Essentials of Advanced Nursing Practice

The role of a nurse is forever changing as healthcare evolves. Importantly, the nurse is a leader to efficiently recognize, advocate and stress positive outcomes for change.

Purpose and Overview

The purpose of this consultation is to identify an area of opportunity for improvement within the organization. The organization chosen for this consultation is ThedaCare Regional Medical Center Neenah. The Nurse Leader I selected to interview was Tabitha Uitenbroek, Trauma Program Manager (T. Uitenbroek, personal communication, April 5, 2019). During our interview conversation, several needed opportunities were explored and discussed as were strengths of this organization.

The data collection procedures that were used during this consultation were performance improvement projects, Hospital Consumer Assessment of Healthcare Provider Surveys (HCAHPS), hospital patient outcome data, The Joint Commission, and incident reports.

Description of Organization

ThedaCare Regional Medical Center Neenah (TCMC Neenah) is located in northeastern Wisconsin. This hospital is one of seven hospitals within the ThedaCare health system. TCMC Neenah is a 120 bed hospital serving a community and connecting communities with a population of 150,000+. TCMC Neenah is fully accredited by The Joint Commission and offers a 14 bed Intensive Care Unit, emergency services and Level II Trauma Services, primary care, and specialty outpatient care as well as inpatient rehabilitation and mental health care. The emergency department sees slightly over 25,000 patients per year, nearly 700 of those patient visits are trauma related. TCMC Neenah has approximately 10,000 inpatient hospital encounters yearly without including the inpatient mental health and inpatient rehab patient stays.

ThedaCare employs approximately 6,800 staff and is the third largest healthcare employer in Wisconsin. (Thedacare, 2016) The actual number of TCMC Neenah employees is not available since TCMC Neeanh is part of the ThedaCare system and employees may work at several different hospitals or in different roles.

ThedaCare employs approximately 6,800 staff and is the third largest healthcare employer in Wisconsin. (Thedacare, 2016) The actual number of TCMC Neenah employees is not available since TCMC Neeanh is part of the ThedaCare system and employees may work at several different hospitals or in different roles.

ThedaCare system is a not-for-profit healthcare system. The ThedaCare system has an executive leadership team that is led by the Chief Executive Officer and President. Other staff that are part of the executive leadership team and ultimately report to the President and Chief Executive Officer are the Chief Information Officer, Chief Strategy Officer, Chief Clinical Officer, Chief Human Resources Officer, Chief Brand Officer, Senior Innovation Executive, Senior Transformation Executive, Chief Legal Officer, Chief of Staff, Chief of Financial Officer, and Chief Operating Officer. Their structure also includes a Board of Trustees and clinical leadership that have Vice Presidents and/or Medical Directors for Anesthesiology, Surgical Services, Emergency Medicine, Trauma, Intensive Care, Obstetrics and Gynecology, Imaging, Family/Internal Medicine, Pharmacy, Specialty Service lines (Orthopedics, Spine, Cardiology, and Bariatrics), Physical Medicine and Rehabilitation, Mental Health, Laboratory/Pathology, Nursing Education, Quality/Compliance/Legal, Support Services, Technology and Finance.

Primary Needs of Population

ThedaCare health system service area involves 9 counties and 235,000 patients. TCMC Neenah is located in Winnebago County for which a community based needs assessment was performed and compiled in 2016 for the next three years. Since this is the primary county for TCMC Neenah and to avoid any duplication of data, this consultation will use this report for the needs assessment of the population.

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In 2014, 92.7 percent of the population identified as White; 4.1 percent as Hispanic/Latino; 2.8 percent as Asian; 2.1 percent as African American; and 0.7 percent as Native American. (Thedacare, 2016) Median household income is $51,241, slightly below the Wisconsin median household income of $51,474. (Thedacare, 2016) Thirteen percent live below the Federal Poverty Level and nine percent are uninsured. (Thedacare, 2016) Nearly eighteen percent of the population in Winnebago County are fourteen or younger; fifteen percent are fifteen to twenty-four, twenty-five percent are twenty-five to forty-four; twenty-seven percent are forty-five to sixty-four; and nearly fifteen percent are sixty-five and above. (Thedacare, 2016)

The significant health needs identified for this community are mental health and access to mental health resources, alcohol and other drug abuse treatment access, physical activity and nutrition. (Thedacare, 2016) TCMC Neenah has inpatient mental health care, outpatient mental health and resources for alcohol and drug abuse victims. The community where TCMC Neenah resides has many recreational parks and sports facilities. TCMC Neenah offers resources for nutrition and nutritional education. Building on all these resources should be the goal of TCMC Neenah.

