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Compiled by | Jordan Colwell, MHA, BSN, RN Contact | Jordan Colwell, MHA, BSN, RN P 308.630.1450 E Jordan.Colwell@rwmc.net 4021 Avenue B Scottsbluff, NE 69361

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Table of Contents A Note From The Editor

Service Excellence

A Message From Shirley

Breakfast with Shirley

Professional Development

Clinical Coordinator Corner

Special Article

Shared Governance Updates

Survey Preparedness/Magnet Coordinator Greetings and welcome to this edition of the Magnetic Times! I hope everyone is having a great summer and taking many vacations as the school year is fast approaching.

F. Jordan Colwell F. JORDAN COLWELL, MHA, BSN, RN Survey Preparedness/Magnet Coordinator

June and July are often months to play catch up on projects and tasks started at the beginning of the year. But these past two months one of the Patient Services Shared Governance Councils has excelled and not relaxed since starting their project last year. I would like to spotlight the Patient Care and Practice Council led by Janelle Schroeder, Chair; Brooke Borgman, Chair-elect; and Sarah Shannon, Management Advisor. These three individuals, along with their council members, have been instrumental in getting the new falls program off the ground and implemented. On June 3 the Acute Rehab Unit (ARU) began the pilot launch with the new Hendrich II Fall Risk Model. This model is a

valid research-based assessment that can help with the prediction of falls. It also helps identify appropriate fall risk interventions according to the patient’s area of risk. Prior to this implementation, Regional West Medical Center did not have a formal fall prevention program. Due to this council’s diligence and perseverance, Regional West now has a formal evidencebased fall risk model that will be used across the house in all areas of clinical practice. At this time, ARU is 31 days without a patient fall! If you see members of this council or their leaders, please tell them “thank you” for helping continue to make our patients safe! Yours, Jordan

Have you ever had one of those conversations where you walk away wondering, “Okay, exactly what am I supposed to do now?” Patients sometimes feel that way after their interactions with us as health care providers. Most patient complaints are related to communication problems rather than poor medical care.

Shirley Knodel SHIRLE Y KNODEL, MS, RN Chief Nursing Officer VP of Patient Care

A 2011 study of communication skills training effectiveness summarized communication as sensitivity to verbal and nonverbal messages, effective listening, and responding (Mehmet Ak, 2011). Communication skills are innate and intuitive, but also are able to be learned and are teachable. As with any skill, we move through a process of learning that takes time and practice to perfect. This study measured patient satisfaction scores before and after staff communication skills training. The communication skills training dramatically improved the patient satisfaction scores with nursing kindness. The perception of individualized attention given as well as devotion to

adequate time to listening both improved. The number of patient complaints decreased. The lesson from this is that we all need to seek opportunities to learn to improve our communication skills and to take the time to practice them. If we are able to improve our patients’ satisfaction by conveying empathy, actively listening to them, and responding in a warm friendly manner, their stays will be improved and our work will become more enjoyable. Mehmet Ak, O. C. (2011). Communication Skills Training For Emergency Nurses. International Journal of Medical Sciences, 397-401.

“The greatest illusion in communication is the idea that it has been accomplished.” —George Bernard Shaw

Melissa Snyder, BSN, RN New Clinical Coordinator, 3rd Floor Stacey Powell, BSN, RN New Clinical Coordinator, 2 West

I started my new position as Clinical Coordinator on 2 West in April. My most recent position was a staff nurse and back-up Charge Nurse on 2 West/2 East. Before that I was a school nurse, worked as a Head Start health coordinator, and have also worked in the pediatrician’s office. I started my career as a staff nurse on Pediatrics and then spent two years on 2 West before going back to pediatrics. Nursing is all I have ever wanted to do. I like helping people and love the diversity that nursing provides. I graduated from UNMC CON in 1990 and hopefully will start the LEAD program with an education track this January. My one piece of advice I would give a new grad is to always ask questions, don’t be afraid to ask for help, and never stop asking why.

