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A Performance Improvement Plan to Increase Nurse Adherence to Use of Medication Safety Software
Journal of Pediatric Nursing (2012) 27, 375–382
A Performance Improvement Plan to Increase Nurse Adherence to Use of Medication Safety Software1,2 Carrie Gavriloff MSN, RN, Ed ⁎ Akron Children's Hospital, Akron, OH
Key words: Medication safety software; Performance improvement; Intravenous medications; Pediatrics
Nurses can protect patients receiving intravenous (IV) medication by using medication safety software to program “smart” pumps to administer IV medications. After a patient safety event identified inconsistent use of medication safety software by nurses, a performance improvement team implemented the Deming Cycle performance improvement methodology. The combined use of improved direct care nurse communication, programming strategies, staff education, medication safety champions, adherence monitoring, and technology acquisition resulted in a statistically significant (p b .001) increase in nurse adherence to using medication safety software from 28% to above 85%, exceeding national benchmark adherence rates (Cohen, Cooke, Husch & Woodley, 2007; Carefusion, 2011). © 2012 Elsevier Inc. All rights reserved.
THE INSTITUTE FOR Safe Medication Practice (ISMP) adopted the term smart pumps for infusion devices that use medication safety software (Cohen, Cooke, Husch, & Woodley, 2007; Keohane, Hayes, Saniuk, Rothschild, & Bates, 2005; Leape, 2005). This software protects patients and nurses from medication errors by “remembering” hospital-defined dosing limits and other clinical “rules” and applying them when administering intravenous (IV) medications (Hertzel & Sousa, 2009; Keohane et al., 2005). Evidence supports the use of medication safety software programs to prevent medication errors associated with IV infusions by preventing administration of doses that are too high or too low and preventing errors during pump programming (ECRI, 2002; Fields & Peterman, 2005; Hertzel & Sousa, 2009; ISMP, 2007; Keohane et al., 2005; Morgan & Siv-Lee, 2009; Rothschild, Keohane, Cook, Orav, Burdick, Thompson, Hayes, & Bates, 2005; Vanderveen, 1
Previous presentation of paper: Poster Presentation: Society of Pediatric Nurses Convention, April, 2010, Orlando Florida. Poster Presentation: Pediatric Nursing Conference, October, 2009, Akron, Ohio. 2 The author has no conflict of interest and this project has received no commercial financial support. ⁎ Corresponding author: Carrie Gavriloff, MSN, RN, Ed. E-mail address: [email protected]. 0882-5963/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.06.004
2005). Smart pumps have been implemented in health care organizations, but they do not prevent medication errors unless they are properly programmed by the nurse end users. In October 2007, a 359-bed, freestanding pediatric hospital in the Midwest identified that nurses bypassed the medication safety software in large volume smart pumps. A root cause analysis conducted after a medication error revealed bypassing of the medication safety software, and determined use of the medication safety software would have prevented the error. A performance improvement (PI) project was initiated to improve nurse adherence to the use of the smart pump medication safety software. The organization defines adherence as nurses using the medication safety software library created by the organization. Prior to the implementation of the smart pumps in the organization, nurses administered IV medications by programming the pump with the total volume of the medication and the total number of minutes over which the medication was to be infused. This is referred to as volume over time programming and does not demonstrate nurse adherence to the organization's definition of adherence to use of medication safety software. This describes the process and outcomes of a PI project designed to improve nurse adherence to use of medication safety software programs.
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Background IV infusions account for an estimated 35% to 60% of incidents in which the use of a medication or medication dose may have resulted in an adverse patient outcome in the pediatric population (Kaushal, Bates, Landrigan, McKenna, Clapp, Federico, Goldmann, 2001). However, a gap in the literature exists regarding the use of smart pumps in pediatric settings. The literatures identifies that in adult populations, smart pumps can reduce errors associated with IV infusions and provide safety protection during the medication administration process as long as they are programmed properly (Conroy, Sweis, Planner, Yeung, Collier, Haines, & Wong, 2007; Larsen, Parker, Cash, O'Connell, & Grant, 2005; Nuckols, Bower, Paddock, Hilborne, Wallace, Rothschild, Griffin, 2008; Rosenthal, 2004; Rothschild et al., 2005; Wilson & Sullivan, 2004). Success in reducing IV medication errors associated with smart pumps in adult populations can be achieved when education and training focus on using the medication safety software (Rothschild et al., 2005). Smart pumps are considered an important component of medication safety. For organizations to see a return on the investment of smart pumps, the features must avert errors: It is not enough to purchase smart pumps, program the library to enable the technology, distribute the pumps, educate users, and hope that the dose-checking feature will always be used. A culture of safety must exist that drives clinicians to avoid bypassing such a safety feature, or to report conditions that encourage work-arounds so they can be remedied (Cohen et al., 2007).
