IMPROVING COLLABORATION, COLLEGIALITY AND PATIENT SAFETY. Laura Bozeman, MSN, RN, CNL

Transcription

1 NURSE-LED MULTIDISCIPLINARY OBSTETRIC PATIENT SUMMARIES IMPROVING COLLABORATION, COLLEGIALITY AND PATIENT SAFETY Laura Bozeman, MSN, RN, CNL

2 Since the landmark Institute of Medicine (IOM) report on patient safety (IOM, 2000) was released, quality, safety and efficiency are no longer fleeting considerations in health care. The first decade since the report s release has been tumultuous at best, as health care institutions scramble to identify methods to decrease errors. More recent methods include initiatives such as value-based purchasing (i.e., achieving optimal results for specific medical conditions, which carry financial reimbursement implications) (Porter & Teisberg, 2006). Consequently, nurses must focus their attention on patient care measures and activities to improve outcomes. There is little room for error when nurse and physician providers are forced to move toward specific measurable outcomes. With such initiatives, errors in patient care are ultimately decreased (IOM, 2001; The Joint Commission, 2010). The Joint Commission (2007) has cited communication barriers as the largest contributing factor to patient care errors.

3 SAFETY IN THE OBSTETRIC ENVIRONMENT Obstetric (OB) safety challenges prevail in today s high-risk OB environment, and OB departments are certainly not exempt from mandated improvements. Increased rates of cesarean surgical deliveries, epidurals and complications related to comorbid conditions, such as obesity, diabetes and depression, add challenges for care providers in Labor and Delivery (L&D) (Centers for Disease Control and Prevention, 2010). According to the Michigan Health and Hospital Association (MHA) Keystone OB project, there are three potentially preventable birth injuries for every 1,000 births (MHA, 2011). Created by MHA, the Keystone OB project is an example of one safety initiative incorporated into numerous Michigan OB units (MHA). The project audits practices such as oxytocin administration Bottom Line Gaps in communication can jeopardize patient safety. The obstetric environment presents unique challenges with regard to communication and safety. A system of nurse-led multidisciplinary obstetric patient summaries can enhance communication and collegiality and promote a culture of safety. and interventions for tachysystole. Other OB units may have already implemented recommended practices, such as simulations, safety drills and mandatory certifications, to enhance team communication and patient safety (Knox, Simpson, & Townsend, 2003; Mazza et al., 2008). Implementation of such safety measures should also include collaborative methods to effectively communicate plans of care and necessary changes based on maternal-fetal status (Simpson, James, & Knox, 2006). OUR FACILITY Located in southeast Michigan, our 537-bed regional tertiary care academic facility provides numerous specialty services. The Family Birth Center s L&D department represents one such specialty. Designed as a Level III OB unit, it accommodates approximately 3,500 deliveries each year and includes 7 Laura Bozeman, MSN, RN, CNL, is a full-time clinical nurse leader in Labor & Delivery at St. Joseph Mercy Hospital in Ann Arbor, MI. The author reports no conflicts of interest or relevant financial relationships. Address correspondence to: BozemaLL@trinity-health.org. DOI: /j X x triage bays, 6 antepartum rooms and 16 private L&D suites. At the opposite end of the unit are three operating room suites and a four-bed postanesthesia care unit. The patient population of the Family Birth Center is broad. While most of the women admitted are young and in good health, numerous patients present with very complex issues. OB nurses manage the potential for morbidity and mortality of every patient (see Box 1). In addition to circumventing OB complications in a fast-paced environment, attempting to satisfy patients and families demands and desires can create ongoing challenges for the OB team. COMMUNICATION DEFICITS One proposed communication practice change in our department was a result of several hospital-wide initiatives to increase patient safety. Previously, exchange of patient information occurred numerous times throughout the day within the silos of individual disciplines (i.e., physician-to-physician or nurse-tonurse). There was one time per day, however, when OB residents, attending physicians and nursing staff convened in a 7-minute turnover of patients listed on the labor board (see Figure 1). During this one morning meeting, the OB intern provided a very brief introduction to the inpatient labor patients. There was limited information provided and minimal input from the nursing staff, since they had not yet received a formal nurse-tonurse handoff. Brief patient updates occurred throughout the remainder of the 24-hour period during change-of-shift nursing handoffs. Although frequent briefings or huddles have been shown to be effective communication enhancements (Nadzam, 2009), we wondered whether more formal, multidisciplinary meetings could produce added communication benefits. The old method contained potential communication gaps and opportunities for knowledge sharing. Each discipline had its own team of providers. Bedside nursing handoffs occurred every 4 hours throughout a given 24-hour day, but collaborative discussions between disciplines was not equitable. Other disciplines important to the OB patient s plan of care were not present for any patient discussions. There was no time spent reviewing patient cases with an entire cohesive team. According to Gambino (2008, p. 65), As patient conditions increase in complexity, information in isolation becomes less and less useful for decision making. Additional communication deficits existed. Not all patient cases were discussed. Patients in the antepartum and triage units, as well as postoperative cesarean delivery patients and those recovering from vaginal deliveries were not included in any of formal group report processes. Rather, those patients were discussed in isolated bedside handoffs. Potential concerns were not always communicated or discussed with the entire team. Frequently, patient information exchanged between the OB residents was outdated or contained inaccuracies. Most days, a fragment of time remains informally dedicated to a discussion between OB residents and the on-call , AWHONN

