Tools that Improve Clinician-Patient Communication
One way to see more of your patients is to schedule more time with them. That’s one of the lessons that nurse leaders can take away from Presbyterian Intercommunity Hospital, a 444-bed hospital in Whittier, Calif. that is striving to provide the best possible care to patients.
“We have created deliberate work patterns that allow nurses to go in and have conversations with patients,” says CNO Reanna Thompson, RN, MSN. “We created deliberate acts that are worked into the nurses’ work day.”
Both patients and staff are benefiting from the extra interaction. The hospital has not yet conducted time studies to see if nurses are spending more time with patients. But they have tracked call light usage, which is a good indicator of nursing efficiency and patient satisfaction. One pilot unit at Presbyterian Intercommunity saw call light usage decrease 24 percent from January/February 2007 to January/February 2008. Nurses are also noting an improvement in patient outcomes. For example, one pilot unit has documented a major decrease in hospital-acquired pressure ulcers--from 20.22 percent for the second quarter of 2007 (prior to project) to zero in June 2008.
Communication Problems
Another lesson to be gained from Presbyterian Intercommunity: Listen to your frontline staff. “They are the ones who know what’s broken, and they are the ones who know the solutions,” says Thompson.
Recognizing this truism, hospital leaders at Presbyterian Intercommunity launched 34 partnership councils in 2006. These teams follow a nursing shared governance type approach; however, the teams are interdisciplinary and include representatives from all the disciplines involved in patient care on a unit/department.
One issue kept coming up again and again in the partnership councils, says Denise Authier, RN, BSN, professional practice coordinator. “Virtually all the nursing units said we needed to improve how we worked as a team and how we communicated.”
Since this was a global theme, Authier set up a hospitalwide work team, which included nurse leaders, RNs, and certified nurse assistants (CNAs), to come up with a solution. Team members interviewed staff on various nursing units and identified several problems:
- There was no standard method for staff to share information about patients.
- The shift assignments--with CNAs reporting to up to six RNs per shift--were causing dissatisfaction and confusion among staff.
- CNAs were often working independently--as opposed to under the direction of an RN.
- RNs were not delegating nursing tasks as they should.
Working as a Team
To address these problems, the team piloted a new RN-CNA team approach that encompasses the following:
A defined nursing scope of practice. The RN is now identified as the “captain of the ship” who delegates appropriate nursing tasks to the CNA or LVN, says Michele Grams, RN, BSN, care center coordinator, medical/respiratory. The team developed a formal scope of practice based on The Joint Statement on Delegation by the American Nurses Association and the National Council of State Boards of Nursing. RNs and CNAs also attended educational classes about their roles and responsibilities on the patient care team.
“Nurses began to understand on a practical level that they are responsible and accountable for the care that’s delivered to that patient that day, not only by themselves, but by whomever they delegate care to,” says Thompson. “Another positive thing is that the CNAs have raised their level of functioning, and they now see the true value of their work. They also now appreciate the role of the nurse … that the nurse must truly oversee what they do.”
Limit RN-CNA ratios. Each CNA has eight to nine patients and reports to no more than two or three RNs.
Put Communication Tools in Place
Finally, the team put several formal communication methods in place that encourage staff to communicate with patients and with each other:
Structured shift reports. The CNAs now wear badges that list eight “shift points,” or important patient care issues they need to pay attention to, including diet, skin condition, and code status. When CNAs arrive for their shifts, they meet all their patients and then report back to the RN for a start-of-shift meeting. The RN and CNA use the list of shift points to guide their discussions about each patient and set goals for each patient. The CNA continues to check in with the RN throughout the day, and reports back to the RN for an end-of-shift report.
White boards in patient rooms. The goals for each patient are written on the white board. “We’ve really engaged patients and their families more in the plan of care,” says Katrina Rodriguez, RN, BSN, care center coordinator, medical/surgical. “A lot of times, a patient will say something like, ‘I’ve only gotten out of bed once today and I’m supposed to get up three times. When am I going to get up again?’”
Hourly patient rounding. “Every hour, we have a member of the team (RN/LVN or CNA) round on the patient, observing or assessing the patient and making sure the patient and the environment is safe,” says Grams. “We plan on the RN/LVN round on the even hours, and the odd hours, a CNA rounds on the patient. On rounding, we make sure the patient has everything he or she needs. We are really trying to anticipate patients’ needs. If the patient is awake, we ask, ‘Is there anything I can do for you.’ We tell nurses to say they ‘have time’ so the patient doesn’t feel rushed or that they are imposing on the staff’s time.”
Staff Satisfaction and Clinical Outcomes Improve
This new team approach has now been piloted on two medical-surgical units at Presbyterian Intercommunity--with great success. A survey conducted on the medical-respiratory unit found that 95 to 97 percent of staff were more satisfied overall after the new team model was implemented than before. The same unit has had zero voluntary turnover between January and December 2007. “I’ve always had pretty good turnover rates,” says Grams. “But this is the first time I can say that I have a waiting list for people who want to work on my unit.”
“Our unlicensed staff tell us, “We feel more respected and more like members of the team,’” says Rodriguez, who manages the other med-surg pilot unit. “Nursing tends to be a hierarchal culture, but this approach has helped break down this hierarchy. The patient is everyone’s responsibility. It’s not, ‘I’m in charge of this part of patient care, and you’re in charge of that.’ We work together toward the same goals.”
Nurses also think that patients are safer now that nursing staff are visiting them more regularly. One hundred percent of the nursing staff surveyed on medical-respiratory unit thought patients were safer under this new team model. And they have the data to prove it. In addition to seeing pressure ulcer rates fall to zero, unit staff have happily seen patient falls decrease from 2.98 falls per 1,000 patient days in March 2007 (prior to project) to 2.0 falls per 1,000 patient days March 2008.
Back to Basics
The nurse leaders at Presbyterian Intercommunity provide a third lesson worth remembering: “Get back to the basics of nursing practice: delegation, communication, and scope of practice,” says Grams. “How did we get away from these things? We outlined all of these, formalized them, and made it clear that these were expectations. It’s very empowering to have a clear understanding of your scope of practice.”
This article originally appeared in The Business of Caring, a newsletter dedicated to helping nurse managers develop business and leadership skills.