It has been reported that nurses do not value smart pump technology because of perceptions associated with its use, including (a) the low risk for errors associated with IV medications, (b) extra time and work associated with pump
programming, (c) alert fatigue as a result of false alarms, and (d) hospital culture that tolerates process work-arounds (Keohane et al., 2005; Leape, 2005; Rothschild et al., 2005). In contradiction to other findings, one study concluded that nurses did perceive medication safety software as a way to prevent medication errors but did not believe it created extra workload (Rosenkoetter, Bowcutt, Khasanshina, Chernecky, & Wall, 2008). Adherence to proper use of medication safety software is as important as its purchase (Birk, 2008; Rothschild et al., 2005). Cohen et al (2007) identified an overall adherence rate for programming IV pumps using the medication safety software in an adult institution at 75%. The literature does not report current adherence rates when using medication safety software in pediatric settings. Data measuring compliance using safety software provided courtesy of an IV pump manufacturer (CareFusion®) found overall adherence rates from January 2009 through May 2010 in 400 adult and pediatric hospitals to be approximately 75% (Figure 1).
Problem The root cause analysis identified that nurses were bypassing the medication safety software and identified the need to establish a baseline measure of adherence. Adherence was established through a random visual audit conducted in the inpatient units and emergency department. The observation audit found that the medication safety software was used properly 28% of the time on the large volume IV pumps in use at the time of audit (n = 90). The nurse and pharmacist overseeing the audit reviewed the baseline results, and an opportunity to improve performance was identified and shared with the Directors of Nursing and
Figure 1 National nurse adherence to use of medication safety software monthly trend: January 2009–May 2010. Data provided courtesy of CareFusion® (2011).
A PI Plan to Increase Nurse Adherence to Medication Safety Software Pharmacy and the Chief Nursing Officer (CNO). Next, an interdisciplinary PI team co-led by a nurse (Education Coordinator of Nursing Products) and a pharmacist (Pharmacy Clinical Coordinator, Pediatric Intensive Care Unit) oversaw and reported the baseline audit was created. The PI team included representatives from nursing, who used the medication safety software, pharmacy, biomedical engineering, and the IV pump manufacturer (CareFusion®).
Deming's PI Methodology Description of Methodology
Table 1
377 Reasons for Bypassing Medication Safety Software
Reasons Identified by Project Site Nurses
Reasons Identified in the Literature ⁎
“I don't need to do this”
Low risk for errors associated with IV medications “It's too much work for me Extra time and work to program” associated with pump programming “The alarm always goes off Alert fatigue as a result of when I program this med” false alarms “I did not program the pump Hospital culture that tolerates so it's not my responsibility” process work-around ⁎ ISMP, (2007); Keohane et al. (2005), Rothschild et al. (2005).
Commonly used within the organization for PI, Deming's Plan–Do–Study–Act (PDSA) PI methodology allowed the project team to address nurse adherence quickly using a plan for change. The methodology allowed for the nurses that use the technology to have input into the process and offer suggestions on how to improve it (Cleary, 1995). The methodology consists of four stages: (a) plan, which allows for the development of the change; (b) do, which tests the change; (c) study, which allows for observation and information to be gathered; and (d) act, where modifications can be made and create future PDSA cycles (Institute for Healthcare Improvement [IHI], 2011). This methodology is scientific, widely used in health care for problem solving, and promotes action-oriented learning (IHI, 2011).
scrolling through a list, and (3) entering the exact patient weight and medication dose for the pump to calculate safe infusion parameters according to the medication safety software library. The second step in the process was found to be the main barrier for poor adherence to using the medication safety software. Nurses reported that scrolling through the long list of medications was cumbersome and proposed creating unit-based medication software libraries that listed the most commonly used medications in the specific patient care areas. Nurses identified that including a list of commonly used medications in the large volume IV pump safety software library would mirror the existing practice used when programming syringe infusion pumps.
Plan
Medication Safety Champions The plan included the recruitment of some nurses to be key resources and would facilitate communication between the PI team and other nurses. The communication would include adherence progress and identification of adjustments needed in the medication safety software. The nurses recruited would be known as the medication safety champions.
The interdisciplinary PI team identified a change plan. Key components of the change included (a) improving communication with nurses, (b) programming of strategies, (c) Medication Safety Champions, (d) staff education, (e) adherence monitoring, and (f) acquisition of technology. The goal of the plan was to increase nurse adherence to 100% using the medication safety software within 6 months of the project. Improving Communication With Nurses The first step focused on unit-based discussions with staff nurses to discover reasons for bypassing the smart pump medication safety software. Table 1 provides examples of reasons given by nurses at the project site for bypassing medication safety software, which aligned with reasons found in the literature (Keohane et al., 2005; Leape, 2005; Rothschild et al., 2005). Programming Strategies Programming the large volume IV pump to administer a medication using the medication safety software profiles requires the nurse to complete a three-step process: (1) selecting the patient weight according to the range parameters, (2) selecting the correct medication by
Staff Education Education focusing on the correct use of the safety software and the benefits in preventing medication errors was included in the plan. The PI team identified an inconsistency in the nurses' knowledge of how to use the pumps. This education was created by the PI team for nurses, super users, and nurses in nursing orientation. The PI team believed that education would address the inconsistency in the nurses' knowledge and would attend to (a) the perception of low risk for errors associated with IV medications; (b) the perception that the hospital culture tolerates process workarounds; and (c) the perception of extra time and work associated with pump programming. Adherence Monitoring As part of the plan, the PI team determined how to measure nursing adherence. Visual audits of all pumps within the
378 organization in use were inspected to determine if they were programmed using the medication safety software. These rounds began weekly and as improvement occurred would be extended to monthly. After each adherence round, the percentage of smart pumps programmed using the medication safety software as compared with volume over time programming was compiled. The team set a goal for nursing adherence when using IV smart pumps at 100% within 6 months of the project beginning. Acquisition of Technology Conducting adherence rounds and gathering data on use of medication safety software was identified as a challenge; as visual inspection by a single nurse auditor of each smart pump in use throughout multiple units of the organization was a time-intensive necessity to determine an accurate adherence rate. The data provided only a snapshot of the organization's adherence and did not capture additional data for use by the PI team, such as nuisance alarms or programming errors averted by use of the medication safety software library. Modifications or updates to the medication safety software library required all pumps to be physically removed from patient care and individually reprogrammed. The pumps had wireless capability; however, the organization did not acquire the additional technology to use the wireless capability. The PI team identified that the purchase of a wireless server would allow for easier accessibility to continuous quality improvement (CQI) data. Using software installed on selected hospital computers, the wireless server communicates with every large volume IV pump to collect, aggregate, and analyze data, including the percentage of pumps using the medication safety software, nuisance alarms, and programming errors averted by use of the medication safety software library. Modifications or updates to the medication safety software library can be made remotely to each pump via the wireless server.
