related to increased rates of SUID. The Baby Box provides an independent sleep environment fitted with a firm mattress, lacking pillows, materials, or bedding that could cause suffocation. This evidence-based intervention meets safe sleep standards approved by the American Academy of Pediatrics (AAP).

Infant Mortality Rates

ObjectivesDevelopment of an implementation plan to decrease infant mortality rates within Lake County, IN.To develop a prenatal program utilizing the Baby Box as an incentive to provide education and promote safe sleep practices. To collaborate with community clinics and hospitals by engaging stakeholders such as physicians, RN’s, and clinical educators in order to promote continuity of safe sleep education for pregnant mothers. Create a pre/post survey to determine pregnant mothers confidence levels and knowledge of safe sleep practices before and after education.

Databases CINAHL, Cochrane, JBI, Medline, PubMed Keywords “Implementation strategies”, hospital, “implementation framework”, marketing strategy, women, hospitals, infant mortality, “implementation science”, implementation, “infant mortality”, “safe sleep”, “baby box”, “strategies”, “knowledge translation”, “knowledge transfer”, babies, infants, “implementation change”, newborn, marketing, pregnant teens, “ intervention strategies”, “low income”, mothers

Appraisal Tools UtilizedJBI Critical Appraisal tools, CASP tools, and RAPID tools JBI Levels of Evidence Level 2.c -2 Level 2.d- 1 Level 3.b- 1 Level 3.c- 1 Level 4.b- 3Level 4.d- 3Level 5.b- 1

Implementation OverviewThe gap between evidence-based research and implementation into clinical practice is a an unpredictable, slow, and complex process. Models The PARIHS model consists of 3 elements including evidence, context, and facilitation. Barriers Identifying and preventing potential barriers is essential to implementation success. Education Parents mimic behaviors at home practiced by nurses in the hospital. HCPs should correlate the increased risk of SIDS with unsafe sleep environments during parent education.

Implementation OverviewStakeholdersParticipation by all levels of hospital staff improves implementation of innovative evidence-based practices. Target Population Self-efficacy is important to access confidence levels and general knowledge on safe sleep. Most young mothers are in the earlier stages of change and need assistance to move into the action stage. Marketing Print, media, brochures and posters placed in locations such as registration desks, bulletin boards, and in front of scales and in examination rooms.

ImplementationSt. Catherine’s Family Birthing Center showed interest in Baby Box utilization. Presentations for staff education at local clinics are in the process of being arranged.

ImplementationMeeting with project director at 2015 Labor of Love presentation which provided the specific zip codes with the highest IMR to identify our target population.Provided contacts at Greene County Hospital, St. Catherine’s Family Birthing Center, clinics in East Chicago.Plans to assist with staff education presentation at specified community health centers. Teleconferences Baby Box Company- Jennifer Weber plans to aide with creation of a letter of intent for future grants. Stork & Co.- Meena Nutbeam , founder of Stork & Co., provided distribution details specific to her company in Milwaukee, WI. Greene County General Hospital, Linton, IN- Teresa Hutton, OB unit mgr., and Melissa Abbott, quality director, provided information and materials regarding their newly launched Sweet Dreams Baby Bundle incentive program.Propose implementation plan to Tracy Sharp, L&D unit manager at St. Catherine’s in East Chicago, IN.Proposed incentive program consists of:Pre survey completed before the first meeting and post survey completed prior to discharge after delivery.Receive binder and bag at first visit to add materials after each session.Outlined education topics adapted for each individual for each trimester visit.Free materials provided each visit to encourage participation with the Baby Box given at time of delivery in the hospital.

Recommendations Marketing strategies to promote incentive program. Funding sources and grant proposals to purchase and fill Baby Boxes. Identify a facilitator to head incentive program and conduct individualized teaching. Distribute pretest survey at first visit and collect data—Revisit QSEN Tools of Quality Improvement. * Post Survey will be distributed and analyzed in Phase 4. Continued community outreach to clinics to engage more community leaders.

Now to What We Have Learned…

Lessons Learned: Revisit Writing and EBP Literacy Skills related to PICO Question, Keywords, and Searching—Focus on QSEN Core

Lesson Learned: The Importance ofWeekly Status ReportsKeep informed/engaged with project management and team responsibilities Watch for conflict…conflict management principles. Emphasize team contract and “rules.” Barriers and Facilitators for EBP project must be addressed. No substitute for face-to-face contact with project team members!!! Keeping everyone on the same page! PAPER TRAIL ON A REGULAR BASIS!!! 46

Lessons Learned: CommunicationCommunication among teams and agencies—problem solving and conflict negotiation Time management and “emergency management” among students and agencies Student accountability for poster development and professional Showcase Encourage Seelio updates Keeping faculty on same page Each team was very different !

