- Email: [email protected]
The Impact of a Performance Improvement Project on Exclusive Breastfeeding
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Auricular Point Acupressure to Improve Sleep Quality in Taiwanese Postpartum Women with Insomnia Objective o evaluate the effectiveness of a 3-week auricular point acupressure (APA) in relieving insomnia in postpartum women.
Implementation Strategies The acupoints selected for APA included three acupoints for improving sleep: shenmen, heart, and kidney. APA was administered by a trained registered nurse.
Design Nonrandomized controlled trial.
Results After 21 days of APA intervention, the experimental group (n = 30) experienced significantly less insomnia than the control group (5.83 ± 2.31 vs. 8.16 ± 2.17, t = −4.11, p = .001) measured by Pittsburgh Sleep Quality Index.
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Chien-Tzu Liu, MSN, Taipei Medical University Hospital, Taipei, Taiwan
Sample Sixty postpartum women reporting poor quality of sleep were recruited in one postpartum center in Yi-Li Ko, RN, MSN, EdD, Fu Jen Catholoc University, Taipei, northern Taiwan from February 2013 to June 2013. Taiwan Keywords auricular point acupressure traditional Chinese medicine postpartum insomnia
Poster Presentation
Methods We used a quasi-experimental, two-group pretest–post test design and a convenience sampling method.
Conclusion/Implications for Nursing Practice The preliminary findings of this study showed improvement in quality of sleep suggesting that APA may be a promising treatment for women with insomnia. Nurses interested in complementary therapies should be encouraged to obtain training in APA and to apply it in postpartum care.
“Keep Me with My Mom”: An Evidenced-Based Initiative to Keep Mother and Newborn Together Following Cesarean Birth Objective o standardize practice to allow mother and newborn to recover together following cesarean birth.
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Michele Romano, MS, RN, IBCLC, LCCE, CEIM, Greenwich Hospital, Greenwich, CT Claire H. Carter, MSN, RNC-OB, C-EFM, CPCE, Greenwich Hospital, Greenwich, CT Keywords skin-to-skin care postbirth recovery care cesarean birth Plan-Do-Study-Act cycle
Poster Presentation
Design Evidence-based guidelines support postbirth recovery of term, stable, newborns skin-to-skin (STS), with mothers to promote mother–newborn synchrony. The Plan-Do-Study-Act (PDSA) Cycle was utilized to implement our practice change. Sample Preimplementation: 3 months (November 2012January 2013) retrospective chart review of recovery care, with 42 term stable newborns born by cesarean birth; 14 newborns per month. Pilot: 1 month project (March 2013) to keep mother and newborn together for four selected cesarean births. Implementation: from April 2013 until present keep mother and newborn together for all cesarean births with ongoing monthly retrospective chart review of recovery care following cesarean birth (14 charts per month).
Methods Retrospective chart review includes date and time of birth, feeding choice, time of breastfeeding initiation, and time of newborn admission to the nursery. Patient satisfaction questions/comments relevant to the project were obtained from the hospital’s patient satisfaction survey. Implementation phase retrospective chart review collected data about documentation of initiation of STS.
Implementation Strategies A list entitled Top Ten Reasons for Keeping Mother and Baby Together Post-Birth was posted prior to implementation to engage staff and prompt dialogue. Labor and delivery staff, designated as project champions, and the education specialist reorganized the cesarean birth recovery room to safely accommodate mother and newborn. Multidisciplinary in-service education was provided. A pilot project was conducted to identify any barriers. A workflow algorithm was created to highlight changes to staff responsibilities. Staff dialogue continues to share progress, address
JOGNN S58
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2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
Bowman, D. S. and LiVolsi, K.
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
challenges and concerns, and offer support and information about keeping mothers and newborns together.
Initiation of STS increased 7% to 57%. Patient satisfaction scores remain consistent at greater than 90%.
Results The length of time mother and newborn stayed together following cesarean birth increased from 35 to 90–120 minutes. The length of time to initiation of breastfeeding decreased from 5 to 2 3/4 hours.
Conclusion/Implications for Nursing Practice The PDSA cycle can be used to accomplish successful implementation of practice change. Standardized care following cesarean birth should include STS and early initiation of breastfeeding. Unexpected practice improvement may be realized.
Beyond 39 Weeks: Sustainability in Decreasing Cesarean Rates in Elective Inductions Donna S. Bowman, MSN, FNP-BC, RNC-OB, EFM-C, Stamford Hospital, Stamford, CT Kathy LiVolsi, MHA, BSN, RNC, Stamford Hospital, Stamford, CT Keywords elective induction Bishop score cesarean
Childbearing Poster Presentation
Objective high cesarean rate led the Perinatal Quality and Safety Committee (PQSC) to investigate opportunities for improvement. We chose to restrict elective inductions by applying evidencebased parameters for selection with the aim of decreasing the cesarean rate.
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Design The PQSC developed a policy restricting elective inductions to women who were at least 39 weeks gestation with a Bishop score of greater than 7. Evidence has demonstrated that infants born prior to 39 weeks gestation have an increased risk for problems leading to admission to the neonatal intensive care unit. Additionally, women who are induced with a Bishop score greater than 7 have a probability of vaginal delivery that is similar to spontaneous labor. Sample Low-risk, healthy women undergoing elective induction. Methods A standardized process for booking inductions was developed, including a physician request form documenting gestational age, Bishop score, and induction indication. Education was provided and feedback was solicited from nursing and physician staff prior to implementation. Implementation Strategies Charts were audited monthly and feedback was provided to staff. Compliance with the 39-week requirement was high. In the first month, only 50%
JOGNN 2014; Vol. 43, Supplement 1
of patients induced electively had documented Bishop scores. During 2010 to 2011, compliance with the requirement to record Bishop scores fluctuated between 55% and 90%. Noncompliant physicians were referred to peer review, but this did not always improve performance. In 2012, the PQSC determined that a nurse-driven hard stop at the time of booking was required. Inductions were not booked until the request form was approved by nursing staff. Physicians were informed that if patients presented to the unit who did not meet criteria, they would not be induced. Results Since 2010 there have been no elective inductions prior to 39 weeks gestation. Compliance with the requirement to record Bishop score has improved steadily. The mean compliance per month for 2010 was 75%, and by July 2013, the rate was 96%. The cesarean rate has decreased from 24.4% 6 months prior to implementation to 12.2% post implementation. Conclusion/Implications for Nursing Practice Empowerment of the nursing staff was a significant contributing factor to the success of this initiative. Originally ambivalent, the nursing staff did not want to police the attending physicians or contribute to patient dissatisfaction. Hard stops resulted in discharged patients, and several physicians were referred for peer review, but over time compliance with the policy became the norm. Supported by leadership, nurses continue to be a driving force in our evidence-based culture of quality and safety.