4 Provider communication differences coupled with a fragmented patient reporting process sets the stage for safety lapses perinatologist. Nursing staff who care for the high-risk patients are not active participants in the discussion. Manias and Street (2001) identified numerous studies that demonstrated that nurses are not necessarily confident or assertive during patient care discussions. Comments, such as, I wish I could participate in the maternal fetal medicine discussions I would learn so much about my patient, have been noted among nursing staff. Historically, communication styles differ between nurses and physicians. Nurses narrative communication style is directly opposite from that of physicians, who primarily prefer brief facts (Leonard, Graham, & Bonacum, 2004). In some cases, nurses fear speaking up or avoid physician discussions BOX 1 SAMPLE PATIENT POPULATION Routine Patient Population Average 3,800 deliveries/year Epidural rate = 92% Use of high alert induction drug (oxytocin) Use of high alert pre-eclampsia drug (magnesium sulfate) Numerous patients with BMI >30 Numerous twin gestations/occasional triplets Overall cesarean surgical delivery rate = 32% Samples of High-Risk Diagnoses Postpartum hemorrhage, intraabdominal hemorrhage Substance abuse Pre-eclampsia, HELLP syndrome Chronic disease, such as hypertension, obesity, type 1 diabetes Autoimmune disorders, such as lupus, multiple sclerosis, etc. Ruptured splenic artery aneurysm Cardiac disorders and arrhythmias Infectious illness, such as H1N1 influenza Pyelonephritis with sepsis and acute respiratory distress syndrome; intensive care admissions for ventilator care Invasive lines, such as PICC, arterial line, triple lumen central line October November 2011 Nursing for Women s Health 385

