EP7EO

 

Interprofessional Care EP7EO

 

1. Provide one example, with supporting evidence, of an improved outcome associated with an interprofessional quality improvement activity, led or co-led by a nurse (exclusive of the CNO).
   • Outcome data must be in the form of a graph and data table.
     
     

AND

 

2. Provide one example, with supporting evidence, of an improved outcome associated with an interprofessional quality improvement activity, led or co-led by a clinical nurse.
   • Outcome data must be in the form of a graph and data table.

 

 

Example a: Increase in Nurses’ Confidence in Responding to Sudden Unexpected Postnatal Collapse (SUPC)

Problem
In February 2017, there was a full-term newborn infant death at 6 hours old in New York, as reported in the national news. The mother was breastfeeding and fell asleep and did not notice that the baby became cyanotic and was not moving. In March 2017, Jeanne Van Sciver, RN, EFM-BC, Senior Perinatal/Labor and Delivery (L&D) Clinical Coordinator, Clinical Nurse, and Loretta Jacobs, MSN, RN, Education Specialist, presented this information as a case review at the L&D daily unit huddle and at the Interdepartmental OB Meeting for discussion. The unit huddle and Interdepartmental group comprises clinical nurses, the nurse manager, clinical coordinator, educator, obstetricians, Maternal Fetal Medicine physicians and representatives from neonatology, anesthesiology and case management.

 

The cause of the infant death was sudden unexpected postnatal collapse (SUPC).This is a rare event with potentially catastrophic outcomes affecting full- or near-term infants. The characteristics of SUPC are neonatal apnea, pallor, limpness, bradycardia, cyanosis, and cardiac or respiratory failure. It occurs most often in the first hours after birth, often during breastfeeding.

 

In April 2017, Loretta Jacobs, MSN, RN, Education Specialist, developed an interprofessional quality improvement activity that included an education program with a PowerPoint presentation titled, “Newborn Emergency: Sudden Unexpected Postnatal Collapse.” The presentation was followed by a simulation that included handouts on the American Academy of Pediatrics Neonatal Resuscitation Program resuscitation algorithm, infant warmer, infant mannequin, oxygen setup including ambu bag, infant intubation equipment, suction equipment and infant resuscitation code cart.

 

A pre/post survey design was developed to measure nurses’ level of confidence with specific skills used to respond to a SUPC event. Confidence using the Self-Efficacy Scale established by Albert Bandura (1977) measures the person’s perceived level of confidence in behavior. The person completing the Self-Efficacy Scale rates their level of self-efficacy in increments ranging from 0% (not confident) to 100% (highly confident) (Albert Bandura, 1977). 

 

In April 2017, Women’s and Children’s nurses took the pre-survey; the level of confidence in responding to sudden unexpected postnatal collapse was 84%. This is the average score of the nurses who participated in the survey.

 

Goal Statement
To increase Women’s and Children’s nurses’ level of confidence in responding to sudden unexpected postnatal collapse, as measured by a pre- and post-survey using the Self-Efficacy scale, expressed as a percent.

 

Participants

 

SUPC Taskforce
Name/Credentials	Discipline	Title/Role	Department
Loretta Jacobs, MSN, RN, EFM-BC	Nursing	Education Specialist, Project Lead	Education
Jeanne Van Sciver, RN, EFM-BC	Nursing	Perinatal Senior Coordinator	Labor & Delivery Neonatal Intensive Care
Emma Eschricht, APRN, NNP	Nursing	Neonatal Nurse Practitioner	NICU
Meghan Ryan, APRN, NNP	Nursing	Neonatal Nurse Practitioner	NICU
Lisa Henderson, APRN, CPNP	Nursing	Pediatric Outpatient Coordinator, APRN, CPNP	Pediatrics
Patricia Basciano, BSN, RN, MNN	Nursing	Nurse Manager	Women’s & Children’s
Patricia Calyag, MD	Physician	Chief of Obstetrics	Labor & Delivery
Stylianos Theofinidis, MD	Physician	Chief of Neonatology	Neonatology
Peter Acker, MD	Physician	Chief of Pediatrics	Pediatrics

 

Description of the Intervention
May-September 2017
The interprofessional quality improvement activity consisted of an education program for nurses to recognize and respond to SUPC. Educators included Jacobs; Lisa Henderson, APRN, CPNP, Pediatric Outpatient Coordinator; Emma Eschricht, APRN, NNP; Meghan Ryan, APRN, NNP; Stylianos Theofinidis, MD, Neonatologist; and Peter Acker, MD Pediatrician. The insitu simulation session was held in the birthing rooms, nursery exam area, and the NICU and Pediatric units. This education was presented from May 2017 to September 2017 to clinical nurses from the Women’s and Children’s Unit, which includes Labor & Delivery, Maternity, NICU and Pediatrics.

 

The interprofessional team provided a pre-brief to the simulation to the set the tone for it: purpose, rules, mind your business, be respectful and cordial for the clinical experience. The clinical situation was reviewed with the interprofessional participants, who were told that they were to respond as though in their actual clinical environment where they provide care for patients as a clinical nurse, nurse practitioner or physician. The simulation follows a real-life experience during a newborn event involving the mother and her newborn experiencing respiratory depression. Steps included immediate resuscitation measures, practicing using equipment and hands-on return demonstration of emergency equipment. The simulation lasted for an hour, followed by a debrief to review the fundamentals of the education.

 

Outcomes
After the education was completed, post-surveys using the Self-Efficacy Scale were conducted. Women’s and Children’s nurses’ participation in this interprofessional quality improvement activity, an education program with insitu simulation, led to an improvement in the nurses’ level of confidence in responding to sudden unexpected postnatal collapse, as measured by a pre- and post-survey using the Self-Efficacy scale.