Nurse Leader’s Role

Ms. Uitenbroek’s role as the Trauma Program Manager is to promote optimal clinical care for patients, promote community health, connect with community healthcare teams and emergency services to advocate for safe and timely care, keep abreast of evidence based practice and share/implement across the caregiver team to continuously improve patient outcomes. She is the key leader in the verification process with the American College of Surgeons. She has to exhibit a team oriented attitude, be decisive, open minded and support the organization’s mission and vision.

Ms. Uitenbroek’s role as Trauma Program Manager supports the Essentials of Master’s Education in Nursing provided by the American Association of Colleges of Nursing. Essential III Quality Improvement and Safety is known very well to this nurse leader (AACN, 2011). It is expected of this nurse leader to bring evidence based best practice to improve the outcomes of our patients. She has been the leader of several improvement projects related to the trauma patient. She leads the Trauma Program physician peer review performance improvement program. Within this program, trauma patients that meet certain criteria are reviewed by physicians integrated in the trauma program to assure best care was given. Any knowledge gained from this review process is then shared accordingly. Essential VII Interprofessional collaboration for improving patient and population health outcomes is also an area this nurse leader succeeds at (AACN, 2011). Within the trauma program, community health is a significant area of focus. Injury prevention is fundamental to improve the health of our community. Through data from past years, it was noted that falls were the number one reason for emergency room visits. A huge fall prevention campaign was facilitated by Ms. Uitenbroek that involved many projects and education in the community. Being involved in various community groups is important to her personally and essential for her role. Ms. Uitenbroek was involved in the community health needs assessment discussed earlier in the paper. Essential IX Master’s –Level Nursing Practice is shown daily in this nurse leader’s work (AACN, 2011). She continually updates her professional practice by reading, attending conferences and connecting with other leaders. Recently she worked with the neurosurgeons to improve starting prophylactic anticoagulants earlier to prevent deep vein thrombosis in traumatic brain injury patients. When a rib fracture protocol was instituted for trauma patients, Ms. Uitenbroek educated the pertinent staff on the protocol. Then when a trauma patient with rib fractures was admitted, Ms. Uitenbroek mentored the staff through the protocol with this patient real time so a more thorough understanding was gained by the staff.

Reducing Risk and Health Promotion

As a nurse, one of my major role is the promotion on the reduction of common health risks in regard to different individual perspectives. This means that as part of reducing the primary health risks, there will be need to conduct various health promotional activities that are guided by the individual nurse perspective. In this regard, the institution takes a holistic approach in their health promotion guidelines and practice. At this I concentrate on activities that entail helping individuals and families or the communities to make the right health decisions in their engagement with the various promotion activities (AACN). Among these strategies for health promotion and risk reduction include providing the patient with information and provision of health education. In addition, other strategies will include ensuring patient participation in their own health, like letting the patient decide on the right menu, when they would like to get to bed and they type of clothes they would like to wear. As a trauma program manager, I would also ensure that the rights of patients is considered, especially when looking at their treatment plan. It is important for individuals to have a say in ways that they would like to be attended to and treated by their doctors. Counselling is a very important aspect in reducing health risks caused by trauma, meaning that I would promote the need for counselling to ensure the impact of trauma is reduced which in the end will also see the reduction of primary health risk for patients in the trauma situations.

Characteristics of Organization

A current strength identified in the interview was that the employees of this organization are community members so they understand the needs of the community and are engaged in making this organization better for their community. The employees take pride in this organization and are hopeful it will remain in their community.