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EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Supporting Kangaroo Care after Cesarean Birth: Going Bare for Better Care Objective o implement a process to support kangaroo care (KC) after cesarean birth and to decrease the amount of time mother and newborn are separated.
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Design Evidence was translated with a quality improvement design using quality improvement (Lean) methodology. Sample Ninety-five women who delivered by cesarean between January 1, 2013 and July 30, 2013 and their newborns were included. Methods This study was conducted at a northeastern, 76 bed Pathway to Excellence community hospital. Key stakeholders were included in the transition to providing KC in the operating room. A swim chart of the current condition identified potential problems. Implementation Strategies A policy for KC after cesarean was communicated to stakeholders, including operating room temperature of 73 degrees, a safe location for mother– newborn recovery, clear roles and responsibilities for stakeholders, access for newborn assessment
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and physical examination, and essential equipment. In addition, education regarding KC benefits was initiated during mothers’ preadmission testing. The policy for KC after cesarean was pilot tested in April/May upon a mother’s request. It was fully implemented in June for all scheduled cesareans. Results Data were collected to measure total time of KC provided by the mother or the significant other and time of mother–newborn separation before and after implementation of KC after cesarean. Between January and July, the average amount of KC a newborn received increased from 30 minutes to 2 ½ hours. Between January and April, mother– newborn separation time averaged 2 hours. Following the shift to encouraging KC, the average separation time decreased to 1 hour and 20 minutes. In July, the separation time further decreased to approximately 20 minutes.
Susan A. Hoffman, BA, BSN, RNC-MNN, Gettysburg Hospital, Gettysburg, PA Stacie K. Massett, BSN, RN, Gettysburg Hospital, Gettysburg, PA Jayne L. Sorber, RN, IBCLC, CCE, Gettysburg Hospital, Gettysburg, PA Keywords kangaroo care skin-to-skin care cesarean separation time
Childbearing Poster Presentation
Conclusion/Implications for Nursing Practice The amount of time mothers and newborns are separated after cesareans had decreased whereas the amount of time newborns are provided KC has increased. Support from stakeholders to implement KC in the operating room helped to translate evidence into clinical practice.
JOGNN, 43, S58-S65; 2014. DOI: 10.1111/1552-6909.12341
http://jognn.awhonn.org
Pisegna, L. and Pyka, J.
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Interobserver Reliability of the Finnegan Neonatal Abstinence Scoring Tool in an Acute Care Setting Objective o determine if interobserver reliability of the Finnegan Neonatal Abstinence Scoring Tool (FNAST) exists among nurses who care for infants with neonatal abstinence syndrome (NAS) in the neonatal intensive care unit (NICU), mother/baby unit, and pediatric/pediatric intenCatherine M. Retskin, DNPc, MSN, RNC, Mission Hospitals sive care unit (PEDS/PICU) of a regional tertiary – Memorial Campus, Asheville, hospital.
Newborn Care
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NC Mary Ellen Wright, MSN, Design ARPN, CPNP, Mission A cross-sectional, interobserver reliability study of Hospital System, Asheville, NC
the Finnegan scoring tool.
Keywords neonatal abstinence syndrome opiate withdrawal in newborns Finnegan scoring tool interobserver reliability interrater reliability
Poster Presentation
Sample A convenience sample of 122 nurses in a regional tertiary hospital yielded 10 nurses from NICU, 65 nurses from mother/baby, and 47 nurses from PEDS/PICU. Institutional Review Board approval was obtained before this study. Methods Participants were asked to complete a demographic survey that provided information on primary unit of practice, education level, years of experience, and certifications. A video vignette of an assessment of an infant with NAS, which is part of an interobserver reliability program developed by D’Apolito and Finnegan, was used with permission. After viewing the video, participants completed the FNAST based on their observations and assessments.
Lily Pisegna, MBAH, BSN, RNC-NICN, NE-BC, Sharp Grossmont Hospital, La Mesa, CA
Implementation Strategies Not applicable. Results The expert rater score of the vignette used for this study was 13. The overall median total score for participants was 12.76 with a standard deviation of 3.306. The interclass correlation coefficient (ICC) relative to average measures calculated to determine the reliability of the participants’ total scores was excellent at 0.996. The ICC relative to single measures or how the score was obtained did not demonstrate reliability at 0.694. The area of greatest discrepancy was noted within the central nervous system portion of the scoring tool. Demographic data indicated that 58% of participants had Bachelor of Science in nursing degrees; 54% had 0 to 5 years of experience; and 46% were certified in their specialty areas. Conclusion/Implications for Nursing Practice Interobserver reliability was established for total score. Interobserver reliability was not established for single measures with the majority of the discrepancies found within the central nervous system portion of the FNAST. If clinical decisions are made based on the reliability of these scores, values should be a minimum of 0.90. Going forward, education in Finnegan scoring should have an increased focus on the central nervous system portion of the scoring tool. We also recommend that interobserver reliability of the FNAST should be part of annual competencies and included in orientation for new nurses on the NICU, mother/baby unit, and PEDS/PICU due to the epidemiology of NAS.
An Interdisciplinary Approach to Improving Exclusive Breast Milk Feeding Rate at Discharge Objective o improve the exclusive breastfeeding and breast milk feeding rates at discharge to 71% by the third quarter of 2013.
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Design An interdisciplinary taskforce was created with representatives from the Women and Infants Service Line. Breastfeeding education was re-
JOGNN 2014; Vol. 43, Supplement 1
vised to support the 10 steps to becoming a Baby Friendly Hospital. Baby Friendly goals and other quality initiatives were adopted by each unit to improve exclusive breastfeeding at discharge. The electronic medical record (EMR) and interdisciplinary resources were leveraged to identify and support mothers throughout their hospitalizations.
