Nurse Led Rounds. 11th Global Forum of Humanitarian Assistance in Cardiology and Cardiac Surgery

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2 Nurse Led Rounds 11th Global Forum of Humanitarian Assistance in Cardiology and Cardiac Surgery International Quality Improvement Collaborative (IQIC) Learning Sessions Geneva June Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder The William Novick Global Cardiac Alliance Nurse Led Rounds by Frank Molloy RN, MSc ANP is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. 2

3 Disclosures Personal and professional observations from over 15 years of international assistance work Covers two large NGO s (current - NCA and former ICHF) No work is proprietary 3

4 Core Messages 4

5 Core messages Rounds - define Other communication agendas Nurse led rounds - how to Experience from sites Visiting teams Pro and con nurse led rounds 5

6 Rounds Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder The William Novick Global Cardiac Alliance 6

7 Rounds Bedside visits by a physician or other health professional to evaluate treatment, assess current course and document the patient s progress or recuperation 7

8 Rounds In a teaching conference which the clinical problems encountered in the practice of medicine, dentistry, nursing, or other service are discussed. 8

9 Rounds 9

10 Rounds Rounds - treatment planning, as a bedside event Information - sequence Discussion and decision Almost always includes teaching Discussion and decision - plan 9

11 Rounds Rounds - treatment planning, as a bedside event Information - sequence Discussion and decision Almost always includes teaching Discussion and decision - plan clinical communication agenda 9

12 Communication Agendas Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder The William Novick Global Cardiac Alliance 10

13 Communicaton Agenda Defined Speaker(s) Specific information Defined time Listeners and Participants Relevant to the information presented 11

14 Communicaton Agendas 12

15 Communicaton Agendas Examples Airline Safety briefing Preoperative time out 12

16 Communicaton Agendas Examples Airline Safety briefing Preoperative time out 12

17 Communicaton Agendas Examples Airline Safety briefing Preoperative time out 12

18 Communicaton Agendas Examples Airline Safety briefing Preoperative time out Reading the rights 12

19 Communicaton Agendas Examples Airline Safety briefing Preoperative time out Reading the rights 12

20 Communicaton Agendas Examples Airline Safety briefing Preoperative time out Reading the rights 12

21 Communicaton Agendas Examples Airline Safety briefing Preoperative time out Reading the rights Information relevant to listener and within the scope of responsibility of the speaker 12

22 Golden Rules - Communication Agenda 13

23 Golden Rules - Communication Agenda Everybody listen 13

24 Golden Rules - Communication Agenda Everybody listen No background conversations 13

25 Golden Rules - Communication Agenda Everybody listen No background conversations No taking calls or looking at phones 13

26 Golden Rules - Communication Agenda Everybody listen No background conversations No taking calls or looking at phones Don t interrupt 13

27 Golden Rules - Communication Agenda Everybody listen No background conversations No taking calls or looking at phones Don t interrupt Speaker - be concise - and correct 13

28 Golden Rules - Communication Agenda Everybody listen No background conversations No taking calls or looking at phones Don t interrupt Speaker - be concise - and correct Listeners - be patient and attentive 13

29 Communicaton Agendas Examples Airline Safety briefing Preoperative time out Reading the rights Information should be relevant to listener and the resposibiitoes of the listener 14

30 Communicaton Agendas Examples Airline Safety briefing Preoperative time out Reading the rights Information should be relevant to listener and the resposibiitoes of the listener 14

31 Communicaton Agendas 15

32 Rounds - Structure 16

33 Rounds - Structure Someone is speaking 16

34 Rounds - Structure Someone is speaking Team is listening 16

35 Rounds - Structure Someone is speaking Team is listening Sequence of information 16

36 Rounds - Structure Someone is speaking Team is listening Sequence of information Added information other team members 16

37 Rounds - Structure Someone is speaking Team is listening Sequence of information Added information other team members Insights, conclusions, 16

38 Rounds - Structure Someone is speaking Team is listening Sequence of information Added information other team members Insights, conclusions, Questions and Plan 16