A current weakness that came with much frustration from the Nurse Leader was a disconnected executive leadership team. The current fifteen on the executive leadership team are new to the organization and Wisconsin. Only two have been with the organization/system for more than two years. Each community comes with similarities, differences, and culture. To understand the needs of the community, leaders need to be connected with the community they serve. Along with connectivity, communication is important. Healthcare is rapidly changing; what was good yesterday is not good today. In this fast paced environment, communication is needed and desired. Often initiatives are put into force without proper or effective communication, leaving the leaders of the front line staff and staff confused, frustrated and upset.

A systematic approach of integrating evidence into practice to ensure best patient outcomes, known as evidence-based practice (EBP), is used in this organization. A current evidence based practice used in this organization is the Rib Fracture Protocol for trauma patients with rib fractures. An algorithm guides the nurse and respiratory therapist on the necessary care for trauma patients with rib fractures. The team collaborates and has a clear vision and expectations of care. The algorithm helps determine when a higher level of nursing care is desired instead of waiting for clinical signs of deterioration to determine higher levels of nursing care. Urgent admissions to the ICU for trauma patients with rib fractures have decreased since incorporating this protocol.

To improve patient safety and clinical outcomes, quality improvement projects are essential. Quality improvement projects involve analyzation of performance for ways to improve. The trauma department recently initiated a system approach to connecting with every trauma patient on resources for treatment and/or recovery, prior to discharge, if alcohol or other drugs were at all related to their admission. Results thus far have been impressive with a ninety-nine percent success rate.

Recommendation for Organizational Change

My recommendation for change is to implement interventions that will quiet the environment at night. TCMC Neenah uses HCAHPS surveys to evaluate patient satisfaction while hospitalized. The last reported score TCMC Neenah received on the question pertaining to noise levels, listed as “the area around my room was always quiet at night” was 56%. This score represents that 56% of patients selected always and the rest selected usually, sometimes, or never. The Wisconsin average for this question is 65% and the national average is 62%. This discrepancy clearly shows the need for change.

The first intervention to quiet the environment would be to put in call light systems that are displayed on the nurse’s hospital provided smart phone used during their shift. Each of the nurses and other healthcare staff will be alerted via their phone when a call light has been set off to eliminate the alarm. These smart phones will also be able to alert the nurse when the patient’s IV is alarming. The smart phones will be set to vibration mode instead of ringing while in the patient’s room. Another intervention would be to have a team of nurses join a ‘quiet committee’. The input of these nurses will be invaluable. Some interventions will be easy, ‘just do it’ style and other interventions may need administrative help. Having the nurses join forces to champion this work will help engage, educate and keep each other accountable for this work.

Rationale for Recommended Change

A quiet environment is essential for sleep. Implementing interventions to provide a quiet environment for sleep is fundamental to improving patient outcomes. (Hedges et al., 2018) This recommended change focuses on the patient, an opportunity for improvement within TCMC Neenah expressed by Ms. Uitenbroek during our conversation. Many times executive leadership emphasized meeting financial budgets more than best patient care was vented by Ms. Uitenbroek. Many interventions for quiet can be easily implemented with minimal to no cost.

A quiet environment is essential for sleep. Implementing interventions to provide a quiet environment for sleep is fundamental to improving patient outcomes. (Hedges et al., 2018) This recommended change focuses on the patient, an opportunity for improvement within TCMC Neenah expressed by Ms. Uitenbroek during our conversation. Many times executive leadership emphasized meeting financial budgets more than best patient care was vented by Ms. Uitenbroek. Many interventions for quiet can be easily implemented with minimal to no cost.

Measures to Evaluate

Evaluation of the effectiveness of a change is vital. Utilizing national benchmarks published by various well known agencies such as The Joint Commission, Centers for Medicare and Medicaid Services, and HCAHPS is an excellent way to evaluate effectiveness of a process change. For my recommended change, HCAHPS would be used to measure if the changes made were effective. Since HCAHPS are received quarterly, this standard survey information would be reported and reviewed quarterly. To evaluate in a shorter term, a simple questionnaire could be done each morning with each patient and given to the leader to compile. The questionnaire would be minimal and straightforward questions for simplicity, consistency and immediate response. Narrative comments would also be available to further explain if needed. This data would be compiled biweekly so the staff and ‘quiet committee’ would know what is working and be able to change what is not working efficiently. Understanding the data, specifically further stratifying the data, will help delineate problem areas which can then be explored for change interventions or adjustments.