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EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Sample All well newborns and all premature infants 28 to 34 weeks gestation (100%). Methods Retrospective chart review using software to abstract charts based on the Joint Commission definitions for perinatal core measures. Implementation Strategies An interdisciplinary taskforce was formed to standardize and reliably implement evidence-based, supportive hospital practices for breastfeeding, including skin to skin in labor and delivery and post anesthesia care units; EMR identification and interdisciplinary plan of care for newborns having difficulty latching or breastfeeding; EMR documentation of 24-hour breast milk totals; and bedside pumping logs and tracking of adequate expressed breast milk supply by 2 weeks in the neonatal intensive care unit (NICU). All mothers are encouraged to log and track their breast milk
production on the breast pump log throughout hospitalization. Lactation consultants develop an interdisciplinary plan of care on all infants having difficulty breastfeeding or requiring specialized care. The plan of care is attached to a specific location within the neonatal EMR. Lactation consultants and registered nursed in the NICU have daily bed huddles to identify mothers who are having difficulty establishing breast milk supply.
Jeanine Pyka, MSN, RNC-MNN, NE-BC, Sharp Grossmont Hospital, La Mesa, CA
Keywords Baby Friendly exclusive breast milk interdisciplinary exclusive breastfeeding Results Based on all the strategies the taskforce imple- NICU breast milk supply mented, we increased our exclusive breast milk lactation consultants rate at discharge from a baseline of 49% (July- electronic medical record September 2011) to 71% (April-June 2013). bed huddle
Conclusion/Implications for Nursing Practice Adopting an interdisciplinary approach involving all key stakeholders throughout hospitalization is critical to the success of improving exclusive breast milk rate at discharge. Implementing evidence-based practice and engaging the staff to take accountability was key to our success.
Newborn Care Poster Presentation
Innovations in Practice: Supporting the Breastfeeding Dyad in Labor & Delivery Objective o improve support of the breastfeeding mother–infant dyad by increasing skin-to-skin (STS) care and initiating breastfeeding within the first hour of birth.
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Design Pre and post intervention design. Exclusive breastfeeding for 6 months of life is endorsed by many healthcare organizations. Both of the proposed interventions have demonstrated improved breastfeeding outcomes. Sample Inclusion criteria included a stable mother–infant dyad not separated after birth. A random sample was selected (minimum of 30 charts/month) of dyads admitted to the mother–baby unit after birth. Methods Retrospective chart review. Implementation Strategies Several nurses in the labor & delivery (L&D) unit initiated this project as one way to increase rates of breastfeeding. The L&D shared governance council committed to improving STS care and early initiation of breastfeeding and this quality improvement initiative. Plan-do-check-act quality im-
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provement methodology was paired with change management theory (Roger’s Theory of Innovation) to enhance outcomes. Baseline data were obtained, and a literature review was conducted. Unit champions or innovators were identified. Implementation of STS care and early initiation of breastfeeding was instituted by the L&D nurses. All staff members were educated, and champions assisted other nurses in accomplishing STS care, even at times in the operating room. Monthly audit data were shared with staff. Challenges were encountered along the way, including the introduction of a new electronic medical record. Physician resistance was overcome by education, persistence, and culture change. Slowly change occurred, and anesthesiologists became champions. STS care and early breastfeeding are now part of routine practice on the L&D unit.
Rita Allen Brennan, DNP, RNC-NIC, APN/CNS, Central DuPage Hospital, Winfield, IL Susan Callaway, BSN, RNC, Central DuPage Hospital, Winfield, IL Keywords skin-to-skin care breastfeeding quality improvement change management labor & delivery
Newborn Care Poster Presentation
Results Monthly data audits were completed for each indicator. Use of STS care increased from a baseline of 25% (July 2010, all delivery types) to nearly 90% by July 2013. In this same timeframe, the rate of breastfeeding within the first hour increased from 66% to 90%. Conclusion/Implications for Nursing Practice STS care and early breastfeeding after birth have proven benefits for the mother and infant. Perinatal
JOGNN, 43, S58-S65; 2014. DOI: 10.1111/1552-6909.12341
http://jognn.awhonn.org
O’Brien, E. E. et al.
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
nurses must find ways to implement these practices. Continual reinforcement is needed to sus-
tain change, and outside factors such as change in documentation system affect care.
The Impact of a Performance Improvement Project on Exclusive Breastfeeding Tamara W. Eberly, PhD, RN, University of Virginia, Charlottesville, VA
Objective growing body of evidence demonstrates that performance improvement initiatives inLisa Hamlett Akers, MS, RD, IBCLC, Virginia Department of crease knowledge, provide resources, and encourage evidence-based improvements in clinical Health, Richmond, VA practice. The objective of this study was to deterKeywords mine whether a web-based performance improveexclusive breastfeeding ment project could improve an important clinical breastfeeding rates Breastfeeding Friendly Hospital outcome: exclusive breastfeeding. Initiative pacifier use skin-to-skin rooming-in breastfeeding assessment tool performance improvement
Newborn Care Poster Presentation
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Design This study was an ad hoc data analysis of the “Breastfeeding Friendly Improvement Project: Meeting the Gold Standard in Infant Nutrition,” a performance improvement, continuing medical education activity designed to promote and support breastfeeding. Participants used a chart audit tool to document exclusive breastfeeding and other explanatory variables that could affect the rate of exclusive breastfeeding. The webbased program using chart data from their individual practice settings allowed participants to proceed at their own pace and to receive individual scores and peer comparisons throughout the process. Sample One hundred sixty-two (162) physicians selfselected to participate in this American Board of Pediatrics approved activity. Methods Random effects tobit regression analysis of chart audit data pre- and postcompletion of the performance improvement activity was used to determine clinical practice changes, the improvement in rate of exclusive breastfeeding among
patients, and which clinical practices had the best association with increases in exclusive breastfeeding. Implementation Strategies A total of 2,587 preperformance improvement patient profiles and 3,240 postperformance improvement profiles were reviewed. Results Improvement in all best practice variables was reported. Following completion of the performance improvement project, exclusive breastfeeding rates in the patient profiles increased 14.50% (p < .01); rates of initiation of skin-to-skin care within 1 hour of delivery increased 14.13% (p < .01); rates of rooming-in ࣙ23 hours increased 13.86% (p < .01); rates of breastfeeding assessment using an objective tool increased 22.58% (p < .01); and rates of pacifier use decreased 19.81% (p < .01). Conclusion/Implications for Nursing Practice Participation in a web-based performance improvement initiative significantly improved use of evidence-based best practices and rates of exclusive breastfeeding. The role of performance improvement initiatives in providing quality health care should not be underestimated and should be embraced by the healthcare community as an effective tool to improve patient outcomes. Though the participants in this study were physicians, the activity can be used by other healthcare providers, especially nurses, and would be especially useful in providing aggregate data about a hospital’s practice.