C. Gavriloff pump programming to check the accuracy and thoroughness of unit-based medication safety software profiles. This also allowed for the identification of alarms that the nurses would experience on a regular basis and be a nuisance when programming. Nurse feedback from the session resulted in further development and refinement of the medication safety software profiles to develop a more user-friendly program and reduce nuisance alerts. These nurses were asked to recheck the program to ensure that the nuisance alert was addressed prior to implementation of the new unit-based profile. Medication Safety Champions The PI team piloted the change by recruiting the Nursing Shared Governance Clinical Practice Council to serve as Medication Safety Champions. These members fulfilled two purposes: to serve as a key resource to the unit they represented and to facilitate communication between the PI team and the nurses. As changes occurred, the champions were asked to provide both positive and negative feedback, which allowed for issues raised to be immediately addressed.
The PI team implemented and tested the project plan over a six month timeframe. The project team met formally twice a month with more frequent meetings of team members to address specific components of the PI change plan. Project team leaders communicated almost daily during this phase of the project.
Staff Education The first phase of education included super-user training for the Medication Safety Champions and unitbased education coordinators. The Education Coordinator of Nursing Products and a manufacturer representative provided in-depth training to the champions on why and how to program pumps using medication safety software and troubleshooting of common problems. These safety champions facilitated the buy-in among the nurses that smart pumps provide another layer of safety during the administration of IV medications. Following the superuser training, the manufacturer representative and the Education Coordinator of Nursing Products provided education for the nurses on the patient care units over a one month period. The education on the units for nurses allowed for any safety concerns to be easily communicated and provided closed loop communication with the nurses. Education on smart pumps then was included in nursing orientation by the Education Coordinator of Nursing Products and focuses on why the organization benefits from medication safety software. Citation of the medication error that initiated this PI project remains part of nursing orientation to date.
Improving Communication With Nurses and Programming Strategies The pharmacist co-leader of the project team created new medication software libraries based on the most commonly used medications in the specific patient care areas as proposed by nurses in the plan phase of the project. The PI team invited nurses to attend “Stump the Pump” sessions. These sessions provided an opportunity for nurses to participate in simulated case scenarios for
Adherence Monitoring After education, the Education Coordinator of Nursing Products initiated weekly adherence rounds on either the day or night shift on units where smart pumps were in use. After each adherence rounds, the percentage of smart pumps programmed using the medication safety software was compiled and reported via email to nurses at all levels of the organization. Weekly adherence rounds were conducted for seven weeks. Adherence was then measured monthly.
Do
A PI Plan to Increase Nurse Adherence to Medication Safety Software Acquisition of Technology The nurse co-leader of the PI team was notified at the end of the capital year that the organization had capital dollars available and a justification was prepared outlining the reasons why a wireless server would benefit the organization. Identification that improved communication with nurses and use of the Nursing Shared Governance Clinical Practice Council Medication Safety Champions had resulted in identification of multiple changes to the medication safety software library At the start of the project, to update the medication safety software the following occurred: 1) pumps were gathered; 2) pumps would be connected to a computer to receive the update to the medication safety software; 3) pumps would be cleaned and exchanged with other pumps needing updates or placed available for use. Data demonstrated that it took 80 staff hours for a single update to the organization’s 267 large volume IV pumps. This was a key component to the need for a wireless server that would support more timely changes to the medication safety software library across the organization. The $253,000 wireless server cost was approved by the CNO through the capital approval process. The PI team planned for implementation for the following year. The purchase of the wireless server allowed for a simpler process for changes to the medication safety software. The pharmacist makes the necessary changes and sends the updates to the server. The server in turn updates the medication safety software on the pumps when the pump is turned on. The process is completed in several minutes as compared to the 80 man hours the process previously took to complete.
Study With the development of unit-based medication software libraries, Medication Safety Champions, education including super-user training, and adherence monitoring, the interdisciplinary team continued to observe and gather information to monitor for improvement. Improving Communication With Nurses and Programming Strategies While observing the changes, the PI team learned of additional challenges with the increased use of the medication safety software. Nurses advised that the programming process required additional work steps as compared with the weight-based programs. These included entering the patient weight first and then scrolling through the list of all formulary medications to find the prescribed medication. Nurses described scrolling through the medication list as cumbersome. They expressed that this contributed to work flow delays and increased the desire to bypass the medication safety software profiles. Although nurses felt that the changes to the software were an improvement, nurses requested further refinement of the medication safety software to increase ease of use.