39 Rounds - Structure Someone is speaking Team is listening Sequence of information Added information other team members Insights, conclusions, Questions and Plan move on. 16

40 Making it work 17

41 Making it work Presenting structure 17

42 Making it work Presenting structure Primary presenter - who? 17

43 Making it work Presenting structure Primary presenter - who? Additional information 17

44 Making it work Presenting structure Primary presenter - who? Additional information Listening structure 17

45 Making it work Presenting structure Primary presenter - who? Additional information Listening structure Know the sequence 17

46 Making it work Presenting structure Primary presenter - who? Additional information Listening structure Know the sequence Dont interrupt 17

47 Making it work Presenting structure Primary presenter - who? Additional information Listening structure Know the sequence Dont interrupt Part of the routine 17

48 Rounds, Handover, OR signout 18

49 Rounds, Handover, OR signout Common features Schedule of who should speak and when Every one else should be listening - or not present The information IS IMPORTANT Transferable team based skills 18

50 Nurse led rounds Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder The William Novick Global Cardiac Alliance 19

51 Nurse led rounds? 20

52 Nurse led rounds? Nurse introduced rounds - nurse is the first speaker on a communication agenda 20

53 Nurse led rounds? Nurse introduced rounds - nurse is the first speaker on a communication agenda Common issues with other clinical Communication Agendas. e.g. 20

54 Nurse led rounds? Nurse introduced rounds - nurse is the first speaker on a communication agenda Common issues with other clinical Communication Agendas. e.g. - OR-ICU (anaesthesiologist or surgeon first), 20

55 Nurse led rounds? Nurse introduced rounds - nurse is the first speaker on a communication agenda Common issues with other clinical Communication Agendas. e.g. - OR-ICU (anaesthesiologist or surgeon first), - end of shift (end of shift person starts), 20

56 Nurse led rounds? Nurse introduced rounds - nurse is the first speaker on a communication agenda Common issues with other clinical Communication Agendas. e.g. - OR-ICU (anaesthesiologist or surgeon first), - end of shift (end of shift person starts), Handovers (Sign-outs, Sign-offs, Hand-offs) 20

57 Clinical Communication Agendas 21

58 Clinical Communication Agendas Quality of information spoken is important Quality of listening is equally important 21

59 Handovers and Rounds - Differences 22

60 Handovers and Rounds - Differences Handover objective is pure information transfer 22

61 Handovers and Rounds - Differences Handover objective is pure information transfer - Go home and don t get called with a question 22

62 Handovers and Rounds - Differences Handover objective is pure information transfer - Go home and don t get called with a question May be less listeners (less pressure) 22

63 Handovers and Rounds - Differences Handover objective is pure information transfer - Go home and don t get called with a question May be less listeners (less pressure) Single responsible individual 22

64 Handover or Rounds - Similarities 23

65 Handover or Rounds - Similarities Rounds - Basic information sequence is same 23

66 Handover or Rounds - Similarities Rounds - Basic information sequence is same Rounds usually closely follows a shift change - Nurse handovers can be a rehearsal for nurse led rounds 23

67 Handover or Rounds - Similarities Rounds - Basic information sequence is same Rounds usually closely follows a shift change - Nurse handovers can be a rehearsal for nurse led rounds Same information structure can be used in both 23

68 Information Structure - nurses 24

69 Information Structure - nurses With a good Information Structure presenting the information - Can be done by nurses at all levels 24

70 Information Structure 25

71 Who is the patient Information Structure Demographics and diagnosis What operation - and when What were the perioperative issues and early post course, recent events What is status and progress in last 12 hours - and now 25

72 Junior Nurses - Information presentation 26

73 Junior Nurses - Information presentation Fact based presentation May miss some rich detail e.g. breath sounds, heart sounds, complexity of operative details Will stick to the script Information may be incomplete - but it is rarely wrong Listener needs to work DO NOT INTERRUPT 26