Implementation of a Comprehensive, Unit-Based Protocol for Prevention of Neonatal Catheter Associated Blood Stream Infections Erin E. O’Brien, MSN, NNP-BC, Northwestern Memorial Hospital, Chicago, IL
Objective o reduce the observed neonatal catheter associated blood stream infection (NCABSI) rate in the neonatal intensive care unit (NICU)
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from baseline standardized infection ratio (SIR) of 1.55 in fiscal year (FY) 2012 to <0.79 in FY13 through a comprehensive, unit-based safety program (CUSP).
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EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Design A surveillance study involving at-risk neonates born during FY13 at an academic level III NICU. By applying CUSP methodology to evaluate local safety processes to identify and learn from errors, we aimed to eliminate NCABSIs. The emphasis was on insertion techniques, appropriate maintenance of central catheters, and changing the local safety culture with promotion of a shared mental model among all staff members.
continued use were regularly assessed. Maintenance interventions included (a) placement of an absorptive foam disk impregnated with 250 µg/mg of chlorhexidine gluconate over insertion sites for infants ࣙ2 kg or at 2 weeks of age for infants <2 kg irrespective of gestational age and (b) passive disinfection of access ports with 70% isopropyl alcohol port protectors. NCABSI was reported as SIR = actual/expected number of infections.
Sample Consecutive neonates with umbilical arterial and venous catheters and percutaneous central venous catheters.
Results Following implementation of CUSP, 282 central lines were placed in 167 infants (56% male), median gestation age 32 weeks (range 23-41 weeks), mean birth weight 1,899 ± 1,096 g. Forty percent of infants were ࣙ34 weeks gestation with main indication for access being hypoglycemia (35%). Bedside registered nurse documentation audits showed 100% compliance. The mean number of line days was 10 ± 8 days with reduction of central line access by 2 to 3 days per patient. NCABSI SIR FY13 was 0.32 (compared to FY12 of 1.55).
Methods A multidisciplinary team of frontline providers was assembled, the culture of safety was measured, deficits were identified, and an improvement plan was generated. Prevention and maintenance measures were developed, including optimal hand hygiene compliance, insertion and maintenance bundles, and institution of electronic medical record central line documentation. Implementation Strategies Feeding practice was standardized for extremely low birth weight infants with discontinuation of central access when feeds were established at 100 to 120 ml/kg/day. Nursing audits for compliance of maintenance bundle documentation and daily review of central lines with justification for
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Conclusion/Implications for Nursing Practice Through implementation of the CUSP initiative, heightened awareness of the shared responsibility for safety processes required for elimination of NCABSI was shared among nursing team members. By adapting a culture of safety, we were able to achieve a fivefold decrease in the rate of NCABSI.
JOGNN, 43, S58-S65; 2014. DOI: 10.1111/1552-6909.12341
Susie Rosenberg, MS, CNS-BC, Northwestern Memorial Hospital, Chicago, IL Ericka Bollinger, BSN, RN, Northwestern Memorial Hospital, Chicago, IL Lindsay Lenhart, BSN, RN, Northwestern Memorial Hospital, Chicago, IL Susan Sramek, BSN, RN, Northwestern Memorial Hospital, Chicago, IL Anessa Mikolajczak, BSN, RN, Northwestern Memorial Hospital, Chicago, IL Janine Y. Khan, MD, Northwestern Memorial Hospital, Chicago, IL Keywords neonatal bloodstream infections central access CUSP
Newborn Care Poster Presentation
http://jognn.awhonn.org
Robinson, N. K. and Dodd, D. R.
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Lateral Violence: The Real Nurse Curse Objective ateral violence (LV) or workplace bullying is a longstanding problem within the healthcare field, so much so that the Joint Commission addressed the subject in 2008. Nurses consider bullying a normal rite of passage, just how it has always been. The current practice of enabling bullying among peers, allowing incivility to go unchecked, and having no accountability needed Nora K. Robinson, BSN, to be addressed. Thus, an LV workgroup was deRNC-OB, Baylor All Saints veloped to decrease the incidences of LV and Medical Center-Andrews Women’s Hospital, Fort Worth, measure its effect on nurse retention.
Professional Issues
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TX Dawn Renee Dodd, BSN, RN, RNC-OB, C-EFM, LCCE, Baylor All Saints Medical Center-Andrews Women’s Hospital, Keller, TX Keywords lateral violence incivility in nursing workplace bullying horizontal violence bullying
Design Plan-do-check-act (PDCA) cycles were used to isolate perceived LV behaviors and develop strategies to reduce their occurrence of or enhance the ability to manage them. Sample Registered nurses (more than 400) from the following units: labor & delivery, postpartum, nursery, neonatal intensive care, antepartum, gynecologic surgery/post anesthesia care.
Poster Presentation Methods One metric used to measure our efficacy was a monthly/quarterly anonymous survey to track the perception how often LV behaviors occurred. This survey was used after the implementation of each educational piece. The human resources department tracked LV complaints and job loss/resignation due to LV.
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Implementation Strategies The PDCA cycles involved educating staff, supervisors, and managers through PowerPoint presentations, posters, e-mails, tip sheets, and meetings. Administrators sent a clear message to the staff in support of this initiative; we were now a no bully zone. Recognizing and appropriately handling LV in conjunction with accountability was a top priority especially for supervisors/managers. Another cycle included a questionnaire asking charge nurses how they made patient/nurse assignments. This led to the creation of a unit-specific tip sheet that showed how assignments were made. Staff could now see the complexities involved in making assignments. Results By the end of our second PDCA cycle, we were seeing a decrease in LV on the units. The end result of this project was an impressive decrease in LV and an increase in nurse retention. Conclusion/Implications for Nursing Practice Education and accountability are paramount when tackling LV. The education must equip supervisors and managers with tools to effectively deal with bullies, witnesses, and victims of LV. This project is being reproduced in our hospital and will spread system wide. The benefits of reducing LV are far reaching and include patient safety and satisfaction, job retention, effective communication, decreased stress, healthy work environments, and better Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.