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Staff Education Within the first month of the project do phase, 38.3% of the RN staff were educated. Within 2 months of the project do phase, 100% of the RN staff was educated, and the content was fully incorporated into nursing orientation. Medication Safety Champions The Medication Safety Champions provided the ongoing link between the nurse co-leader of the project and the nurses. The nurse co-leader met monthly during the Nursing Shared Governance Clinical Practice Council meeting to review adherence data, answer questions, and discuss any issues related to the medication safety software. Information about staff education, changes in technology, and adherence rates continue to be reported. Adherence Monitoring The team set an adherence goal of 100% when smart pumps are in use. The adherence rates were communicated with the nurses via the Education Coordinator of Nursing Products. The first adherence rate, reported at 1 month after the do phase, when staff education was completed was 68%, which was above the baseline of 28% but below the 100% goal. The CNO sent a follow-up e-mail encouraging the nurses to meet the medication safety software goal of 100%, resulting in an adherence rate above 85% within 1 week. Rates calculated monthly using the wireless server continued to range above 85%. Eight months after the implementation of the wireless server, a summation was shared with the nurses and managers and the Nursing Shared Governance Clinical Practice Council. Acquisition of Technology Two months after “Stump the Pump,” the PI team planned organization-wide implementation of new medication safety software libraries with standardized profiles as suggested by nurses in the Plan phase of the project. This programming strategy provided standardization between syringe and large volume infusion pumps. Installation of the wireless server for the pumps occurred at this time and the wireless server allowed for updates to the medication safety software simply by turning the pumps off and on again activating the changes. In addition to the updates, the server also allowed for efficient collection of CQI data. The collection of the data occurs at the beginning of each month by running a report that calculates by the unit profiles the total number of infusions programmed using the medication safety software by the total number of infusions. This allows for a more comprehensive assessment of the change, rather than a random audit of pumps in use at the time of the adherence check.
Act Improving Communication With Nurses and Programming Strategies In response to the nurses concerns, the PI team identified additional modifications to the PI plan. The hospital
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pharmacist made more than 100 changes to the software programming to increase ease of use. Changes included the addition of standard times for medications to be prepopulated and the removal from profiles of medications not normally administered in each unit. Subsequent audits using the wireless server showed that the adherence rates achieved by the organization exceeded the baseline and the national benchmark rate (p b .001) but did not result in the 100% goal adherence rate. One year after the project was initiated, the organization implemented medication safety software in two newly acquired units at geographically distant facilities. As a result, there was a 2% decrease in the overall adherence rates attributed to the adoption of the medication safety software for the year 2009. The following year, the adherence rate returned to an overall rate of 88%, a level congruent with the rates prior to implementation of the additional units (Figure 2). Additional PI plans with nurses continue to improve the medication safety profiles. These smaller plans allow nurses to modify the profiles to increase ease of use, match practice with the programming of the smart pumps, and address practice changes within the organization. Adherence Monitoring The PI team continues to monitor adherence monthly and communicates audit results by email to nurses, and the Nursing Shared Governance Clinical Practice Council. Results of the project were presented at the organization's annual pediatric nursing conference, to the hospital interdis-
Figure 2
ciplinary PI committee, and to the hospital interdisciplinary medication safety committee. Acquisition of Technology Limitations in the manufacturer's medication safety software led to the identification of future PI projects. The current medication safety software has reached the maximum number of unit-based profiles that can be programmed. The team has requested from the manufacturer the ability to increase the number of profiles within the software. In 2011, manufacturer software updates will allow the organization to increase the number of profiles. The improvement plan allows for pharmacy to individualize patient care areas for ease of finding specific medications. The varying parameters in the administration of clinical trial medications and chemotherapy protocols presents another challenge. In the pediatric population, a chemotherapy agent may be prescribed at a low dose in one chemotherapy protocol per diagnosis but may be prescribed at a high dose in another protocol. Current medication safety software does not have capacity to capture all the various parameters in chemotherapy administration. In addition to the maximum number of profiles, the organization has also reached the maximum number of medications that can be programmed into the smart pumps. Medication safety software projects identified for future PDSA cycles to address these issues include (a) increasing the number of unit-based profiles, (b) addressing the varying parameters for administration of clinical trial medications and chemotherapy protocols, and (c)
Nurse adherence to use of medication safety software by nursing division.
A PI Plan to Increase Nurse Adherence to Medication Safety Software identifying the prevention of medication errors in the organization. Ongoing efforts to fully integrate the functionality of medication safety software into the complex pediatric health care system will continue progression toward the organization's goal of 100% adherence when using the medication safety software.