74 Junior Nurses 27

75 Junior Nurses Generally will not create linkages between systems Story will not have a bias based on an opinion 27

76 More experienced Nurses 28

77 More experienced Nurses Fact based presentation 28

78 More experienced Nurses Fact based presentation Add skills based observations 28

79 More experienced Nurses Fact based presentation Add skills based observations Strays from the script - appropriately links cardiac and respiratory and renal issues in a narrative 28

80 More experienced Nurses Fact based presentation Add skills based observations Strays from the script - appropriately links cardiac and respiratory and renal issues in a narrative May be repetitive, and longer 28

81 More experienced Nurses Fact based presentation Add skills based observations Strays from the script - appropriately links cardiac and respiratory and renal issues in a narrative May be repetitive, and longer Forms an opinion, 28

82 Expert / Advanced 29

83 Expert / Advanced Rich observational information throughout Strays from the script - appropriately links cardiac and respiratory and renal issues in a narrative Summarises based on context 29

84 Depth of Presentation 30

85 Depth of Presentation Basic - Short and Factual 30

86 Depth of Presentation Basic - Short and Factual 30

87 Depth of Presentation Basic - Short and Factual Interemediate - combines some opinions, linkeages and suggests diagnosis from issues 30

88 Depth of Presentation Basic - Short and Factual Interemediate - combines some opinions, linkeages and suggests diagnosis from issues 30

89 Depth of Presentation Basic - Short and Factual Interemediate - combines some opinions, linkeages and suggests diagnosis from issues Advanced - Integrated thinking, informed recommendations, can outline majority of the plan 30

90 Examples - sites Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder The William Novick Global Cardiac Alliance 31

91 Sites AFIC - Rawalpindi STAR hospitals Hyderabad Beijing Childrens Hospital Skopje Paediatrc Surgical Clinic Kharkiv Centre for Urgent and General Surgery Tobruk Medical Centre Guayaquil - Hosp Fco y Casa Bustamante 32

92 AFIC - Rawalpindi 33

93 AFIC - Rawalpindi Collaboration June 2005-Dec 2009 (19 trips) 33

94 AFIC - Rawalpindi Collaboration June 2005-Dec 2009 (19 trips) Nurse Led Rounds - introduced at beginning of our collaboration - nurse educator resident in country in first phase 33

95 AFIC - Rawalpindi Collaboration June 2005-Dec 2009 (19 trips) Nurse Led Rounds - introduced at beginning of our collaboration - nurse educator resident in country in first phase Simultaneous creation of new paediatric team within CICU 33

96 AFIC - Rawalpindi Collaboration June 2005-Dec 2009 (19 trips) Nurse Led Rounds - introduced at beginning of our collaboration - nurse educator resident in country in first phase Simultaneous creation of new paediatric team within CICU Nurse (8-12) v Doctor (1) ratio favourable to nurse led rounds structure 33

97 AFIC - Rawalpindi Collaboration June 2005-Dec 2009 (19 trips) Nurse Led Rounds - introduced at beginning of our collaboration - nurse educator resident in country in first phase Simultaneous creation of new paediatric team within CICU Nurse (8-12) v Doctor (1) ratio favourable to nurse led rounds structure Minimal written structure - mentored and taught sequence 33

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99 AFIC - Rawalpindi 35

100 AFIC - Rawalpindi Sustained outcome Nurses respected in team - clinical judgements Key drivers. leadership from Chief anaesthesiologist - and respected visiting educator, appointment of clinically expert head ICU nurse Handover is to all nurse team - and prepares for round 35

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103 STAR - Hyderabad 37

104 STAR - Hyderabad Collaboration Dec 2009-Dec 2011 (7 trips) Anesthesia led ICU - doctors busy in OR much of the day Nurse led rounds - structure introduced on 2nd or 3rd trip Cultural hierarchy initially different to Pakistan team 37

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108 Beijing Childrens Hospital 41

