The EARN Initiative. Structured Rounding in Psychiatry. Michael Hartley, RN, MS, APRN-BC Chief Nursing Executive

The EARN Initiative Structured Rounding in Psychiatry Michael Hartley, RN, MS, APRN-BC Chief Nursing Executive St. Elizabeth s Hospital, Washington, D.C. Janet Merritt, RN, PhD, CNS-BC Assistant Professor Director, Psych/Mental Health Programs The Catholic University of America Washington, D.C. 1

The Problem Recovery focused care has not been actualized for the inpatient psych/mental health units Recovery concepts, trauma informed care need to be incorporated into inpatient care This is an attempt to advance care to include these important concepts. 2

Literature Review and State of the Science Over the past 5-10 years hourly rounds have been initiated on medical/surgical units The research evidence found strong correlations between hourly rounding and Decreased falls Decreased use of call lights Decreased pressure ulcers Increased patient AND staff satisfaction Anecdotal evidence of decreased med errors and a decrease in overtime costs. No literature about rounding on Psych units. Active discussion this spring/summer on the APNA discussion board of safety rounds. There is no evidence of effectiveness of these rounds. We propose researching EARN to determine if there IS evidence that it improves outcomes. 3

Hourly Rounding on Med-Surgical Units The 4 Ps The nurse assesses and responds to needs related to: Pain How is your pain? Medicate patient, administer therapy or schedule for upcoming round contact. Position Are you comfortable? Move up in bed. Re-arrange pillows. Offer extra blankets. Turn patients at risk for skin breakdown. Potty Is this a good time to assist you to the bathroom? Possessions Place telephone / Kleenex within reach, check access to call light. Arrange over- bed table. Fill water pitcher. 4

The hourly rounding initiatives prove very successful in short periods of time. On medical/surgical units the evidence indicates: Reduction in call lights Saved steps for staff Decreased patient anxiety Increased staff satisfaction Improved clinical outcomes Increased patients / families confidence and trust 5

Structured Rounding in Psychiatry In spite of the success of hourly rounding in the medical / surgical settings it has not been widely implemented in psychiatric settings. 6

EARN Structured rounding for Psychiatry (Con t) Goals of EARN are to: Be proactive in identifying client needs, concerns, changes in status Support self efficacy Teach recovery practices Improve safety Decrease patient urgency driven demands Create a Sanctuary Style environment. 7

Theoretical Framework: This approach is consistent with Peplau s theoretical framework emphasizing the nurse-client relationship and the creation of a shared experience with the goal of developing problem solving skills Peplau emphasized the need for a partnership between nurse and client as opposed to the client passively receiving treatment (Wikipedia, 2010). 8

Hourly rounding is: A proactive and intentional approach to patient interaction An approach to make routine or hardwire addressing patients basic needs, even in the presence of conflicting demands, before they become urgent needs. Structured staff /patient interactions, helping to include patients as participants in their care allowing regular, reliable communication and satisfying patients needs. (Recovery focused) 9

Perceived obstacles to structured rounding psychiatry: Psychiatric patients have different needs They are not in their rooms all day They are frequently too disorganized to tell us what they need Milieu treatment encourages more self care 10

New Practice Initiative: EARN Engage Assess Re-Orient / Re-Assure/ Recover Needs met 11

Engage Engage the patient: Make Eye Contact Inquire what current needs the individual has Stop, sit down with the client, assume a posture of active listening Always adding the phrase: I have the time 12

Assess Assess changes in patient status: Mental status Symptom checks Evidence of med side effects Safety status Level of engagement with the milieu Level of activity 13

Re-orient, Reassure, Recover Re-orient clients as needed to person and place Orient client to the schedule and expectations Med times Group schedules Expectations about ADLs Reassure clients: Fear is an underlying emotion in any patient s experience - in any setting. In the psychiatric setting it may be manifested as: The fear of the future Of what is going on in my head Of the individual in the next bed Legal action Any number of other factors. 14