Discussion The organization's implementation of a PI plan to increase nurse adherence was successful. The combined use of improving communication with nurses, programming strategies, Medication Safety Champions, staff education, adherence monitoring, and technology acquisition increased nursing adherence to a rate consistently above 85% with individual units intermittently reaching the 100% adherence rate goal. The PI team continues to work with nurses to further refine the medication safety software library, increase ease of use, and ensure programming strategies reflect nursing practice. Although the literature reports that medication errors are prevented by using medication safety software on IV infusions (Conroy et al., 2007; Larsen et al., 2005; Rosenthal, 2004), there is a gap in the literature specifically related to its use in pediatrics. The PI team chose to focus on increasing nurse adherence to using the medication safety software as an important step in the process. As has been noted in the literature, medication safety software cannot impact patient safety if nurses do not use the software when programming smart pumps (Birk, 2008; Cohen et al., 2007; Rothschild et al., 2005). Future projects are planned to identify if nursing adherence actually prevents errors in pediatric patients. For example, the project team plans to evaluate the CQI data previously collected to determine if using the medication safety software prevented medication errors within the organization. Staff education that focuses not only on the “how” to use the smart pumps but also on the “why” it is used is important to increase medication safety software adherence. Training only on how to use the technology does not assure sustained adherence to the technology's prescribed use. Nurses need to understand medication safety software to provide feedback. Communication between nurses and pharmacy provides ongoing evaluation of needed medication safety software revisions and refinements, which increases ease of use and reduces nuisance alarms. The PI team believes that support of the organization at all levels, commitment to interdisciplinary staff efforts, and vigilance to the change process are essential to successful use of medication safety software. Implementation of medication safety software is a monetary investment for an organization. Integrating use of the medication safety software requires constant refinement to fully realize a return on investment in terms of patient safety. Equally as important as the monetary investment to
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purchase the medication safety software technology is the realization of the investment in human capital of the interdisciplinary team that is needed to implement, enculturate, and sustain meaningful medication safety software use by nurses.
Acknowledgments The author wishes to thank Akron Children's Hospital staff Donna Blair, MSN, RN, CNP, B-C Center for Excellence in Nursing Education, and Aris Eliades, PhD, RN, CNS, Rebecca D. Considine Research Center, for assistance with manuscript preparation and review; and M. David Gothard, MS, Biostatistician, Rebecca D. Considine Research Center for statistical and benchmark comparison assistance.
References Birk, S. (2008). Smart pumps need OK from clinicians. Materials Management in Health Care, 17, 38–40. Carefusion. (2011). National nurse adherence to use of medication safety software monthly trend: January 2009-May 2010. Unpublished raw data. Cleary, B. (1995). Supporting empowerment with Deming's PDSA cycle. Empowerment in Organizations, 3, 34–39. Cohen, M., Cooke, D., Husch, M., & Woodley, M. (2007). Smart pumps are not smart on their own: Measuring and maintaining a high level of compliance. Retrieved from http://www.carefusion.com/center/conferences/Webcasts.aspx. Conroy, S., Sweis, D., Planner, C., Yeung, V., Collier, J., Haines, J., et al. (2007). Interventions to reduce dosing errors in children: A systematic review of the literature. Drug Safety, 30, 1111–1125. Retrieved from http://adisonline.com/drugsafety/pages/default.aspx. ECRI. (2002). Infusion pump safety systems: Their value and effect on operating costs. Health Devices, 31, 361. Retrieved from https:// members2.ecri.org/Components/HDJournal/Pages/default.aspx. Fields, M., & Peterman, J. (2005). Intravenous medication safety system averts high-risk medication errors and provides actionable data. Nursing Administration Quarterly, 29, 78–87. Retrieved from http://journals. lww.com/naqjournal/pages/default.aspx. Hertzel, C., & Sousa, V. (2009). The use of smart pumps for preventing medication errors. Journal of Infusion Nursing, 32, 257–266. Institute for Healthcare Improvement. (2011). Plan–Do–Study–Act (PDSA) worksheet. Retrieved from http://www.ihi.org/IHI/Topics/Improvement/ ImprovementMethods/Tools/Plan-Do-Study-Act+%28PDSA%29 +Worksheet.htm. Institute for Safe Medication Practices. (2007). Smart pumps are not smart on their own. Medication Safety Alert. Retrieved from http://www. ismp.org/newsletters/acutecare/articles/20070419.asp. Kaushal, R., Bates, D., Landrigan, C., McKenna, K., Clapp, M., Federico, F., et al. (2001). Medication errors and adverse drug events in pediatric inpatients. Journal of the American Medical Association, 285, 2114–2120. Keohane, C. A., Hayes, J., Saniuk, C., Rothschild, J. M., & Bates, D. W. (2005). Intravenous medication safety and smart infusion systems: Lessons learned and future opportunities. Journal of Infusion Nursing, 28, 321–328. Larsen, G., Parker, H., Cash, J., O'Connell, M., & Grant, M. (2005). Standard drug concentrations and smart-pump technology reduce
382 continuous medication infusion errors in pediatric patients. Pediatrics, 116, e21–e25. Leape, L. (2005). “Smart” pumps: A cautionary tale of human factors engineering. Critical Care Medicine, 33, 679–680. Morgan, L., & Siv-Lee, L. (2009). Intelligent infusion. Nursing Management, 40, 20–24. Nuckols, T., Bower, A., Paddock, S., Hilborne, L., Wallace, P., Rothschild, J., et al. (2008). Programmable infusion pumps in ICUs: An analysis of corresponding adverse drug events. Journal of General Internal Medicine, 23(Suppl 1), 41–45. Rosenkoetter, M., Bowcutt, M., Khasanshina, E., Chernecky, C., & Wall, J. (2008). Perceptions of the impact of “smart pumps” on nurses and nursing care provided. Journal of the Association for Vascular Access, 13, 60–69. Retrieved from http://www.avainfo.org/website/article.asp?id=1427.