Lessons Learned: Course RevisionsNeed for flexibility in a real world setting! Design project proposals sometimes may take a different direction—manage scope! Attend to EBP barriers and facilitators Importance of student-centered ownership and active participation throughout EBP project with an emphasis on ExL and QSEN competencies

Lessons Learned: Don’t Assume Students Know QSEN Competencies Reinforce selected competencies: teamwork and collaboration; evidence based practice; patient safety; and quality improvement. Teamwork and collaboration Emphasis on knowledge, skills and attitudes!49

Other Lessons LearnedMust start projects selection early Must start project design and implementation early Must start planning showcase early Must start celebrating success early

Our ResourcesExperienced faculty, librarian scientist. good communication , active problem-solving, and “working together” Experienced project directors Students positive with EBP capstone project outcomes (once it is done!) Administrative support and costs associated with poster production and Showcase of EBP projects

PROJECTS EIGHT YEARS LATER… More than 175 projects completed (May, 2016) 25 healthcare organizations partners Undergraduate Research Grants and AwardsHESI scores in all QSEN areas have consistently measured over 1000 to positively since QSEN course began (2012)Local and State collaboration and recognitionNLN Accreditation recognition as strengthStudents obtaining entry level BSN positions based on Capstone strengths

Early Project: CAUTI Prevention

Family Presence During Cardiopulmonary Resuscitation

Creating Evidence-Based Isolation Signage Jillian Kukla, B.A., David Lukomski, B.A., Kerrie Tollerud, B.A., JulieAnn VanVuren, B.A. Purdue University Calumet School of Nursing The new sign layout uses appropriate isolation precautions that are stated in a fifth grade literacy level. The text is 14 point font or larger and is clearly read in black text against a white background. The silhouettes are also clearly visible as black print on white paper and can work as standalone identifiers as to what actions are necessary. Results Abstract Standardizing signage and education materials will simultaneously increase compliance of staff members using personal protective equipment appropriately and decrease the rate of nosocomial infections as well as community-acquired infections. The scope of our project was creating evidence-based isolation signage that is based on the original product presented by Saint Anthony Memorial Hospital. Our literature review showed the original product and other isolation signs available did not follow health literacy research involving public literacy level, appropriate font size for older adults, and clear pictures. We worked with the original product to produce evidence-based signs. Isolation refers to the separation of people who have a specific infectious illness from those who are healthy, as well as restriction of their movement, to stop the spread of the illness Today, isolation is a standard procedure used for patients with tuberculosis and certain other infectious diseases (Siegel, Rhinehart , Jackson, & Chiarello , 2007). Standardizing signage and education materials will simultaneously increase compliance of staff members using personal protective equipment appropriately and decrease the rate of nosocomial infections as well as community-acquired infections. The scope of our project was creating evidence-based isolation signage that is based on the original product presented by Saint Anthony Memorial Hospital. Introduction The book “Health Literacy in Primary Care: A Clinician’s Guide” became the guide book for the creation of the new signage, providing information for proper implementation of signs and information in the appropriate literacy level (Mayer & Villaire , 2007). “Promoting Health Care Equity: Is Health Literacy a Missing Link?” has very clear and concise definitions of health literacy and outlines how literacy affects different racial groups and different levels of education ( Hasnain-Wynia & Wolf, 2010). “Health Literacy: The Gap Between Physicians and Patients” presents statistics showing the gap between the education of staff and patients. They thoroughly cover the concepts of the impact, the assessment, and the addressing of health literacy problems and offer suggestions for assisting with patients of lower health literacy and potential sources for further information for physicians with concerns ( Safeer & Keenan, 2005). The Centers for Disease Control and Prevention (CDC) has created and updated isolation guidelines. Isolation precautions come from these CDC guidelines, and these guidelines are used in creating isolation signage (Siegel, Rhinehart , Jackson, & Chiarello , 2007). North Carolina becoming the “first state to have a ‘voluntary’ unified color scheme for isolation signage” (Hoffman, 2007). Our research shows that there are plenty of isolations signs other than North Carolina’s. With all of the different signs available, there is a variety of designs used involving different content, colors, pictures, and phrases. Review of Literature Our literature review showed the original product and other isolation signs available did not follow health literacy research involving public literacy level, appropriate font size for older adults, and clear pictures. We worked with the original product to produce evidence-based signs. We also needed to incorporate Spanish into the signs in a way that was simple to read and understand. The original signs had North Carolina isolation sign colors, which were the first color standards used and were incorporated by Washington State for their isolation sign standards, so we continued to use those colors so that the new signs will follow those standards already in place. Methods The new signage is not ready, at its current status, to be put up into Indiana hospitals. What we did complete is a product that, if used as the base by which future work is done, will protect patients, staff, and visitors of the hospitals of the state of Indiana. The signs can assist with lowering infection rates because the instructions are easily understood. The first recommendation for future work is to have the Spanish on the signs viewed by a professional translator. Another recommendation is to have the signs evaluated in the community. This process could also be completed for the appropriateness of the Spanish translations. A final recommendation would be for the CDC to create isolation signs for use nationally. Conclusion Faculty Preceptor: Ellen Moore, RN, MHSN, SNP-BC Project Director: Janene Gumz -Pulaski, RN, BSN, MBA, CIC Saint Anthony Memorial Hospital Dr. Peggy S. Gerard, DNSc , RN, Dolores Huffman, PhD, RN Atom Groom Design Acknowledgements References List available upon request

Monitoring Outcomes

Looking Towards the Future…We thank all of our Capstone students and healthcare partners who were actively involved in preparing for the challenges that lie ahead. We embrace a learning organization culture that supports innovation…and…it has been an exciting ExL experience that will continue to grow!

Thank YOU!T