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Auricular Point Acupressure to Improve Sleep Quality in Taiwanese Postpartum Women with Insomnia Objective o evaluate the effectiveness of a 3-week auricular point acupressure (APA) in relieving insomnia in postpartum women.
Implementation Strategies The acupoints selected for APA included three acupoints for improving sleep: shenmen, heart, and kidney. APA was administered by a trained registered nurse.
Design Nonrandomized controlled trial.
Results After 21 days of APA intervention, the experimental group (n = 30) experienced significantly less insomnia than the control group (5.83 ± 2.31 vs. 8.16 ± 2.17, t = −4.11, p = .001) measured by Pittsburgh Sleep Quality Index.
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Chien-Tzu Liu, MSN, Taipei Medical University Hospital, Taipei, Taiwan
Sample Sixty postpartum women reporting poor quality of sleep were recruited in one postpartum center in Yi-Li Ko, RN, MSN, EdD, Fu Jen Catholoc University, Taipei, northern Taiwan from February 2013 to June 2013. Taiwan Keywords auricular point acupressure traditional Chinese medicine postpartum insomnia
Poster Presentation
Methods We used a quasi-experimental, two-group pretest–post test design and a convenience sampling method.
Conclusion/Implications for Nursing Practice The preliminary findings of this study showed improvement in quality of sleep suggesting that APA may be a promising treatment for women with insomnia. Nurses interested in complementary therapies should be encouraged to obtain training in APA and to apply it in postpartum care.
“Keep Me with My Mom”: An Evidenced-Based Initiative to Keep Mother and Newborn Together Following Cesarean Birth Objective o standardize practice to allow mother and newborn to recover together following cesarean birth.
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Michele Romano, MS, RN, IBCLC, LCCE, CEIM, Greenwich Hospital, Greenwich, CT Claire H. Carter, MSN, RNC-OB, C-EFM, CPCE, Greenwich Hospital, Greenwich, CT Keywords skin-to-skin care postbirth recovery care cesarean birth Plan-Do-Study-Act cycle
Poster Presentation
Design Evidence-based guidelines support postbirth recovery of term, stable, newborns skin-to-skin (STS), with mothers to promote mother–newborn synchrony. The Plan-Do-Study-Act (PDSA) Cycle was utilized to implement our practice change. Sample Preimplementation: 3 months (November 2012January 2013) retrospective chart review of recovery care, with 42 term stable newborns born by cesarean birth; 14 newborns per month. Pilot: 1 month project (March 2013) to keep mother and newborn together for four selected cesarean births. Implementation: from April 2013 until present keep mother and newborn together for all cesarean births with ongoing monthly retrospective chart review of recovery care following cesarean birth (14 charts per month).
Methods Retrospective chart review includes date and time of birth, feeding choice, time of breastfeeding initiation, and time of newborn admission to the nursery. Patient satisfaction questions/comments relevant to the project were obtained from the hospital’s patient satisfaction survey. Implementation phase retrospective chart review collected data about documentation of initiation of STS.
Implementation Strategies A list entitled Top Ten Reasons for Keeping Mother and Baby Together Post-Birth was posted prior to implementation to engage staff and prompt dialogue. Labor and delivery staff, designated as project champions, and the education specialist reorganized the cesarean birth recovery room to safely accommodate mother and newborn. Multidisciplinary in-service education was provided. A pilot project was conducted to identify any barriers. A workflow algorithm was created to highlight changes to staff responsibilities. Staff dialogue continues to share progress, address
JOGNN S58
C
2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
Bowman, D. S. and LiVolsi, K.
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
challenges and concerns, and offer support and information about keeping mothers and newborns together.
Initiation of STS increased 7% to 57%. Patient satisfaction scores remain consistent at greater than 90%.
Results The length of time mother and newborn stayed together following cesarean birth increased from 35 to 90–120 minutes. The length of time to initiation of breastfeeding decreased from 5 to 2 3/4 hours.
Conclusion/Implications for Nursing Practice The PDSA cycle can be used to accomplish successful implementation of practice change. Standardized care following cesarean birth should include STS and early initiation of breastfeeding. Unexpected practice improvement may be realized.
Beyond 39 Weeks: Sustainability in Decreasing Cesarean Rates in Elective Inductions Donna S. Bowman, MSN, FNP-BC, RNC-OB, EFM-C, Stamford Hospital, Stamford, CT Kathy LiVolsi, MHA, BSN, RNC, Stamford Hospital, Stamford, CT Keywords elective induction Bishop score cesarean
Childbearing Poster Presentation
Objective high cesarean rate led the Perinatal Quality and Safety Committee (PQSC) to investigate opportunities for improvement. We chose to restrict elective inductions by applying evidencebased parameters for selection with the aim of decreasing the cesarean rate.
A
Design The PQSC developed a policy restricting elective inductions to women who were at least 39 weeks gestation with a Bishop score of greater than 7. Evidence has demonstrated that infants born prior to 39 weeks gestation have an increased risk for problems leading to admission to the neonatal intensive care unit. Additionally, women who are induced with a Bishop score greater than 7 have a probability of vaginal delivery that is similar to spontaneous labor. Sample Low-risk, healthy women undergoing elective induction. Methods A standardized process for booking inductions was developed, including a physician request form documenting gestational age, Bishop score, and induction indication. Education was provided and feedback was solicited from nursing and physician staff prior to implementation. Implementation Strategies Charts were audited monthly and feedback was provided to staff. Compliance with the 39-week requirement was high. In the first month, only 50%
JOGNN 2014; Vol. 43, Supplement 1
of patients induced electively had documented Bishop scores. During 2010 to 2011, compliance with the requirement to record Bishop scores fluctuated between 55% and 90%. Noncompliant physicians were referred to peer review, but this did not always improve performance. In 2012, the PQSC determined that a nurse-driven hard stop at the time of booking was required. Inductions were not booked until the request form was approved by nursing staff. Physicians were informed that if patients presented to the unit who did not meet criteria, they would not be induced. Results Since 2010 there have been no elective inductions prior to 39 weeks gestation. Compliance with the requirement to record Bishop score has improved steadily. The mean compliance per month for 2010 was 75%, and by July 2013, the rate was 96%. The cesarean rate has decreased from 24.4% 6 months prior to implementation to 12.2% post implementation. Conclusion/Implications for Nursing Practice Empowerment of the nursing staff was a significant contributing factor to the success of this initiative. Originally ambivalent, the nursing staff did not want to police the attending physicians or contribute to patient dissatisfaction. Hard stops resulted in discharged patients, and several physicians were referred for peer review, but over time compliance with the policy became the norm. Supported by leadership, nurses continue to be a driving force in our evidence-based culture of quality and safety.