 

Nurse’s average confidence level pre-education was 84% (April 2017). Post-education, this increased to 88% (October 2017), 93% (November 2017) and 97% (December 2017).

 

 

Evidence EP7EO-1, Greenwich Hospital Women’s & Children’s Nurses’ Confidence Level in Responding to Sudden Unexpected Postnatal Collapse (percent)

 

 

Example b: Nurses Lead a Quality Improvement Activity, Simulation, to Improve Nurse Self-Efficacy in Palliative Care Provision

Problem
National and international students and practicing nurses report feeling under-prepared to competently and confidently provide palliative care upon graduation. In November 2015, Donna Coletti, MD, Director of Palliative Care, and the Palliative Care team surveyed nurses at Greenwich Hospital, with the results revealing a knowledge deficit in palliative and end-of-life (EOL) care. Research supports simulation as an innovative educational approach to improve nurses’ comfort and competence. A literature review revealed that while palliative care education in the form of simulations were developed for prelicensure nursing students, these were not found to be used for practicing nurses.

 

From July to November, 2016, Gina Trovato, MSN, RN, CHPN and Nicole Generales, BSN, RN, CHPN developed the Palliative Care Simulation Program (PCSP) for nurses in collaboration with Cheryl Mayeran, MPH, Yale New Haven Health System (YNHHS) Simulation Learning Consultant. Trovato and Generales attended an eight-hour course on simulation and debriefing in November 2016 in preparation for the program. They collaborated with Coletti; Rev. Eddie Lopez, Chaplain, Director of Spiritual Care; Anne Swallow, DNP, RN, Director of Education; Priscilla Sterne, DNP, RN, NEA-BC, Director of Magnet/Nursing Programs; Barbara Flanagan, MSN, RN, CNL, Education Specialist; and Alison Kris, PhD, RN, Greenwich Hospital Nurse Research Consultant, to discuss educational resources, determine logistics for a research study and ensure a suitable platform for the program pilot. The Institutional Review Board (IRB) proposal was drafted by Kris and reviewed by Trovato and Generales. In March 2017, the IRB deemed the study exempt.

 

Trovato and Generales designed the research study using a pre-test/post-test design with the objective of improving clinical nurse self-efficacy for palliative care provision. In December 2018, Trovato and Generales collected pre-test data with the help of Flanagan, who distributed paper copies of the valid and reliable Palliative Care Self-Efficacy Scale (PCSES; Phillips, Salamonson, & Davidson, 2011).

 

In December 2018, the average self-efficacy score for the cohort of clinical nurses was 1.92 on a scale of 1 to 4 (1 = needs further basic instruction; 4 = confident to perform independently).

 

Goal Statement

To improve self-efficacy of clinical nurses related to palliative and end-of-life care. Self-efficacy was measured using a valid and reliable survey pre- and post-intervention.

 

Participants

 

Interprofessional Palliative Care Simulation Program
Name/Credentials	Discipline	Title/Role	Department
Gina Trovato, MSN, RN, CHPN	Nursing	Clinical Resource Nurse, Clinical Nurse, Project Lead	Intermediate Care
Nicole Generales, BSN, RN, CHPN	Nursing	Clinical Nurse Project Co-Lead	MSICU
Cheryl Mayeran, MPH	Education	Simulation Education Consultant	Simulation
Donna Coletti, MD	Medicine	Director of Palliative Care	Palliative Care
Barbara Flanagan, MSN, RN, CNL	Education	Education Specialist	Education
Alison Kris, PhD, RN	Research	Nursing Research Consultant	Consultant
Reverend Eddie Lopez	Chaplain	Director of Spiritual Care	Spiritual Care
Jeffrey Collins, BSN, RN, CCRN	Nursing	Clinical Nurse	MSICU
Alicia Alickaj, MD	Medicine	Palliative Care	Palliative Care
Jennifer Trocola, APRN	Nursing	Palliative Care Nurse Practitioner	Palliative Care

 

Description of the Intervention
Interprofessional Quality Improvement Activity: Palliative Care Simulation
In January 2019, one month after the cohort’s pre-test, Trovato and Jeffrey Collins, BSN, RN, CCRN, Palliative Care Resource Nurse, facilitated the first simulation. Following the simulation, Trovato facilitated the debrief while Collins, in preparation for the role of facilitator, observed. This was followed by an interprofessional education session. Trovato; Alicia Alickaj, MD, Palliative Care Physician; and Jennifer Trocola, APRN, Palliative Care Nurse Practitioner, educated the clinical nurses on:

• The definition of palliative care in relation to end-of-life (EOL) and hospice care
• Physician orders including do-not-resuscitate and comfort measures only
• Advance directives
• Conversation tools to navigate challenging conversations

 

During the session, Trovato empowered the clinical nurses to discuss these options, including palliative care, with their patients and families. Trovato and Collins facilitated the second simulation. Following this simulation, Trovato facilitated the debriefing and led the second interprofessional education session with Lopez. The second session focused on EOL symptom management using the CARES tool, EOL medication use, bereavement care, spiritual care and self-care. 

 

Outcomes

One month prior to the interprofessional quality improvement activity, the palliative care simulation program, the average self-efficacy score was 1.92 (range of 1-4). Post-intervention the clinical nurses rated their self-efficacy as 2.81, 3.02, 3.13, demonstrating an increase in palliative care self-efficacy for clinical nurses.

 

 

Evidence EP7EOb-1, Clinical Nurses Palliative Care Self-Efficacy Scale Scores