5 FIGURE 1 COMMUNICATION SILOS altogether due to feelings of inferiority. This mentality is generated from a medical model of hierarchy in which physicians are more powerful than nurses (Leonard et al.). Provider communication differences coupled with a fragmented patient reporting process sets the stage for safety lapses (Mann, Marcus, & Sachs, 2006). MULTIDISCIPLINARY COLLABORATION Complexity theory states that complex adaptive systems, such as hospitals, are composed of numerous agents, including patients and any person directly or indirectly affiliated with patients, such as nurses, physicians, ancillary personnel, family members, pharmaceutical vendors, etc. (Lindberg, Nash, & Lindberg, 2008). Complexity theory posits that theories and models, most of which originated in the middle of the 20th century, are no longer effective; that is, individual disciplines can no longer continue to work within isolated care silos (Gambino, 2008). A more effective patient care model encompasses multidisciplinary collaboration, which ultimately enhances patient safety (McCaffrey et al., 2010; Wanzer, Wojtaszczyk, & Kelly, 2009). A collaborative model incorporates a partnership between disciplines and includes knowledge sharing and problem solving, all while placing the patient at the center (Gambino, 2008). However, medical education programs generally do not emphasize collaboration and interpersonal communication skills (Wanzer et al., 2009), and, unfortunately, physicians don t always value information provided by nurses, which can complicate the existing communication challenges between disciplines (McCaffrey et al., 2010). The IOM has published numerous recommendations for increasing health care quality and safety, including five core competencies for integration into the educational curriculum of all health professionals. One of the core competencies includes an interdisciplinary or multidisciplinary approach to patient care that includes collaboration (IOM, 2003). Improved patient outcomes, job satisfaction and nursing retention have been observed when teams work collaboratively (Lindeke & Sieckert, 2005; Wanzer et al., 2009). COLLEGIALITY Coupled with collaboration, professional team efforts should consider the concept of collegiality, where there is equal power or authority from both disciplines when concerns are verbalized (Kramer & Schmalenberg, 2003). Nurses and physicians should exhibit mutual respect and trust for ideas that each discipline brings to the table, recognizing that perspectives may be different but of equal importance (Kramer & Schmalenberg, 2003). Collegiality can be difficult to foster, especially when each discipline evolves from diverse educational backgrounds. A survey administered to a group of medical students for each of the 4-year residency demonstrated that the students perceptions of nurses included lack of academic ability, competence and status (Rudland & Miers, 2005, p. 448). In today s complex health care system, attitudes such as this can be detrimental to the development of collaboration and collegiality and can create communication gaps that jeopardize patient safety. The question remains What methods might improve the gap? 386 Nursing for Women s Health Volume 15 Issue 5

6 NURSE-LED MULTIDISCIPLINARY OB PATIENT SUMMARIES Clinical decision-making is enhanced by the ability to communicate effectively in a multidisciplinary team, not merely within the silo of each discipline (Lindberg et al., 2008). Bringing disciplines together also facilitates knowledge acquisition. In addition, it can create an environment for innovative solutions for managing patient care challenges (Lindeke & Sieckert, 2005). Nurse-led multidisciplinary OB patient summaries (MOPS) represent an enhanced communication process that was created for our OB department as a proposed method to improve collaboration, collegiality and ultimately patient safety. Initiatives to improve communication processes have been at the forefront of our health care facility over the past 2 years. Initial efforts included changing the bedside nursing reporting process during shift change. This was quickly followed by hospital-wide plans to incorporate a multidisciplinary bedside rounding processes. Numerous discussions ensued to determine the responsible discipline to lead the daily rounds. Since our hospital recently supported a program to educate 17 Clinical Nurse Leaders (CNLs), a decision was made by many departments to enlist CNLs as the rounding facilitators. Our L&D department, managed by proactive physician and nurse leaders, quickly embraced the nurse-led rounding concept. Nurse-led MOPS allow all team members to complete disciplinespecific change-of-shift handoffs, followed by a multidisciplinary meeting to summarize updates, identify potential safety challenges and agree on a plan of care The CNL is a new emerging role created by the American Association of Colleges of Nursing (AACN) in Board-certified as advanced generalists, CNLs assume accountability for patient care outcomes (Harris & Roussel, 2010). More specifically, the CNL designs, implements and evaluates patient care by coordinating, delegating, and supervising the care provided by the health care team, including licensed nurses, technicians, and other health professionals (Harris & Roussel, p. 9). Nurse-led MOPS allow all team members to complete discipline-specific change-of-shift handoffs, followed by a FIGURE 2 MOPS October November 2011 Nursing for Women s Health 387