Re-orient, Reassure, Recover (con t) Reassure client that staff are always available Reassure that someone will be touching base with them in another 2 hours (specify the time of the unit rounding schedule; this may vary for clients based on mental status but there should be a minimum such as every 2 hours) During the interactions, teach recovery principles Self management techniques Letting needs be known Teaching active participation in the therapeutic process 15

Needs Met! Clients should feel that their needs have been met Clients should know when a staff member will be meeting with them again 16

Documentation & Data Collection All staff record their EARN contact time (in units) and any observations or ideas for supervision. Staff members list their EARN contacts on the Community Contact Board A log is kept of EARN contact time in units. (Conversion to units 5 minutes or less equals 1 unit) Daily contacts (Scheduled and Other) collected and entered into a spreadsheet. 17

Expected Outcomes: Increased Patient Satisfaction Decreased use of IM and PRN Medications Decreased Seclusion / Restraint Decreased Outbursts Decreased Patient initiated requests. (now met proactively) Increased sense of self efficacy for clients Increased sense of partnership for both clients and staff 18

Future Implications This approach needs to be researched in multiple settings Different types of units, acute, forensic, long term care Different sizes of units With varying staffing mixes In different parts of the country With different patient groups Adults Adolescents and children Geriatric 19

Future Research (con t) After EARN in initiated, outcomes can be measured to determine if there is a significant difference when using EARN Outcome measures that may be measured: LOS Patient satisfaction Seclusion and Restraint usage IM and PRN med rates Staff satisfaction Safety record 20

The EARN Initiative Structured Rounding in Psychiatry Michael Hartley, RN, MS, APRN-BC Chief Nursing Executive 202 645-5355 michael.hartley@dc.gov St. Elizabeth s Hospital, Washington, D.C. Janet Merritt, RN, PhD, CNS-BC Assistant Professor merrittj@cua.edu Director, Psych/Mental Health Programs The Catholic University of America Washington, D.C.

The Problem Recovery focused care has not been actualized for the inpatient psych/mental health units Recovery concepts, trauma informed care need to be incorporated into inpatient care This is an attempt to advance care to include these important concepts.

Literature Review and State of the Science Over the past 5-10 years hourly rounds have been initiated on medical/surgical units The research evidence found strong correlations between hourly rounding and Decreased falls Decreased use of call lights Decreased pressure ulcers Increased patient AND staff satisfaction Anecdotal evidence of decreased med errors and a decrease in overtime costs. No literature about rounding on Psych units. Active discussion this spring/summer on the APNA discussion board of safety rounds. There is no evidence of effectiveness of these rounds. We propose researching EARN to determine if there IS evidence that it improves outcomes.

Hourly Rounding on Med-Surgical Units The 4 Ps The nurse assesses and responds to needs related to: Pain How is your pain? Medicate patient, administer therapy or schedule for upcoming round contact. Position Are you comfortable? Move up in bed. Re-arrange pillows. Offer extra blankets. Turn patients at risk for skin breakdown. Potty Is this a good time to assist you to the bathroom? Possessions Place telephone / Kleenex within reach, check access to call light. Arrange over- bed table. Fill water pitcher.

The hourly rounding initiatives prove very successful in short periods of time. On medical/surgical units the evidence indicates: Reduction in call lights Saved steps for staff Decreased patient anxiety Increased staff satisfaction Improved clinical outcomes Increased patients / families confidence and trust

Structured Rounding in Psychiatry In spite of the success of hourly rounding in the medical / surgical settings it has not been widely implemented in psychiatric settings.

EARN Structured rounding for Psychiatry (Con t) Goals of EARN are to: Be proactive in identifying client needs, concerns, changes in status Support self efficacy Teach recovery practices Improve safety Decrease patient urgency driven demands Create a Sanctuary Style environment.

Theoretical Framework: This approach is consistent with Peplau s theoretical framework emphasizing the nurse-client relationship and the creation of a shared experience with the goal of developing problem solving skills Peplau emphasized the need for a partnership between nurse and client as opposed to the client passively receiving treatment (Wikipedia, 2010).