109 Beijing Childrens Hospital Collaboration 5/2004-9/

110 Beijing Childrens Hospital Collaboration 5/2004-9/

111 Beijing Childrens Hospital Collaboration 5/2004-9/

112 Beijing Childrens Hospital Collaboration 5/2004-9/2010 Nursing team increased in numbers - year new larger ICU 41

113 Beijing Childrens Hospital Collaboration 5/2004-9/2010 Nursing team increased in numbers - year new larger ICU Single intensivist (plus 1 trainee) - 20 nurses 41

114 Beijing Childrens Hospital Collaboration 5/2004-9/2010 Nursing team increased in numbers - year new larger ICU Single intensivist (plus 1 trainee) - 20 nurses Simple sequence - minimal detail in structure 41

115 Beijing Childrens Hospital Collaboration 5/2004-9/2010 Nursing team increased in numbers - year new larger ICU Single intensivist (plus 1 trainee) - 20 nurses Simple sequence - minimal detail in structure 41

116 Beijing Childrens Hospital Collaboration 5/2004-9/2010 Nursing team increased in numbers - year new larger ICU Single intensivist (plus 1 trainee) - 20 nurses Simple sequence - minimal detail in structure 41

117 Beijing Childrens Hospital Collaboration 5/2004-9/2010 Nursing team increased in numbers - year new larger ICU Single intensivist (plus 1 trainee) - 20 nurses Simple sequence - minimal detail in structure NO hierarchical issues (personality of intensivist) 41

118 Beijing Childrens Hospital Collaboration 5/2004-9/2010 Nursing team increased in numbers - year new larger ICU Single intensivist (plus 1 trainee) - 20 nurses Simple sequence - minimal detail in structure NO hierarchical issues (personality of intensivist) Presented in Chinese initially.. then over the space of 2 years almost all nurses learned english. 41

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121 Kharkiv - Ukraine 44

122 Kharkiv - Ukraine Collaboration 5/2008- continuing (32 trips) 44

123 Kharkiv - Ukraine Collaboration 5/2008- continuing (32 trips) Night nurse led handover / rounds at 8am - all teams start at same time 44

124 Kharkiv - Ukraine Collaboration 5/2008- continuing (32 trips) Night nurse led handover / rounds at 8am - all teams start at same time One nurse (night senior) presents every patent - about people listening (or not) - night duty doctor minimal input unless exceptions (critical) 44

125 Kharkiv - Ukraine Collaboration 5/2008- continuing (32 trips) Night nurse led handover / rounds at 8am - all teams start at same time One nurse (night senior) presents every patent - about people listening (or not) - night duty doctor minimal input unless exceptions (critical) Many nurses are 4th year medical students 44

126 Kharkiv - Ukraine Collaboration 5/2008- continuing (32 trips) Night nurse led handover / rounds at 8am - all teams start at same time One nurse (night senior) presents every patent - about people listening (or not) - night duty doctor minimal input unless exceptions (critical) Many nurses are 4th year medical students Core plan made at this round 44

127 Kharkiv - Ukraine Collaboration 5/2008- continuing (32 trips) Night nurse led handover / rounds at 8am - all teams start at same time One nurse (night senior) presents every patent - about people listening (or not) - night duty doctor minimal input unless exceptions (critical) Many nurses are 4th year medical students Core plan made at this round Weaknesses - no individual responsibility, too much background conversation & too much for one person 44

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129 Skopje - FYR Macedonia 46

130 Skopje - FYR Macedonia Collaboration March 2013-continuing (12 trips) 46

131 Skopje - FYR Macedonia Collaboration March 2013-continuing (12 trips) Nursing team only 4 - no interim trip experience as yet, early focus year 1 on tasks and safety 46

132 Skopje - FYR Macedonia Collaboration March 2013-continuing (12 trips) Nursing team only 4 - no interim trip experience as yet, early focus year 1 on tasks and safety Nurse led handover all trips - from visiting team but did not place responsibly on local nurse too early 46

133 Skopje - FYR Macedonia Collaboration March 2013-continuing (12 trips) Nursing team only 4 - no interim trip experience as yet, early focus year 1 on tasks and safety Nurse led handover all trips - from visiting team but did not place responsibly on local nurse too early Newest nurse - age 18, first to present - using guide structure - in Macedonian 46