I started my new position as Clinical Coordinator of the Medical Oncology Unit in March. I graduated from the University of Nebraska College of Nursing with my Bachelor of Science Degree in 2007 and am currently enrolled at the University of Nebraska Medical Center working on my master's degree in leadership and education. I began my nursing career on the Medical Oncology Unit here at Regional West. After a few years I transferred to work in the Intensive Care and Progressive Care Units, which taught me many skills—I gained a vast amount knowledge while working there. After enrolling in school for my master's degree and taking classes, that path eventually led me back to the Medical Oncology Unit as the clinical coordinator. My grandmother was diagnosed with breast cancer, which later metastasized. I watched her go through chemotherapy, radiation, and finally finish her life on hospice. As this was hard to watch, it really made me realize life is a gift. It has helped me appreciate the different stages she had to go through, which helps me be able to relate better to patients and their families. Cancer patients

touch my heart because sometimes they are going through the hardest trials, yet they are the most positive and inspiring people. My one piece of advice for new nurses is to learn everything you possibly can about nursing. You may think it does not apply to you now or it is not pertinent to your current job but at some point you may need that knowledge or skill to work in an area, or you may need to understand someone else's perspective from their unit or department, so gaining the knowledge now will help you later. It has been a pleasure working with all the clinical coordinators throughout the entire hospital. Each department and unit has its own unique skills but in the end we are one TEAM working together to help all of our patients and be there to support the staff. "The strength of the team is each individual member. The strength of each member is the team." —Unknown

Patient Care and Practice members educating ARU staff for New Falls Program during staff meeting

Social Media: Who is listening? Who is watching? “Hey Suzie, heads up on 6 north. Miss Ford has her broom out, what a witch today! The guy you told me about in 608 is really a pain; did you see his gross wounds? Whines and complains all the time. And co-worker Andy is falling all over himself for Nancy Jane. Really? Hope you have a better night than me, it was awful with two codes and not enough help, again! Sal.” Sounds innocent enough for Facebook or other social media, doesn’t it? Unfortunately messages similar to this and those that are even more graphic can be read by many people on a daily basis. Twitter, blogs, Facebook, and other sites often carry messages intended by the writer for one person but may be viewed by many. Caution must be taken to guard against content that may be inappropriate. In the above message, the manager was criticized, a patient identified by room number and symptoms, and a coworker gossiped about. Other privileged information also was released (codes) and, again, the organization criticized in the staffing for the shift. These are unprofessional statements for any public media system. Nurses are using blogs, chat rooms, and other social networking sites on an increasing basis. The Internet is one means of releasing tensions that occurred at the work place. Studies have shown that journaling and reflective practices are valuable tools for nurses. Self-debriefing practices do help release negative emotions and allow the channeling of the negative energy to a less destructive path, even if the material is meant for one other person.

It is easy, though, to disclose too much information in an emotionally charged message and, therefore, violate patient privacy and confidentiality. Instances of inappropriate use of social and electronic media may be reported to the State Board of Nursing (BON). The National Council of State Boards of Nursing, of which the Nebraska BON is a member, has statement papers with rules guarding the rights of others that are infringed upon by the nurse in inappropriate networking. A BON may investigate reports of inappropriate disclosures on any type of social media, including some gaming programs, by a nurse on the grounds of: •

Unprofessional conduct

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Unethical conduct

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Moral turpitude

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Mismanagement of patient records

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Revealing a privileged communication

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Breach of confidentiality

If allegations are found to be substantiated, the BON may place upon the nurse disciplinary action including a reprimand or sanction, assessment of a monetary fine, or temporary or permanent loss of licensure.

Kathi Yost Kathi Yost, RN (Retired) Outpatient Surgery Staff Nurse Professional Practice Committee member State Board of Nursing member

The Shared Governance Professional Practice Council has submitted a statement concerning the use of social media in relationship to the professional practice of any nursing employee. This includes licensed persons, CNAs, and students at all levels. The statement is before administration and it will be the expectation of Regional West Medical Center for nursing staff to comply with the statement once it is released. A full article from the National Council of State Board of Nursing (NCSBN) was reprinted in the Nebraska Nursing News this past year. Every licensed nurse in Nebraska receives this magazine four times a year. The magazine keeps you updated on the regulation changes pertinent to your practice and offers valuable articles for you to read. A copy of the full article is available from Jordan Colwell, Magnet Coordinator, if you would like to read it. Information for printing came from the NCSBN article and other available material. When writing a message to your friend, think HIPAA before you press “send!”

Summer Parker Summer Parker Service Excellence Manager

Over the next few months I will be working with all departments within Regional West Medical Center to help improve patient satisfaction survey scores. We will be focusing on implementing two tools that have been proven to improve communication with our patients.

No doubt Key Words and AIDET benefit hospitals financially in many other hard-tomeasure ways. They reduce errors and improve compliance, and they improve employee satisfaction, which decreases costly turnover and attracts the best new talent in the field.

The first tool that we will be implementing is AIDET/Key Words at Key Times. What are Key Words at Key Times? Simply stated they are carefully chosen words health care professionals use to help patients, families, and customers understand what we are doing and why. Examples of Key Words used by staff members are as follows:

The second tool that will be implemented is Leader Rounding on Patients and Staff. Leader rounding allows leaders to connect with patients to reinforce care, verify staff behaviors, and recognize staff members who go above and beyond the call of duty.