C. Gavriloff Rosenthal, K. (2004). Smart pumps help crack the safety code. Nursing Management, 35, 49–51. Retrieved from http://journals.lww.com/ nursingmanagement/pages/default.aspx. Rothschild, J., Keohane, C., Cook, E., Orav, E., Burdick, E., Thompson, S., et al. (2005). A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Critical Care Medicine, 33, 533–540. Vanderveen, T. (2005). Averting highest-risk errors is first priority. Part 1: Risk of harm, speed to impact, smart infusions and CQI. Patient Safety Quality Healthcare, 16–21. Retrieved from http://www.psqh.com/ mayjun05/averting.html. Wilson, K., & Sullivan, M. (2004). Preventing medication errors with smart infusion technology. American Journal of Health-System Pharmacy, 61, 177–183.
A Performance Improvement Plan to Increase Nurse Adherence to Use of Medication Safety Software1,2 Carrie Gavriloff MSN, RN, Ed ⁎ Akron Children's Hospital, Akron, OH
Key words: Medication safety software; Performance improvement; Intravenous medications; Pediatrics
Nurses can protect patients receiving intravenous (IV) medication by using medication safety software to program “smart” pumps to administer IV medications. After a patient safety event identified inconsistent use of medication safety software by nurses, a performance improvement team implemented the Deming Cycle performance improvement methodology. The combined use of improved direct care nurse communication, programming strategies, staff education, medication safety champions, adherence monitoring, and technology acquisition resulted in a statistically significant (p b .001) increase in nurse adherence to using medication safety software from 28% to above 85%, exceeding national benchmark adherence rates (Cohen, Cooke, Husch & Woodley, 2007; Carefusion, 2011). © 2012 Elsevier Inc. All rights reserved.
THE INSTITUTE FOR Safe Medication Practice (ISMP) adopted the term smart pumps for infusion devices that use medication safety software (Cohen, Cooke, Husch, & Woodley, 2007; Keohane, Hayes, Saniuk, Rothschild, & Bates, 2005; Leape, 2005). This software protects patients and nurses from medication errors by “remembering” hospital-defined dosing limits and other clinical “rules” and applying them when administering intravenous (IV) medications (Hertzel & Sousa, 2009; Keohane et al., 2005). Evidence supports the use of medication safety software programs to prevent medication errors associated with IV infusions by preventing administration of doses that are too high or too low and preventing errors during pump programming (ECRI, 2002; Fields & Peterman, 2005; Hertzel & Sousa, 2009; ISMP, 2007; Keohane et al., 2005; Morgan & Siv-Lee, 2009; Rothschild, Keohane, Cook, Orav, Burdick, Thompson, Hayes, & Bates, 2005; Vanderveen, 1
Previous presentation of paper: Poster Presentation: Society of Pediatric Nurses Convention, April, 2010, Orlando Florida. Poster Presentation: Pediatric Nursing Conference, October, 2009, Akron, Ohio. 2 The author has no conflict of interest and this project has received no commercial financial support. ⁎ Corresponding author: Carrie Gavriloff, MSN, RN, Ed. E-mail address: [email protected]. 0882-5963/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.06.004
2005). Smart pumps have been implemented in health care organizations, but they do not prevent medication errors unless they are properly programmed by the nurse end users. In October 2007, a 359-bed, freestanding pediatric hospital in the Midwest identified that nurses bypassed the medication safety software in large volume smart pumps. A root cause analysis conducted after a medication error revealed bypassing of the medication safety software, and determined use of the medication safety software would have prevented the error. A performance improvement (PI) project was initiated to improve nurse adherence to the use of the smart pump medication safety software. The organization defines adherence as nurses using the medication safety software library created by the organization. Prior to the implementation of the smart pumps in the organization, nurses administered IV medications by programming the pump with the total volume of the medication and the total number of minutes over which the medication was to be infused. This is referred to as volume over time programming and does not demonstrate nurse adherence to the organization's definition of adherence to use of medication safety software. This describes the process and outcomes of a PI project designed to improve nurse adherence to use of medication safety software programs.
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Background IV infusions account for an estimated 35% to 60% of incidents in which the use of a medication or medication dose may have resulted in an adverse patient outcome in the pediatric population (Kaushal, Bates, Landrigan, McKenna, Clapp, Federico, Goldmann, 2001). However, a gap in the literature exists regarding the use of smart pumps in pediatric settings. The literatures identifies that in adult populations, smart pumps can reduce errors associated with IV infusions and provide safety protection during the medication administration process as long as they are programmed properly (Conroy, Sweis, Planner, Yeung, Collier, Haines, & Wong, 2007; Larsen, Parker, Cash, O'Connell, & Grant, 2005; Nuckols, Bower, Paddock, Hilborne, Wallace, Rothschild, Griffin, 2008; Rosenthal, 2004; Rothschild et al., 2005; Wilson & Sullivan, 2004). Success in reducing IV medication errors associated with smart pumps in adult populations can be achieved when education and training focus on using the medication safety software (Rothschild et al., 2005). Smart pumps are considered an important component of medication safety. For organizations to see a return on the investment of smart pumps, the features must avert errors: It is not enough to purchase smart pumps, program the library to enable the technology, distribute the pumps, educate users, and hope that the dose-checking feature will always be used. A culture of safety must exist that drives clinicians to avoid bypassing such a safety feature, or to report conditions that encourage work-arounds so they can be remedied (Cohen et al., 2007).