134 Skopje - FYR Macedonia Collaboration March 2013-continuing (12 trips) Nursing team only 4 - no interim trip experience as yet, early focus year 1 on tasks and safety Nurse led handover all trips - from visiting team but did not place responsibly on local nurse too early Newest nurse - age 18, first to present - using guide structure - in Macedonian Now - patient allocations in SKP, one patent local nurse one visiting team nurse 46

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140 Tobruk - Libya.. nurse rounds here is a very structured handover of facts to the next shift and as yet they have not moved on to critical analysis or even patient comparison... feel more responsible for the patient if they know they have to hand over.. next trip will start asking for their input in planning care 52

141 Tobruk - Libya Collaboration - Feb 2015 Small Nursing team from closed benghazi centre Very early - nurse led handovers.... nurse rounds here is a very structured handover of facts to the next shift and as yet they have not moved on to critical analysis or even patient comparison... feel more responsible for the patient if they know they have to hand over.. next trip will start asking for their input in planning care 52

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144 Guayaquil - Ecuador 55

145 Guayaquil - Ecuador Collaboration

146 Guayaquil - Ecuador Collaboration No nurse led rounds attempted in these first 4 years 55

147 Guayaquil - Ecuador Collaboration No nurse led rounds attempted in these first 4 years Small number of nurses - not consistently allocated to the cardiac side 55

148 Guayaquil - Ecuador Collaboration No nurse led rounds attempted in these first 4 years Small number of nurses - not consistently allocated to the cardiac side Large number of paediatric residents - 2 per shift 55

149 Guayaquil - Ecuador Collaboration No nurse led rounds attempted in these first 4 years Small number of nurses - not consistently allocated to the cardiac side Large number of paediatric residents - 2 per shift 55

150 Visiting teams (or individuals) Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder The William Novick Global Cardiac Alliance 56

151 Can visitors mentor good practice? 57

152 Can visitors mentor good practice? May be first appearance of truly collaborative interdisciplinary working 57

153 Can visitors mentor good practice? May be first appearance of truly collaborative interdisciplinary working Visiting team itself needs a structure 57

154 My Briefing to visitors - Handover 58

155 My Briefing to visitors - Handover Shift Handover - is not the treatment planning round 58

156 My Briefing to visitors - Handover Shift Handover - is not the treatment planning round Information exchange, get people home with clarity 58

157 My Briefing to visitors - Handover Shift Handover - is not the treatment planning round Information exchange, get people home with clarity Presented by the person who is leaving - to ALL ICU TEAM 58

158 My Briefing to visitors - Handover Shift Handover - is not the treatment planning round Information exchange, get people home with clarity Presented by the person who is leaving - to ALL ICU TEAM Don t interrupt 58

159 My Briefing to visitors - Handover Shift Handover - is not the treatment planning round Information exchange, get people home with clarity Presented by the person who is leaving - to ALL ICU TEAM Don t interrupt Save teaching for later 58

160 My Briefing to visitors - Handover Shift Handover - is not the treatment planning round Information exchange, get people home with clarity Presented by the person who is leaving - to ALL ICU TEAM Don t interrupt Save teaching for later No side conversations 58

161 My Briefing to visitors - Handover Shift Handover - is not the treatment planning round Information exchange, get people home with clarity Presented by the person who is leaving - to ALL ICU TEAM Don t interrupt Save teaching for later No side conversations Ensure all have had a chance to clarify before moving on 58

162 Language 59

163 Language Local language preferred 59

164 Language Local language preferred American English is not same as UK engish or Indian English 59

165 Language Local language preferred American English is not same as UK engish or Indian English English as a second language team members - who apparently speak good english still need consideration. 59

166 Language - Avoid Abbreviations CBC, FBC, TBC, BMP, U&E, RBG, BM, O s, I s and O s DC, IDC, ICD, FG & E CVS RS 60

167 Improving the presentation 61

168 Improving the presentation Don t interrupt Junior staff unless completely wrong Presentation should not be from memory - Team responsible for accurate bedside written information Visual or graphical teaching aids - 61