• “I want to make sure you are very satisfied with the cleanliness of your room. Have I missed anything?” • “Dr. Jones is one of the best physicians at this hospital. He is highly trained and has been practicing for more than 20 years. You are in great hands!” • “Do you have any questions before I leave?” AIDET is another example of using Key Words at Key Times. AIDET is an acronym for a communication framework that utilizes just five very important key words: Acknowledge, Introduce, Duration, Explanation, and Thank You.

At first rounding will unearth process improvement opportunities and require the leader to spend additional time as things are first identified. It will allow all leaders to recognize staff as well as promptly address issues if need be. The key to hardwiring rounding is consistency, consistency, consistency! It is important that logs are kept and items are followed up with immediately. These two tools will help Regional West in its mission to provide excellent care! Keep a look out for more updates as we continue our journey. If you have any questions or concerns please contact Summer Parker at Ext. 1021. Resources: “The Nurse Leader Handbook” by Studer Group, 2010

What do Key Words and AIDET accomplish? Key Words at Key Times create better patient experiences. They help patients feel more relaxed and confident about their care; they help nurses, physicians, and other staff members do a better job; and they improve outcomes.

May 28 Attending: Brenda Sindt, Vanessa Sussex, Mary Sue Larson, Joellen Campbell, Virginia Blackburn, Evie Russel, Melissa Snyder • A staff nurse asked about the research project on scrub uniforms. Shirley explained that the uniform research project is still on but has had to go through several hoops, for example, Regional West Medical Center IRB and University of Nebraska Medical Center IRB. Shirley will be meeting with two local vendors in the area to make sure the colors that the Professional Practice Council picked out are still available. It is important to make sure that staff nurses can pick out their own style but stay with the color that was chosen. Shirley explained that the research project is based on whether or not patients can identify their registered nurses better if they are all in the same color. The research project will be conducted on 2E, 2W, and 3E and those staff nurses will be the only ones wearing the same color uniform. • Shirley explained that Linda Rock, Hospice Director, will go part-time in July and Diana Rohrick will oversee Home Health, Hospice, and Palliative Care. Shirley also explained that Hospice will be moving from the North Plaza to St. Mary Plaza. The reason for this move is because the North Plaza needs more room for providers.

• A staff nurse voiced concern in the Surgery Department regarding terminal cleaning. Shirley explained that terminal cleaning is important for MRSA and back and joint surgeries. Shirley will work with the directors of Environmental Services and OR to determine what the current practices are for terminal cleaning and if a new approach is needed. Shirley will also work with the Anesthesia Department to determine if one of their office spaces could be used for isolation patients. • Another concern was that some of the surgery patients who go through Pre-Admit testing get cultures drawn and do not know the results prior to surgery so patients might have an open case of MRSA and do not know it before they go to surgery. Staff in the breakfast notices it more with Orthopaedics and Neurosurgery. Shirley mentioned that Dr. Morgan discussed this issue with the orthopaedic surgeons and she will follow up with him to see if the information was given. • Shirley discussed the Nurse/Finance Council and how we need broader representation from other departments. If you know of names or if you are interested, please let Shirley or Jordan Colwell know. She explained that this council is working on ways to cut five percent of waste out of the general operating

expenses. For example, disposable blood pressure cuffs— patients in isolation need the disposable cuffs, but everyone else could use the non-disposable cuffs. • A staff nurse from 3E wanted to know why we don’t use more carpujects like our morphine. People are not using the morphine medication preparations as it is. They are pulling the morphine and using more syringes and needles then need be. Shirley stated that the Nurse/Pharmacy Council has addressed this issue before and she will check on them re-addressing. • Shirley asked how the new CPOE installation is going. One nurse stated that one physician is still struggling with the program and Shirley mentioned that Lisa Bewley sat down with that physician one-on-one to help him put in orders. Shirley reiterated that this new program will not go away and the more you use it, the more comfortable you will be with it.

June 26 Attending: Billie Kniss, A’ndrea Spracklen—Hogan, Marlyce Burkey • A nurse voiced a concern that when the census is low, patients should receive the best care possible and we still have patients who are upset with the care they receive. • A nother nurse voiced a concern with schedules and how patients are still confused on when their case is. Shirley asked the group where they think communication is lacking. A Pre-Admit testing nurse mentioned that they ask the patient what time the doctor told the patient to come in for the procedure and they write it down on their record so the staff have an idea. Shirley will ask Judy Bowlin in Pre-Admit Testing for their schedule record and follow those cases to determine how long the patients are waiting and then she will work with Dr. Morgan and Dr. Massey.