It has been reported that nurses do not value smart pump technology because of perceptions associated with its use, including (a) the low risk for errors associated with IV medications, (b) extra time and work associated with pump
programming, (c) alert fatigue as a result of false alarms, and (d) hospital culture that tolerates process work-arounds (Keohane et al., 2005; Leape, 2005; Rothschild et al., 2005). In contradiction to other findings, one study concluded that nurses did perceive medication safety software as a way to prevent medication errors but did not believe it created extra workload (Rosenkoetter, Bowcutt, Khasanshina, Chernecky, & Wall, 2008). Adherence to proper use of medication safety software is as important as its purchase (Birk, 2008; Rothschild et al., 2005). Cohen et al (2007) identified an overall adherence rate for programming IV pumps using the medication safety software in an adult institution at 75%. The literature does not report current adherence rates when using medication safety software in pediatric settings. Data measuring compliance using safety software provided courtesy of an IV pump manufacturer (CareFusion®) found overall adherence rates from January 2009 through May 2010 in 400 adult and pediatric hospitals to be approximately 75% (Figure 1).
Problem The root cause analysis identified that nurses were bypassing the medication safety software and identified the need to establish a baseline measure of adherence. Adherence was established through a random visual audit conducted in the inpatient units and emergency department. The observation audit found that the medication safety software was used properly 28% of the time on the large volume IV pumps in use at the time of audit (n = 90). The nurse and pharmacist overseeing the audit reviewed the baseline results, and an opportunity to improve performance was identified and shared with the Directors of Nursing and
Figure 1 National nurse adherence to use of medication safety software monthly trend: January 2009–May 2010. Data provided courtesy of CareFusion® (2011).
A PI Plan to Increase Nurse Adherence to Medication Safety Software Pharmacy and the Chief Nursing Officer (CNO). Next, an interdisciplinary PI team co-led by a nurse (Education Coordinator of Nursing Products) and a pharmacist (Pharmacy Clinical Coordinator, Pediatric Intensive Care Unit) oversaw and reported the baseline audit was created. The PI team included representatives from nursing, who used the medication safety software, pharmacy, biomedical engineering, and the IV pump manufacturer (CareFusion®).
Deming's PI Methodology Description of Methodology
Table 1
377 Reasons for Bypassing Medication Safety Software
Reasons Identified by Project Site Nurses
Reasons Identified in the Literature ⁎
“I don't need to do this”
Low risk for errors associated with IV medications “It's too much work for me Extra time and work to program” associated with pump programming “The alarm always goes off Alert fatigue as a result of when I program this med” false alarms “I did not program the pump Hospital culture that tolerates so it's not my responsibility” process work-around ⁎ ISMP, (2007); Keohane et al. (2005), Rothschild et al. (2005).
Commonly used within the organization for PI, Deming's Plan–Do–Study–Act (PDSA) PI methodology allowed the project team to address nurse adherence quickly using a plan for change. The methodology allowed for the nurses that use the technology to have input into the process and offer suggestions on how to improve it (Cleary, 1995). The methodology consists of four stages: (a) plan, which allows for the development of the change; (b) do, which tests the change; (c) study, which allows for observation and information to be gathered; and (d) act, where modifications can be made and create future PDSA cycles (Institute for Healthcare Improvement [IHI], 2011). This methodology is scientific, widely used in health care for problem solving, and promotes action-oriented learning (IHI, 2011).
scrolling through a list, and (3) entering the exact patient weight and medication dose for the pump to calculate safe infusion parameters according to the medication safety software library. The second step in the process was found to be the main barrier for poor adherence to using the medication safety software. Nurses reported that scrolling through the long list of medications was cumbersome and proposed creating unit-based medication software libraries that listed the most commonly used medications in the specific patient care areas. Nurses identified that including a list of commonly used medications in the large volume IV pump safety software library would mirror the existing practice used when programming syringe infusion pumps.
Plan
Medication Safety Champions The plan included the recruitment of some nurses to be key resources and would facilitate communication between the PI team and other nurses. The communication would include adherence progress and identification of adjustments needed in the medication safety software. The nurses recruited would be known as the medication safety champions.