7 MOPS are an exemplar for demonstrating nursing communication confidence, which may remove communication barriers for physicians and nurses multidisciplinary meeting to summarize updates, identify potential safety challenges and agree on a plan of care (see Figure 2). The nurse facilitator makes every effort to complete an overview of all fetal tracings and maternal vital sign trends before the multidisciplinary meeting. A preparatory overview of patient trends brings urgent safety issues to the forefront of the discussion. In the CNL s absence, the responsibility for leading the rounds falls to the charge nurse. Meeting participants include OB nurses, surgical techs, OB interns and residents, OB staff physicians, anesthesia team, pediatric team, division-wide clinical nurse specialist (CNS), departmental CNL and departmental manager. Unlike other hospital departments, and due to the rapid patient turnover of L&D departments, the goal is to conduct MOPS twice within 24 hours, 7 days per week. The MOPS theme is centered on patient safety. The discussion occurs in the departmental reporting area using a dryerase board consisting of each patient s labor graph. Central monitoring is readily available for fetal tracing review. Every OB patient including antepartum, labor, surgical and OB patients housed in intensive care units is presented during the discussion. All care providers are encouraged to consider elements of concern or potential risks by pondering questions such as: What potential risks exist for this patient? (Is there risk of stroke, hemorrhage, sepsis, fetal injury, etc.?) Are there trends that indicate concern? (e.g., vital signs, fetal trends, lab trends, vaginal birth after cesarean [VBAC] concerns, etc.) Is there any information or task that I don t understand or know how to perform? What is the plan of care based on the given information? Do I feel uncomfortable or I am concerned about the plan of care? Do I feel qualified or have I never cared for a patient like this? Are there concerns I would like to have addressed? There may be situations when care providers are unsure of the potential outcome. The MOPS venue provides opportunities for the team to brainstorm, offer next steps solutions or satisfy a lingering question. Obstetricians have posed questions such as, How will the baby s lungs fare since the mother has had preterm premature rupture of membranes for 14 weeks? Nurses have asked questions such as, Is there any evidence to support sending this patient home? The bottom line is that it teaches the team to speak up and work together through issues. No question is considered unreasonable; the prevailing attitude is that this is a safe place to voice your concerns about your patient. BENEFITS Situational Awareness The MOPS process may hold potential future benefits (see Figure 3). First, members of the high-risk multidisciplinary OB team become mindful of situations that may affect their work. Situational awareness may include characteristics of the fetal heart rate tracings, maternal vital sign dynamics, second stage labor duration, high-risk potentials and availability of physician assistance (Mann et al., 2006). As the OB team is briefed, members can anticipate the next event and know what to do if the established plans fail (Knox et al., 2003). The theme of What can happen to this patient today and how do we prevent adverse outcomes? is prominent within the discussion. MOPS clearly accomplish the goal of situational awareness and offer additional input from team members other than the immediate caregiver. Box 2 shows a brief case example of situational awareness in MOPS. 388 Nursing for Women s Health Volume 15 Issue 5