• Shirley commented that May was a good month financially for Regional West but we are still not where we need to be. We need to continue to get rid of waste and be smart with the supplies we order. Shirley gave an example of a supply that is used in the OR and how in working with Dr. Morgan and Dr. Massey, Janet Lewis, and Linda Lund, they have found a cost savings of over $18,000 a year just for one supply. • S hirley asked the group about staffing and how the workflow on each unit is going. One nurse gave an example of how she works in a department that has cut back on staffing and how she is scheduled to work eight hours and she ends up staying nine and 10 hours. Shirley will discuss this with the manager and have her conduct a study to see if they will need another nurse. Shirley also asked the staff if the infusions on the schedule are more predictable than regular surgery. A nurse said it would help if the physicians level out their surgery schedule so days are more predictable. Shirley mentioned that a few years ago there was a rapid cycle study conducted to identify patterns of the days, weeks, and months for surgeries to identify how much staffing is needed. Shirley will talk with Karna Kleager, nurse manager of

Pre-Operative Services. • Shirley mentioned that the Professional Practice Council is working hard on staff retention. One nurse said she has been here for many years and the communication is the best it can be. She also likes Dr. Morgan in his new position! One nurse brought up that scheduling can always be an issue for some nurses but working out the schedule equally is a big satisfier. Shirley mentioned that there is a new compensation model out in scheduling. All of the staff nurses present said that they don’t self-schedule and it works better. Shirley mentioned that she will talk with the Professional Practice Council about possibly changing to a scheduling committee instead of a self-scheduling model. • Shirley asked the group if they were taking their breaks. One nurse mentioned that she doesn’t get a break that she would call “formal.” She gets meal breaks, but not her 15 minute break. Shirley explained the fatigue study that the Professional and EvidenceBased Practice Councils is currently working on. • Shirley asked the group about professional autonomy. One nurse said that this is the best job she could have.

Science and the BATH I recently signed up for and listened to a webinar on bathing. What! A whole lecture on bathing? Yes! I have heard the rhetoric throughout the unit. I see the finger pointing of who should give the bath and who did not. I also hear occasional comments from patients and families about not getting a bath.

Linda Fowler LINDA FOWLER BSN, RN, CEN, CCRN ICU/PCU Clinical Coordinator

So I thought I would like to share some of what I learned. Wikipedia states that “bathing is the washing of the body in water. It may be practiced for personal hygiene, religious ritual, or therapeutic purposes or as a recreational activity.” It also states that bathing creates a feeling of well-being and the physical appearance of cleanliness. “Bathing can take place in any situation where there is water, ranging from warm to cold. It can take place in a bathtub or shower, or it can be in a river, lake, water hole, pool, or the sea, or any other water receptacle. The term for the act can vary. It is best taken place during the times from early night (civil darkness) through early morning (civil daylight). For example, a ritual religious bath is sometimes referred to as immersion, the use of water for therapeutic purposes can be called water treatment or hydrotherapy, and two recreational water activities are known as swimming and paddling.” Wikipedia

But let’s talk about bathing and hygiene in the Critical Care Unit. AACN released a practice alert about bathing in April 2013. Our first goal should be to do no harm. We need to maintain skin health because it is our best barrier to infection. Remember, our patients are ill and they have breaks in the skin from lines, catheters, and incisions. The skin may be thinner and more fragile (not just the elderly). It heals/recovers more slowly. We want to provide the comfort and care that giving a bath brings for patients. But what does the research say? Bath basins are reservoirs of bacteria. The bacteria come from the environment, the patient’s skin, the water, and what we put in the basin–products, emesis, stool, and water. Soap–needs to be pH balanced and an emollient used (all over the body). So anti-bacterial or Ivory soap is out. The cloth needs to be soft to avoid abrading the skin and creating micro openings. Wash cloths have been shown to increase transdermal water loss. AND WATER. This one was a surprise to me. There are published meta-analysis and meta-synthesis on water contamination. This leads to the only Class A recommendation in the alert. A biofilm in institution pipes has been linked to health care associated infections. The other research we need to consider is the use of chlorhexidine (CHG) in care. The research shows significant decrease in pathogens