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EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Supporting Kangaroo Care after Cesarean Birth: Going Bare for Better Care Objective o implement a process to support kangaroo care (KC) after cesarean birth and to decrease the amount of time mother and newborn are separated.
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Design Evidence was translated with a quality improvement design using quality improvement (Lean) methodology. Sample Ninety-five women who delivered by cesarean between January 1, 2013 and July 30, 2013 and their newborns were included. Methods This study was conducted at a northeastern, 76 bed Pathway to Excellence community hospital. Key stakeholders were included in the transition to providing KC in the operating room. A swim chart of the current condition identified potential problems. Implementation Strategies A policy for KC after cesarean was communicated to stakeholders, including operating room temperature of 73 degrees, a safe location for mother– newborn recovery, clear roles and responsibilities for stakeholders, access for newborn assessment
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and physical examination, and essential equipment. In addition, education regarding KC benefits was initiated during mothers’ preadmission testing. The policy for KC after cesarean was pilot tested in April/May upon a mother’s request. It was fully implemented in June for all scheduled cesareans. Results Data were collected to measure total time of KC provided by the mother or the significant other and time of mother–newborn separation before and after implementation of KC after cesarean. Between January and July, the average amount of KC a newborn received increased from 30 minutes to 2 ½ hours. Between January and April, mother– newborn separation time averaged 2 hours. Following the shift to encouraging KC, the average separation time decreased to 1 hour and 20 minutes. In July, the separation time further decreased to approximately 20 minutes.
Susan A. Hoffman, BA, BSN, RNC-MNN, Gettysburg Hospital, Gettysburg, PA Stacie K. Massett, BSN, RN, Gettysburg Hospital, Gettysburg, PA Jayne L. Sorber, RN, IBCLC, CCE, Gettysburg Hospital, Gettysburg, PA Keywords kangaroo care skin-to-skin care cesarean separation time
Childbearing Poster Presentation
Conclusion/Implications for Nursing Practice The amount of time mothers and newborns are separated after cesareans had decreased whereas the amount of time newborns are provided KC has increased. Support from stakeholders to implement KC in the operating room helped to translate evidence into clinical practice.
JOGNN, 43, S58-S65; 2014. DOI: 10.1111/1552-6909.12341
http://jognn.awhonn.org
Pisegna, L. and Pyka, J.
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Interobserver Reliability of the Finnegan Neonatal Abstinence Scoring Tool in an Acute Care Setting Objective o determine if interobserver reliability of the Finnegan Neonatal Abstinence Scoring Tool (FNAST) exists among nurses who care for infants with neonatal abstinence syndrome (NAS) in the neonatal intensive care unit (NICU), mother/baby unit, and pediatric/pediatric intenCatherine M. Retskin, DNPc, MSN, RNC, Mission Hospitals sive care unit (PEDS/PICU) of a regional tertiary – Memorial Campus, Asheville, hospital.
Newborn Care
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NC Mary Ellen Wright, MSN, Design ARPN, CPNP, Mission A cross-sectional, interobserver reliability study of Hospital System, Asheville, NC
the Finnegan scoring tool.
Keywords neonatal abstinence syndrome opiate withdrawal in newborns Finnegan scoring tool interobserver reliability interrater reliability
Poster Presentation
Sample A convenience sample of 122 nurses in a regional tertiary hospital yielded 10 nurses from NICU, 65 nurses from mother/baby, and 47 nurses from PEDS/PICU. Institutional Review Board approval was obtained before this study. Methods Participants were asked to complete a demographic survey that provided information on primary unit of practice, education level, years of experience, and certifications. A video vignette of an assessment of an infant with NAS, which is part of an interobserver reliability program developed by D’Apolito and Finnegan, was used with permission. After viewing the video, participants completed the FNAST based on their observations and assessments.
Lily Pisegna, MBAH, BSN, RNC-NICN, NE-BC, Sharp Grossmont Hospital, La Mesa, CA
Implementation Strategies Not applicable. Results The expert rater score of the vignette used for this study was 13. The overall median total score for participants was 12.76 with a standard deviation of 3.306. The interclass correlation coefficient (ICC) relative to average measures calculated to determine the reliability of the participants’ total scores was excellent at 0.996. The ICC relative to single measures or how the score was obtained did not demonstrate reliability at 0.694. The area of greatest discrepancy was noted within the central nervous system portion of the scoring tool. Demographic data indicated that 58% of participants had Bachelor of Science in nursing degrees; 54% had 0 to 5 years of experience; and 46% were certified in their specialty areas. Conclusion/Implications for Nursing Practice Interobserver reliability was established for total score. Interobserver reliability was not established for single measures with the majority of the discrepancies found within the central nervous system portion of the FNAST. If clinical decisions are made based on the reliability of these scores, values should be a minimum of 0.90. Going forward, education in Finnegan scoring should have an increased focus on the central nervous system portion of the scoring tool. We also recommend that interobserver reliability of the FNAST should be part of annual competencies and included in orientation for new nurses on the NICU, mother/baby unit, and PEDS/PICU due to the epidemiology of NAS.
An Interdisciplinary Approach to Improving Exclusive Breast Milk Feeding Rate at Discharge Objective o improve the exclusive breastfeeding and breast milk feeding rates at discharge to 71% by the third quarter of 2013.
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Design An interdisciplinary taskforce was created with representatives from the Women and Infants Service Line. Breastfeeding education was re-
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vised to support the 10 steps to becoming a Baby Friendly Hospital. Baby Friendly goals and other quality initiatives were adopted by each unit to improve exclusive breastfeeding at discharge. The electronic medical record (EMR) and interdisciplinary resources were leveraged to identify and support mothers throughout their hospitalizations.