169 Summary 62

170 Improving the presentation 63

171 Improving the presentation 63

172 Improving the presentation 63

173 Pro and cons and - conclusions Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder The William Novick Global Cardiac Alliance 64

174 Why not? 65

175 Why not? Might impose on medical teaching curriculum 65

176 Why not? Might impose on medical teaching curriculum Junior nurse may not correctly report the operation 65

177 Why not? Might impose on medical teaching curriculum Junior nurse may not correctly report the operation Some units more doctors than nurses, - residents need the practice 65

178 Why not? Might impose on medical teaching curriculum Junior nurse may not correctly report the operation Some units more doctors than nurses, - residents need the practice Different model for morning rounds as evening rounds 65

179 Why? Cardiac Surgery VERY suitable 66

180 Why? Cardiac Surgery VERY suitable Operation report should be easily available 66

181 Why? Cardiac Surgery VERY suitable Operation report should be easily available Nurse present at Operation Signout - hears same information 66

182 Why? Cardiac Surgery VERY suitable Operation report should be easily available Nurse present at Operation Signout - hears same information Majority of patients should follow predictable course 66

183 Why? Cardiac Surgery VERY suitable Operation report should be easily available Nurse present at Operation Signout - hears same information Majority of patients should follow predictable course Sequence of events - predictable 66

184 Why? Cardiac Surgery VERY suitable Operation report should be easily available Nurse present at Operation Signout - hears same information Majority of patients should follow predictable course Sequence of events - predictable Morbidity exceptions - recognised - can trigger plan changes 66

185 Why? Cardiac Surgery VERY suitable Operation report should be easily available Nurse present at Operation Signout - hears same information Majority of patients should follow predictable course Sequence of events - predictable Morbidity exceptions - recognised - can trigger plan changes The nurses should know the expected plan 66

186 Features of easy implementation sites 67

187 Features of easy implementation sites AFIC - Rawalpindi, Beijing Childrens Hospital 67

188 Features of easy implementation sites AFIC - Rawalpindi, Beijing Childrens Hospital Nurses outnumber doctors 67

189 Features of easy implementation sites AFIC - Rawalpindi, Beijing Childrens Hospital Nurses outnumber doctors Regular cardiac surgical practice in large numbers (including adults?) 67

190 Features of easy implementation sites AFIC - Rawalpindi, Beijing Childrens Hospital Nurses outnumber doctors Regular cardiac surgical practice in large numbers (including adults?) ICU medical and nursing lead 67

191 My experience - 40 PICU s 24 countries 68

192 My experience - 40 PICU s 24 countries Probably not typical - but is broad 68

193 My experience - 40 PICU s 24 countries Probably not typical - but is broad If Rounds happen - always in the presence of the nurse 68

194 My experience - 40 PICU s 24 countries Probably not typical - but is broad If Rounds happen - always in the presence of the nurse Mostly open plan units 68

195 My experience - 40 PICU s 24 countries Probably not typical - but is broad If Rounds happen - always in the presence of the nurse Mostly open plan units A few sites do partial rounds in office first (x-rays etc..) 68

196 My experience - 40 PICU s 24 countries Probably not typical - but is broad If Rounds happen - always in the presence of the nurse Mostly open plan units A few sites do partial rounds in office first (x-rays etc..) Nurse led rounds is possible - almost everywhere - without structural change 68

197 My experience - 40 PICU s 24 countries Probably not typical - but is broad If Rounds happen - always in the presence of the nurse Mostly open plan units A few sites do partial rounds in office first (x-rays etc..) Nurse led rounds is possible - almost everywhere - without structural change But we are only visitors - can show example - but may not exactly fit the local situation 68

198 final advice Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder The William Novick Global Cardiac Alliance 69

199 try to look interested 70

200 71

201 or.. 72

202 LISTEN attentively 73

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