Hourly rounding is: A proactive and intentional approach to patient interaction An approach to make routine or hardwire addressing patients basic needs, even in the presence of conflicting demands, before they become urgent needs. Structured staff /patient interactions, helping to include patients as participants in their care allowing regular, reliable communication and satisfying patients needs. (Recovery focused)

Perceived obstacles to structured rounding psychiatry: Psychiatric patients have different needs They are not in their rooms all day They are frequently too disorganized to tell us what they need Milieu treatment encourages more self care

New Practice Initiative: EARN Engage Assess Re-Orient / Re-Assure/ Recover Needs met

Engage Engage the patient: Make Eye Contact Inquire what current needs the individual has Stop, sit down with the client, assume a posture of active listening Always adding the phrase: I have the time

Assess Assess changes in patient status: Mental status Symptom checks Evidence of med side effects Safety status Level of engagement with the milieu Level of activity

Re-orient, Reassure, Recover Re-orient clients as needed to person and place Orient client to the schedule and expectations Med times Group schedules Expectations about ADLs Reassure clients: Fear is an underlying emotion in any patient s experience - in any setting. In the psychiatric setting it may be manifested as: The fear of the future Of what is going on in my head Of the individual in the next bed Legal action Any number of other factors.

Re-orient, Reassure, Recover (con t) Reassure client that staff are always available Reassure that someone will be touching base with them in another 2 hours (specify the time of the unit rounding schedule; this may vary for clients based on mental status but there should be a minimum such as every 2 hours) During the interactions, teach recovery principles Self management techniques Letting needs be known Teaching active participation in the therapeutic process

Needs Met! Clients should feel that their needs have been met Clients should know when a staff member will be meeting with them again

Documentation & Data Collection All staff record their EARN contact time (in units) and any observations or ideas for supervision. Staff members list their EARN contacts on the Community Contact Board A log is kept of EARN contact time in units. (Conversion to units 5 minutes or less equals 1 unit) Daily contacts (Scheduled and Other) collected and entered into a spreadsheet.

Expected Outcomes: Increased Patient Satisfaction Decreased use of IM and PRN Medications Decreased Seclusion / Restraint Decreased Outbursts Decreased Patient initiated requests. (now met proactively) Increased sense of self efficacy for clients Increased sense of partnership for both clients and staff

Outcomes thus far (anecdotally) Patients who would tend to isolate are now engaged by the staff on a regular basis Patients now anticipate the EARN contact Staff can no longer let sleeping dogs lie. They interact with ALL clients and can focus on what they can and can t fix There are 8 contacts/day from 7am 11pm 4-6 contacts per shift Regular bed checks are conducted through the night shift 11pm 6 am.

Outcomes, continued Patient satisfaction rates significantly improved! Most of the surveyed patients deemed their unit staff supportive, responsive and approachable 94% of 77 staff respondents felt they made a positive difference for their patients

Unexpected Findings to date: Significant increase in the frequency of staff approaching managers for direction/help. I don t know how to deal with this person. When visitors/hospital administrators come onto the units they are overcome with patient complaints/concerns/needs. Staff refer to the EARN engagements during clinical conferences and care planning meetings.

Future Implications This approach needs to be researched in multiple settings Different types of units, acute, forensic, long term care Different sizes of units With varying staffing mixes In different parts of the country With different patient groups Adults Adolescents and children Geriatric

Future Research (con t) After EARN is initiated, outcomes can be measured to determine if there is a significant difference when using EARN Outcome measures that may be measured: LOS Patient satisfaction Seclusion and Restraint usage IM and PRN med rates Staff satisfaction Safety record

References Patient care: Hourly rounds keep call lights quiet.(2006). Nursing, 36(2), 33-33. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=r zh&an=2009121539&site=ehost-live Halm, M. A. (2009). Hourly rounds: What does the evidence indicate? American Journal of Critical Care, 18(6), 581-584. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=r zh&an=2010464309&site=ehost-live Jacobson, N., & Greenley, D. (2001). What is recovery? A conceptual model and explication. Psychiatric Services, 52(4), 482-485. doi:10.1176/appi.ps.52.4.482