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EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Sample All well newborns and all premature infants 28 to 34 weeks gestation (100%). Methods Retrospective chart review using software to abstract charts based on the Joint Commission definitions for perinatal core measures. Implementation Strategies An interdisciplinary taskforce was formed to standardize and reliably implement evidence-based, supportive hospital practices for breastfeeding, including skin to skin in labor and delivery and post anesthesia care units; EMR identification and interdisciplinary plan of care for newborns having difficulty latching or breastfeeding; EMR documentation of 24-hour breast milk totals; and bedside pumping logs and tracking of adequate expressed breast milk supply by 2 weeks in the neonatal intensive care unit (NICU). All mothers are encouraged to log and track their breast milk
production on the breast pump log throughout hospitalization. Lactation consultants develop an interdisciplinary plan of care on all infants having difficulty breastfeeding or requiring specialized care. The plan of care is attached to a specific location within the neonatal EMR. Lactation consultants and registered nursed in the NICU have daily bed huddles to identify mothers who are having difficulty establishing breast milk supply.
Jeanine Pyka, MSN, RNC-MNN, NE-BC, Sharp Grossmont Hospital, La Mesa, CA
Keywords Baby Friendly exclusive breast milk interdisciplinary exclusive breastfeeding Results Based on all the strategies the taskforce imple- NICU breast milk supply mented, we increased our exclusive breast milk lactation consultants rate at discharge from a baseline of 49% (July- electronic medical record September 2011) to 71% (April-June 2013). bed huddle
Conclusion/Implications for Nursing Practice Adopting an interdisciplinary approach involving all key stakeholders throughout hospitalization is critical to the success of improving exclusive breast milk rate at discharge. Implementing evidence-based practice and engaging the staff to take accountability was key to our success.
Newborn Care Poster Presentation
Innovations in Practice: Supporting the Breastfeeding Dyad in Labor & Delivery Objective o improve support of the breastfeeding mother–infant dyad by increasing skin-to-skin (STS) care and initiating breastfeeding within the first hour of birth.
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Design Pre and post intervention design. Exclusive breastfeeding for 6 months of life is endorsed by many healthcare organizations. Both of the proposed interventions have demonstrated improved breastfeeding outcomes. Sample Inclusion criteria included a stable mother–infant dyad not separated after birth. A random sample was selected (minimum of 30 charts/month) of dyads admitted to the mother–baby unit after birth. Methods Retrospective chart review. Implementation Strategies Several nurses in the labor & delivery (L&D) unit initiated this project as one way to increase rates of breastfeeding. The L&D shared governance council committed to improving STS care and early initiation of breastfeeding and this quality improvement initiative. Plan-do-check-act quality im-
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provement methodology was paired with change management theory (Roger’s Theory of Innovation) to enhance outcomes. Baseline data were obtained, and a literature review was conducted. Unit champions or innovators were identified. Implementation of STS care and early initiation of breastfeeding was instituted by the L&D nurses. All staff members were educated, and champions assisted other nurses in accomplishing STS care, even at times in the operating room. Monthly audit data were shared with staff. Challenges were encountered along the way, including the introduction of a new electronic medical record. Physician resistance was overcome by education, persistence, and culture change. Slowly change occurred, and anesthesiologists became champions. STS care and early breastfeeding are now part of routine practice on the L&D unit.
Rita Allen Brennan, DNP, RNC-NIC, APN/CNS, Central DuPage Hospital, Winfield, IL Susan Callaway, BSN, RNC, Central DuPage Hospital, Winfield, IL Keywords skin-to-skin care breastfeeding quality improvement change management labor & delivery
Newborn Care Poster Presentation
Results Monthly data audits were completed for each indicator. Use of STS care increased from a baseline of 25% (July 2010, all delivery types) to nearly 90% by July 2013. In this same timeframe, the rate of breastfeeding within the first hour increased from 66% to 90%. Conclusion/Implications for Nursing Practice STS care and early breastfeeding after birth have proven benefits for the mother and infant. Perinatal
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http://jognn.awhonn.org
O’Brien, E. E. et al.
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
nurses must find ways to implement these practices. Continual reinforcement is needed to sus-
tain change, and outside factors such as change in documentation system affect care.
The Impact of a Performance Improvement Project on Exclusive Breastfeeding Tamara W. Eberly, PhD, RN, University of Virginia, Charlottesville, VA
Objective growing body of evidence demonstrates that performance improvement initiatives inLisa Hamlett Akers, MS, RD, IBCLC, Virginia Department of crease knowledge, provide resources, and encourage evidence-based improvements in clinical Health, Richmond, VA practice. The objective of this study was to deterKeywords mine whether a web-based performance improveexclusive breastfeeding ment project could improve an important clinical breastfeeding rates Breastfeeding Friendly Hospital outcome: exclusive breastfeeding. Initiative pacifier use skin-to-skin rooming-in breastfeeding assessment tool performance improvement
Newborn Care Poster Presentation
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Design This study was an ad hoc data analysis of the “Breastfeeding Friendly Improvement Project: Meeting the Gold Standard in Infant Nutrition,” a performance improvement, continuing medical education activity designed to promote and support breastfeeding. Participants used a chart audit tool to document exclusive breastfeeding and other explanatory variables that could affect the rate of exclusive breastfeeding. The webbased program using chart data from their individual practice settings allowed participants to proceed at their own pace and to receive individual scores and peer comparisons throughout the process. Sample One hundred sixty-two (162) physicians selfselected to participate in this American Board of Pediatrics approved activity. Methods Random effects tobit regression analysis of chart audit data pre- and postcompletion of the performance improvement activity was used to determine clinical practice changes, the improvement in rate of exclusive breastfeeding among
patients, and which clinical practices had the best association with increases in exclusive breastfeeding. Implementation Strategies A total of 2,587 preperformance improvement patient profiles and 3,240 postperformance improvement profiles were reviewed. Results Improvement in all best practice variables was reported. Following completion of the performance improvement project, exclusive breastfeeding rates in the patient profiles increased 14.50% (p < .01); rates of initiation of skin-to-skin care within 1 hour of delivery increased 14.13% (p < .01); rates of rooming-in ࣙ23 hours increased 13.86% (p < .01); rates of breastfeeding assessment using an objective tool increased 22.58% (p < .01); and rates of pacifier use decreased 19.81% (p < .01). Conclusion/Implications for Nursing Practice Participation in a web-based performance improvement initiative significantly improved use of evidence-based best practices and rates of exclusive breastfeeding. The role of performance improvement initiatives in providing quality health care should not be underestimated and should be embraced by the healthcare community as an effective tool to improve patient outcomes. Though the participants in this study were physicians, the activity can be used by other healthcare providers, especially nurses, and would be especially useful in providing aggregate data about a hospital’s practice.