on environment surfaces when CHG is part of the bath. There are significant decreases in catheter-related blood stream infections and decreases in urinary catheter infections. So after all this, what is the bottom line in our unit? Patients need hygiene–oral, perianal, and bathing daily. It should be performed at the patient-preferred time for comfort and satisfaction. The hours of midnight to 6 a.m. should be avoided. Ask during admission history when a patient usually bathes–evening or morning. Prepackaged bath wipes are preferred. The bath wipes have an emollient included. Lotion is used for back rubs and special care. CHG two percent impregnated cloths are recommended from the jawline down (not face or perineal). They are a therapy to prevent health care-acquired infections. A trial of the product started July 9. It will be evaluated based on infection data. Unit recommendation is that these wipes be used for all patients with foley catheters, central lines, and vents–in other words, sick. Water baths should be reserved for when the skin is grimy and dirty. If the patient is ill, a final coating with a CHG cloth should be used after a water bath. There was an excellent suggestion in the lecture about the message to patients. A suggestion is “We are using research and science to give you the best type of bath while you are sick and in our unit.” My message is that care is not in a basin but in the attitude we use to approach patients and hygiene. If we use science and research to provide care with a healing touch, we deliver the best care. Resources http://www.aacn.org/wd/practice/content/practicealerts/bathing-adult-patient-practice-alert. pcms?menu=practice http://en.wikipedia.org/wiki/Bathing

Shared Governance Council Updates Coordinating Council (CC) New Business Magnet vs. Pathways to Excellence: Jordan will conduct a crosswalk between the two programs to identify similarities and differences for consideration. Old Business Ice Cream Social and Membership Drive is scheduled for July 24 from 4 to 6 p.m. Consensus attained for the revised council charters.

Projects and Status Hand Hygiene–Presented barriers and potential interventions to 3rd floor UPC this month. Also working with 2nd floor UPC. Goal for implementation: 90 days from presentation date(s). Nursing Peer Review–(NPR) Members have been selected for committee! Education has begun and will begin reviewing cases July 16. Members of the council have been to 14 staff meetings to educate about NPR. This month’s meeting will identify triggers for case review. There are three cases ready for review (from physician peer review) at this time.

Shared Governance model revision. Projects and Status Staff Retention: Phase One will focus on staff scheduling and staff meal breaks. Professional Practice Council will work on staff scheduling, and the Care and Practice Council along with the Night—Shift Council will work on staff meal breaks.

Professional Practice Council (PPC) New Business Retention issues. Old Business Calling across state lines/Wyoming State Licensure.

Quality and Safety Council (QSC) New Business None anticipated. Old Business Paul Hofmeister and Austin Engel have completed the confidentiality agreement that will be signed by members/ participants of Nursing Peer Review.

Projects and Status Retention continues to be an issue. Asked to look at turnover stats, and how to better engage new staff in our culture, and externally how to engage them/welcome them and their families to the community. Will look at satisfaction scores. Shirley was going to visit with someone from the community to talk to Regional West Medical Center Human Resources staff. Goal: increase retention which in turn saves dollars. Jordan received an update from Wyoming State Board of Nursing. Response: “Sharing treatment planning information ► Continued to page 17

with a physician or communicating directly to a patient for the purpose of gathering information would not constitute the practice of nursing. As such, a Wyoming license would not be necessary. However, if you provide the patient with advice about his health condition or treatment plan whether telephonically or in person, then you are providing nursing care and would be required to have a Wyoming license.â€? This information may impact how phone calls are completed across state lines going forward.

Alarm Fatigue as possible project. Survey results are in. Projects and Status Fatigue recommendation is complete. Recommendation has been shared with Shared Governance Council, Nursing Leadership Council, and Environment of Care. Journal club: July 24 at 4 p.m. in SB I. Topic: Sepsis. Survey results will be shared at the July council meeting.

Care and Practice Council (CPC) New Business None. Old Business Fall Prevention Program. Projects and Status The council continues work on the house-wide Launch Plan including staff education, informatics request, and transition to organizationwide, multidisciplinary Falls Team. A sub-committee has been working on job aids for staff. ARU staff has been successful with the Pilot Launch. As of June 20, ARU is 31 days without a patient fall!

Evidence-Based Practice Council (EBPC) New Business

Night-Shift Council (NSC) New Business None. Projects and Status Lori Miller did not attend the meeting as she has no updates. Currently there have no changes in respect to the food cart and how night shift gets their food delivered Projects and Status Food Cart: No changes as of yet. Will email Lori Miller to see how we can help facilitate as a committee. Contact Nancy Sloan to consider changing med pass time to cover med passes from 2201-2200 to 2301-2300. There are fewer meds administered and will possibly help prevent missing doses taken. IV meds should not be affected too much.

Brainstorm future path for the council. Old Business Health care worker fatigue and patient safety. Journal Club.