8 Nursing Confidence Second, MOPS are an exemplar for demonstrating nursing communication confidence, which may remove communication barriers for physicians and nurses. Nationally, perinatal safety projects have been implemented and, in some cases, the multidisciplinary component continues to be physician-led (McFerran, Nunes, Pucci, & Zuniga, 2005). With a nurse-led multidisciplinary system, MOPS may eliminate the intimidation factor of communicating with physicians, particularly for new nurses. Equitable Communication Previous studies have noted inequality between nurses and physicians during rounding processes (Manias & Street, 2001). To prevent such inequality, the nurse facilitator utilizes the situation, background, assessment and recommendation (SBAR) format to present each case. The facilitator then calls on the bedside nurse, resident and staff physician to add additional elements. The facilitator always closes each patient presentation by calling for additional comments, which opens the door for any of the other disciplines, such as pediatrics or anesthesia. Presenting each patient using the SBAR format meets physician-desired communication styles (McCaffrey et al., 2010). FIGURE 3 CHALLENGES AND BENEFITS OF NURSE-LED MOPS Simultaneously, encouraging group participation and conversation adds additional details that nurses are accustomed to. The MOPS format appears to utilize communication styles applicable to both disciplines. To further enhance nurse participation and education, the perinatologist has a designated time each day to meet with any available members of the team to discuss high-risk patients. Perinatology discussions should not be limited to a residents only educational forum. Multidisciplinary education sessions and avoidance of a hierarchal communication style may increase mutual respect and add to nurse satisfaction (Manojlovich, 2005; Rudland & Miers, 2005). As the nursing profession faces a future shortage, efforts to increase nurse satisfaction and retention are necessary considerations. MOPS tighten existing gaps for collaboration, collegiality and patient safety. All patients are accounted for, and no patient s story is left untouched. Every care provider team member, nurse, obstetrician, resident, anesthesiologist and neonatologist has a voice to share perceptions and is offered the ability to question. A shared mental model exists. Potentially, up to 30 or more care providers hear each patient s story, creating a larger safety net. Massachusetts General Hospital in Boston successfully accomplished nurse-led rounds in 2008 on its general medical units (Stefancyk, 2008), and physicians acknowledged that the change was very effective (Stefancyk, 2008). Last, and certainly not least, the presence of the divisional CNS adds the dimension of seamless patient care. The CNS is afforded the ability to communicate high-risk patient concerns to the postpartum CNL. Care providers across the continuum are on heightened awareness for high-risk patients. The process also provides an opportunity to identify outcome trends and improvement opportunities. Interdepartmental collaboration is crucial in maintaining patient safety. CHALLENGES The specific nuances of OB units present unique challenges when attempting to coordinate MOPS. Scheduled OB surgeries and procedures, varied physician schedules, mothers actively birthing and antepartum patients who desire uninterrupted sleep all prevent opportunities for a lengthy room-to-room rounding process. Due to these departmental characteristics, the MOPS process is completed within 15 minutes. The nurse facilitator uses SBAR to introduce the patient, then the team must assertively report concerns, ask appropriate questions and define the action plan. October November 2011 Nursing for Women s Health 389

9 One identified gap to the multidisciplinary patient safety rounds is the inability to include the patient or family members as active participants. To incorporate a patient-centered care philosophy, nurses inform their patients of the MOPS process. Patient-specific concerns can be communicated through the patient s nurse and the option for a bedside discussion can be accommodated at the patient s bedside. An additional challenge presented in high-risk OB BOX 2 MOPS CASE EXAMPLE The team is briefed on a full patient census. A patient in one labor, delivery and recovery (LDR) room was noted to have a category III tracing (i.e., absent variability) and presence of decelerations, indicating potential fetal acidemia. At the onset of the MOPS process, the CNL announced a change in order of patient reporting. The evolving situation was announced as the most concerning patient on the board, and there was a necessity to establish an immediate plan of care. A dialogue including all members of the team ensued. The patient was quickly assessed, the team assembled and the patient was transferred to the operating room. departments include frequent patient turnover, which can cause alterations to the departmental atmosphere in a matter of hours. Frequent nurse turnover adds to this complexity. To strengthen the safety net, the MOPS process repeats every 12 hours. In the event that any team member feels a sense of urgency due to rapid patient turnover and/or high acuity, a multidisciplinary team huddle may be requested. This supports an ongoing theme of open communication. The goal of patient safety is the ongoing mantra from department leadership. CONCLUSION The 21st century health care system has been charged with the responsibility to make significant changes. It is no longer acceptable to avoid reportable concerns due to uncertainty or fear of ridicule. In 2007, the Joint Commission released a National Patient Safety Goal to improve communication among caregivers. Institutions are permitted the freedom to create methods to effectively accomplish the goal. Professional nurses should possess confident communication skills equal to their clinical skills (McCaffrey et al., 2010). Nurses should rest assured that their voices matter. All providers responsible for patient care, whether directly or indirectly, are considered critical participants within the complex health care system. Everyone is a vital team member. Individuals who work in teams encounter fewer errors (IOM, 2000). MOPS are one communication method that eliminates hierarchal interference, teaches team collaboration and hopefully 390 Nursing for Women s Health Volume 15 Issue 5