Implementation of a Comprehensive, Unit-Based Protocol for Prevention of Neonatal Catheter Associated Blood Stream Infections Erin E. O’Brien, MSN, NNP-BC, Northwestern Memorial Hospital, Chicago, IL
Objective o reduce the observed neonatal catheter associated blood stream infection (NCABSI) rate in the neonatal intensive care unit (NICU)
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from baseline standardized infection ratio (SIR) of 1.55 in fiscal year (FY) 2012 to <0.79 in FY13 through a comprehensive, unit-based safety program (CUSP).
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Design A surveillance study involving at-risk neonates born during FY13 at an academic level III NICU. By applying CUSP methodology to evaluate local safety processes to identify and learn from errors, we aimed to eliminate NCABSIs. The emphasis was on insertion techniques, appropriate maintenance of central catheters, and changing the local safety culture with promotion of a shared mental model among all staff members.
continued use were regularly assessed. Maintenance interventions included (a) placement of an absorptive foam disk impregnated with 250 µg/mg of chlorhexidine gluconate over insertion sites for infants ࣙ2 kg or at 2 weeks of age for infants <2 kg irrespective of gestational age and (b) passive disinfection of access ports with 70% isopropyl alcohol port protectors. NCABSI was reported as SIR = actual/expected number of infections.
Sample Consecutive neonates with umbilical arterial and venous catheters and percutaneous central venous catheters.
Results Following implementation of CUSP, 282 central lines were placed in 167 infants (56% male), median gestation age 32 weeks (range 23-41 weeks), mean birth weight 1,899 ± 1,096 g. Forty percent of infants were ࣙ34 weeks gestation with main indication for access being hypoglycemia (35%). Bedside registered nurse documentation audits showed 100% compliance. The mean number of line days was 10 ± 8 days with reduction of central line access by 2 to 3 days per patient. NCABSI SIR FY13 was 0.32 (compared to FY12 of 1.55).
Methods A multidisciplinary team of frontline providers was assembled, the culture of safety was measured, deficits were identified, and an improvement plan was generated. Prevention and maintenance measures were developed, including optimal hand hygiene compliance, insertion and maintenance bundles, and institution of electronic medical record central line documentation. Implementation Strategies Feeding practice was standardized for extremely low birth weight infants with discontinuation of central access when feeds were established at 100 to 120 ml/kg/day. Nursing audits for compliance of maintenance bundle documentation and daily review of central lines with justification for
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Conclusion/Implications for Nursing Practice Through implementation of the CUSP initiative, heightened awareness of the shared responsibility for safety processes required for elimination of NCABSI was shared among nursing team members. By adapting a culture of safety, we were able to achieve a fivefold decrease in the rate of NCABSI.
JOGNN, 43, S58-S65; 2014. DOI: 10.1111/1552-6909.12341
Susie Rosenberg, MS, CNS-BC, Northwestern Memorial Hospital, Chicago, IL Ericka Bollinger, BSN, RN, Northwestern Memorial Hospital, Chicago, IL Lindsay Lenhart, BSN, RN, Northwestern Memorial Hospital, Chicago, IL Susan Sramek, BSN, RN, Northwestern Memorial Hospital, Chicago, IL Anessa Mikolajczak, BSN, RN, Northwestern Memorial Hospital, Chicago, IL Janine Y. Khan, MD, Northwestern Memorial Hospital, Chicago, IL Keywords neonatal bloodstream infections central access CUSP
Newborn Care Poster Presentation
http://jognn.awhonn.org
Robinson, N. K. and Dodd, D. R.
EVIDENCE-BASED Q UALITY IMPROVEMENT RESEARCH PROJECTS Proceedings of the 2014 AWHONN Convention
Lateral Violence: The Real Nurse Curse Objective ateral violence (LV) or workplace bullying is a longstanding problem within the healthcare field, so much so that the Joint Commission addressed the subject in 2008. Nurses consider bullying a normal rite of passage, just how it has always been. The current practice of enabling bullying among peers, allowing incivility to go unchecked, and having no accountability needed Nora K. Robinson, BSN, to be addressed. Thus, an LV workgroup was deRNC-OB, Baylor All Saints veloped to decrease the incidences of LV and Medical Center-Andrews Women’s Hospital, Fort Worth, measure its effect on nurse retention.
Professional Issues
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TX Dawn Renee Dodd, BSN, RN, RNC-OB, C-EFM, LCCE, Baylor All Saints Medical Center-Andrews Women’s Hospital, Keller, TX Keywords lateral violence incivility in nursing workplace bullying horizontal violence bullying
Design Plan-do-check-act (PDCA) cycles were used to isolate perceived LV behaviors and develop strategies to reduce their occurrence of or enhance the ability to manage them. Sample Registered nurses (more than 400) from the following units: labor & delivery, postpartum, nursery, neonatal intensive care, antepartum, gynecologic surgery/post anesthesia care.
Poster Presentation Methods One metric used to measure our efficacy was a monthly/quarterly anonymous survey to track the perception how often LV behaviors occurred. This survey was used after the implementation of each educational piece. The human resources department tracked LV complaints and job loss/resignation due to LV.
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Implementation Strategies The PDCA cycles involved educating staff, supervisors, and managers through PowerPoint presentations, posters, e-mails, tip sheets, and meetings. Administrators sent a clear message to the staff in support of this initiative; we were now a no bully zone. Recognizing and appropriately handling LV in conjunction with accountability was a top priority especially for supervisors/managers. Another cycle included a questionnaire asking charge nurses how they made patient/nurse assignments. This led to the creation of a unit-specific tip sheet that showed how assignments were made. Staff could now see the complexities involved in making assignments. Results By the end of our second PDCA cycle, we were seeing a decrease in LV on the units. The end result of this project was an impressive decrease in LV and an increase in nurse retention. Conclusion/Implications for Nursing Practice Education and accountability are paramount when tackling LV. The education must equip supervisors and managers with tools to effectively deal with bullies, witnesses, and victims of LV. This project is being reproduced in our hospital and will spread system wide. The benefits of reducing LV are far reaching and include patient safety and satisfaction, job retention, effective communication, decreased stress, healthy work environments, and better Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.
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