NICHE Online Connect Webinar The Miriam Hospital (TMH)

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1 A Collaborative Approach Amongst Registered Nurses and Certified Nurse Assistants to Improve Nurse Satisfaction and Selected Patient Outcomes Kelly Castle MBA, RN-BC, Erin Dellagrotta BSN, RN-BC, Nelia Sousa BSN, RN, Martha Watson MSN, RN, CNS-BC, Karen Joost MS, RN, NE-BC, Cynthia Padula PhD, RN, Carolyn Piatek, MA, RN The Miriam Hospital (TMH) Located in Providence, RI NICHE Member Five-time, consecutive Magnet designee Private, not for profit Academic medical center Specialties in Cardiology, Orthopedics, Oncology, Bariatrics 247 Beds, acute adult care NICHE Online Connect Webinar

2 Background 4 East 30 bed medical-surgical telemetry unit Review of 2011 NDNQI scores revealed dissatisfaction in regards to staffing and resource adequacy on the unit Employees also verbalized a decrease in job satisfaction, ineffective delegation and decreased accountability amongst their peers. Literature Review Job Satisfaction of Hospital-Based Registered Nurses Garon & Ringl Literature review Understanding RN and Unlicensed Assistive Personnel Working Relationships in Designing Care Delivery Strategies Grant & Potter Qualitative study Literature Review Critical Thinking, Delegation, and Missed Care in Nursing Practice Bittner and Gravlin Qualitative study NICHE Online Connect Webinar

3 Purpose To explore the impact of a structured educational intervention, designed to improve a collaborative approach to work flow between RNs and CNAs, improve staff satisfaction, teamwork, and selected patient outcomes. Goals Short Term Improvement in teamwork Improvement in staff satisfaction Long Term Decrease in sitter cases Decrease in patient falls Past Practice CNAs were not assigned or working cohesively with specific nurses throughout their shift. CNAs could be involved in the care of up to a 30 patients within one shift. No reporting structure between RNs and CNAs Secretaries did not have a standard approach in directing patient call lights. NICHE Online Connect Webinar

4 Implementation Phase One All staff attended two one-hour mandatory educational sessions. Participants were asked to complete two surveys prior to the first educational session: How Well Are We Working Together NDNQI Adapted Index of Work Satisfaction Task Subscale Instruments The How Well Are We Working Together Survey Developed by a member of the Lifespan HR team Measure: teamwork RN to RN Interaction Subscale of the NDNQI Adapted Index of Work Satisfaction Task Subscale Widely used NDNQI measure Measure: staff satisfaction The How Well Are We Working Together Survey Developed by Dept. of HRD at Rhode Island Hospital, circa, NICHE Online Connect Webinar

5 RN to RN Interaction Subscale of the NDNQI Adapted Index of Work Satisfaction Task Subscale Adapted Index of Work Satisfaction Nursing staff (RNs, CNAs) with whom I work would say that: 1. They are satisfied with the nursing care they provide to patients. a. Strongly agree b. Agree c. Tend to agree d. Tend to disagree e. Disagree f. Strongly disagree 2. They could do a better job if they did not have so much to do all the time. a. Strongly agree b. Agree c. Tend to agree d. Tend to disagree e. Disagree f. Strongly disagree 3. They have plenty of time to discuss patient care problems with other nursing staff.* a. Strongly agree b. Agree c. Tend to agree d. Tend to disagree e. Disagree f. Strongly disagree 4. They have sufficient time for direct patient care. a. Strongly agree b. Agree c. Tend to agree d. Tend to disagree e. Disagree f. Strongly disagree 5. They have plenty of opportunity to discuss patient-care problems with other nursing service personnel.* Educational Session One Session 1 60 minutes 1. Completion of 2 surveys (How Well Are We Working Together & NDNQI Adapted Index of Work Satisfaction) 2. Introductions, Description of Purpose of these sessions & the project Roles & Responsibilities and the new Communication Structure 3. What Is GENESIS & Advanced GENESIS? 4. This Project as a pilot and performance expectations Implementation Phase Two One CNA is assigned to work with 2-2 ½ RNs for the entirety of the shift. A brief report is given to CNAs by their corresponding RNs within the team. Report is focused on the current plan of care and goals for each patient, with the incorporation of GENESIS protocols. A secretary algorithm was utilized to route all patient call lights to the designated individual within the team. NICHE Online Connect Webinar

6 Implementation Phase Two (continued) Daily Assignment Sheets were updated to reflect new model Staffing Scenarios identified based upon patient volume and available staff on the unit Suggestion Box Unit Secretary Algorithm Utilized to triage patient call lights to the appropriate member within the team Patient call lights regarding pain of any nature, IV pumps, and specific requests to speak/see RN bypass the CNA and are reported directly to the RN. Available to assist patient (STOP) Primary RN unavailable Patient Calls CNA within team Call primary RN within team Unavailable to assist patient Primary RN available (STOP) Call secondary RN within team Updated Assignment Sheet NICHE Online Connect Webinar

7 Staffing Scenarios What didn t work today? Please indicate what inhibited the team model approach today: Date and Shift Insufficient Staff: Number of RNs CNAs Secretaries Sitter Cases: Please specify medical record number of patient MR Other (specify): Challenges Four common themes were identified amongst staff Insufficient Staff Good concept (referring to research project) but failed due to lack of CNA. Organization Secretaries over-heading throughout the entire unit to help a patient [instead of calling specific team members]. Staff Duty Issues RN s not helping CNA s with patient care. Circulating CNA Don t like being in circulation- prefer own assignment. NICHE Online Connect Webinar

8 Educational Session Two Session 2 60 minutes 1. Welcome Back Overview of Session 2 2. Questions about material in session 1 3. Delegation & Some techniques 4. Push Back & Other difficult communication/team situations -Some techniques 5. What Didn t Work Today Feedback Check sheet Leadership Response Active role in training educational sessions Leadership presence on the unit Setting expectations to new employees Review of concerns at staff meetings and unit council How did we do? NICHE Online Connect Webinar

9 Pre/Post Scores: How Well are We Working Together Range of scores: 1-5; 1 = Strongly Disagree; 5 = Strongly Agree * = statistically significant difference Pre/Post Scores: Adapted Index of Work Satisfaction, Task Subscale Range of scores 1-6; Items 1, 3, 4, 5: 1= Strongly Disagree; 6 = Strongly Agree Items 2, 6: 1= Strongly Agree; 6 = Strongly Disagree *= statistically significant difference NDNQI Practice Environment Scale NICHE Online Connect Webinar

10 HCAHPS Implications for Practice Improvement in six of the major categories in the NDNQI survey. Post implementation, unit based surveys demonstrated an increase in work satisfaction and cohesion and a statistically significant improvement in many of the survey categories. An increase was noted in the two categories driving the inception of the project, staffing resource and adequacy and group cohesion. Improved communication, accountability, and efficiency for RNs and CNAs, which may result in improvement in cohesion, retention, and ultimately patient outcomes. Today How are we working together today? NICHE Online Connect Webinar

11 Questions References Bittner, N., Gravlin, G. (2009). Critical thinking, delegation, and missed care in nursing practice. The Journal of Nursing Administration, 39(3), Garon, M., Ringl, K. (2004). Job satisfaction of hospital-based registered nurses. Online Journal of Clinical Innovations, 7(2), Grant, E., Potter, P. (2004). Understanding rn and unlicensed assistive personnel working Relationships in designing care delivery strategies. JONA, 34(1), National Database of Nursing Quality Indicators. Available at Accessed May 2012 NICHE Online Connect Webinar