10 reduces errors through an enhanced communication process. All health care professionals should strive for solutions to embrace the IOM goals of patient safety. To date, it has been noted that the OB team asks more questions and contributes more to the discussion surrounding the patients plan of care. Many have verbalized that they like and support the new process. We are hopeful that this enhanced communication process will create improved collaboration, which will ultimately increase patient safety. Ongoing evaluations of the MOPS process will be necessary and will include input from all care provider disciplines. NWH REFERENCES Centers for Disease Control and Prevention. (2010). Maternal and infant health research: Pregnancy complications. Retrieved from PregComplications.htm Gambino, M. (2008). Complexity and nursing theory: A seismic shift. In C. Lindberg, S. Nash, & C. Lindberg (Eds.), On the edge; nursing in the age of complexity (pp ). Bordentown, NJ: PlexusPress. Harris, J., & Roussel, L. (2010). Initiating and sustaining the clinical nurse leader role. Sudbury, MA: Jones and Bartlett. Institute of Medicine. (2000). L. T., Kohn, J. M. Corrigan, & M. S. Donaldson (Eds.), To err is human: Building a safer Health system. Washington, DC: National Academies Press. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. Institute of Medicine. (2003). A. C. Greiner & E. Knebel (Eds), Health professions education: A bridge to quality. Washington, DC: National Academies Press. Knox, E., Simpson, K., & Townsend, K. (2003). High reliability perinatal units: Further observations and a suggested plan for action. ASHRM Journal (American Society for Healthcare Risk Management), Fall 2003, Kramer, M., & Schmalenberg, C. (2003). Securing good nurse physician relationships. Nursing Management, 34(7), Leonard, M., Graham, S., & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 13(Suppl. 1), i85 i90. Lindberg, C., Nash, S., & Lindberg, C. (2008). On the edge: Nursing in the age of complexity. Bordentown, NJ: Plexus Press. Lindeke, L., & Siecker, A. (2005). Nurse-physician workplace collaboration. Online Journal of Issues in Nursing, 10(1). Manias, E., & Street, A. (2001). Nurse-doctor interactions during critical care ward rounds. Journal of Clinical Nursing, (10), Mann, S., Marcus, R., & Sachs, B. (2006). Lessons from the cockpit: How team training can reduce errors on L&D. Contemporary Ob/Gyn, 51(1), Manojlovich, M. (2005). Linking the practice environment to nurses job satisfaction through nurse-physician communication. Journal of Nursing Scholarship, Fourth Quarter 2005, Mazza, F., Kitchens, J., Akin, M., Elliott, B., Fowler, D., Henry E., et al. (2008). The road to zero preventable birth injuries. Joint Commission Journal on Quality and Patient Safety, 34(4), McCaffrey, R., Hayes, R., Stuart, W., Cassell, A., Farrell, C., Miller- Reyes, C., et al. (2010). A program to improve communication and collaboration between nurses and medical residents. Journal of Continuing Education in Nursing, 41(4), McFerran, S., Nunes, J., Pucci, D., & Zuniga, A. (2005). Perinatal patient safety project a multicenter approach to improve performance reliability at Kaiser Permanente. Journal of Perinatal Neonatal Nursing, 19(1), Michigan Health and Hospital Association. (2011). Keystone Ob initiative. Retrieved from ob_overview.htm. Nadzam, D. (2009). Nurses role in communication and patient safety. Journal of Nursing Care Quality, 24(3), Porter, M., & Teisberg, E. O. (2006). Redefining health care, creating value-based competition on results. Boston: Harvard Business Press. Rudland, J., & Miers, G. (2005). Characteristics of doctors and nurses as perceived by students entering medical school: Implications for shared teaching. Medical Education, 39(5), Simpson, K., James, D., & Knox, E. (2006). Nurse-Physician communication during labor and birth: implications for patient safety. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 4(35), Stefancyk, A. (2008). Nurses participate in presenting patients in rounds: Part 2. American Journal of Nursing, 108(12), The Joint Commission. (2007). Communication during patient hand-overs. Patient Safety Solutions, Volume 1, Solution 3. The Joint Commission. (2010). Preventing Maternal Death. Sentinel Event Alert. Issue 44. Wanzer, M., Wojtaszcyzyk, A., & Kelly, J. (2009). Nurses perceptions of physicians communication: the relationship among communication practices, satisfaction, and collaboration. Health Communication, 24, October November 2011 Nursing for Women s Health 391