The interdisciplinary PI team identified a change plan. Key components of the change included (a) improving communication with nurses, (b) programming of strategies, (c) Medication Safety Champions, (d) staff education, (e) adherence monitoring, and (f) acquisition of technology. The goal of the plan was to increase nurse adherence to 100% using the medication safety software within 6 months of the project. Improving Communication With Nurses The first step focused on unit-based discussions with staff nurses to discover reasons for bypassing the smart pump medication safety software. Table 1 provides examples of reasons given by nurses at the project site for bypassing medication safety software, which aligned with reasons found in the literature (Keohane et al., 2005; Leape, 2005; Rothschild et al., 2005). Programming Strategies Programming the large volume IV pump to administer a medication using the medication safety software profiles requires the nurse to complete a three-step process: (1) selecting the patient weight according to the range parameters, (2) selecting the correct medication by
Staff Education Education focusing on the correct use of the safety software and the benefits in preventing medication errors was included in the plan. The PI team identified an inconsistency in the nurses' knowledge of how to use the pumps. This education was created by the PI team for nurses, super users, and nurses in nursing orientation. The PI team believed that education would address the inconsistency in the nurses' knowledge and would attend to (a) the perception of low risk for errors associated with IV medications; (b) the perception that the hospital culture tolerates process workarounds; and (c) the perception of extra time and work associated with pump programming. Adherence Monitoring As part of the plan, the PI team determined how to measure nursing adherence. Visual audits of all pumps within the
378 organization in use were inspected to determine if they were programmed using the medication safety software. These rounds began weekly and as improvement occurred would be extended to monthly. After each adherence round, the percentage of smart pumps programmed using the medication safety software as compared with volume over time programming was compiled. The team set a goal for nursing adherence when using IV smart pumps at 100% within 6 months of the project beginning. Acquisition of Technology Conducting adherence rounds and gathering data on use of medication safety software was identified as a challenge; as visual inspection by a single nurse auditor of each smart pump in use throughout multiple units of the organization was a time-intensive necessity to determine an accurate adherence rate. The data provided only a snapshot of the organization's adherence and did not capture additional data for use by the PI team, such as nuisance alarms or programming errors averted by use of the medication safety software library. Modifications or updates to the medication safety software library required all pumps to be physically removed from patient care and individually reprogrammed. The pumps had wireless capability; however, the organization did not acquire the additional technology to use the wireless capability. The PI team identified that the purchase of a wireless server would allow for easier accessibility to continuous quality improvement (CQI) data. Using software installed on selected hospital computers, the wireless server communicates with every large volume IV pump to collect, aggregate, and analyze data, including the percentage of pumps using the medication safety software, nuisance alarms, and programming errors averted by use of the medication safety software library. Modifications or updates to the medication safety software library can be made remotely to each pump via the wireless server.
C. Gavriloff pump programming to check the accuracy and thoroughness of unit-based medication safety software profiles. This also allowed for the identification of alarms that the nurses would experience on a regular basis and be a nuisance when programming. Nurse feedback from the session resulted in further development and refinement of the medication safety software profiles to develop a more user-friendly program and reduce nuisance alerts. These nurses were asked to recheck the program to ensure that the nuisance alert was addressed prior to implementation of the new unit-based profile. Medication Safety Champions The PI team piloted the change by recruiting the Nursing Shared Governance Clinical Practice Council to serve as Medication Safety Champions. These members fulfilled two purposes: to serve as a key resource to the unit they represented and to facilitate communication between the PI team and the nurses. As changes occurred, the champions were asked to provide both positive and negative feedback, which allowed for issues raised to be immediately addressed.
The PI team implemented and tested the project plan over a six month timeframe. The project team met formally twice a month with more frequent meetings of team members to address specific components of the PI change plan. Project team leaders communicated almost daily during this phase of the project.
Staff Education The first phase of education included super-user training for the Medication Safety Champions and unitbased education coordinators. The Education Coordinator of Nursing Products and a manufacturer representative provided in-depth training to the champions on why and how to program pumps using medication safety software and troubleshooting of common problems. These safety champions facilitated the buy-in among the nurses that smart pumps provide another layer of safety during the administration of IV medications. Following the superuser training, the manufacturer representative and the Education Coordinator of Nursing Products provided education for the nurses on the patient care units over a one month period. The education on the units for nurses allowed for any safety concerns to be easily communicated and provided closed loop communication with the nurses. Education on smart pumps then was included in nursing orientation by the Education Coordinator of Nursing Products and focuses on why the organization benefits from medication safety software. Citation of the medication error that initiated this PI project remains part of nursing orientation to date.
Improving Communication With Nurses and Programming Strategies The pharmacist co-leader of the project team created new medication software libraries based on the most commonly used medications in the specific patient care areas as proposed by nurses in the plan phase of the project. The PI team invited nurses to attend “Stump the Pump” sessions. These sessions provided an opportunity for nurses to participate in simulated case scenarios for
Adherence Monitoring After education, the Education Coordinator of Nursing Products initiated weekly adherence rounds on either the day or night shift on units where smart pumps were in use. After each adherence rounds, the percentage of smart pumps programmed using the medication safety software was compiled and reported via email to nurses at all levels of the organization. Weekly adherence rounds were conducted for seven weeks. Adherence was then measured monthly.
Do
A PI Plan to Increase Nurse Adherence to Medication Safety Software Acquisition of Technology The nurse co-leader of the PI team was notified at the end of the capital year that the organization had capital dollars available and a justification was prepared outlining the reasons why a wireless server would benefit the organization. Identification that improved communication with nurses and use of the Nursing Shared Governance Clinical Practice Council Medication Safety Champions had resulted in identification of multiple changes to the medication safety software library At the start of the project, to update the medication safety software the following occurred: 1) pumps were gathered; 2) pumps would be connected to a computer to receive the update to the medication safety software; 3) pumps would be cleaned and exchanged with other pumps needing updates or placed available for use. Data demonstrated that it took 80 staff hours for a single update to the organization’s 267 large volume IV pumps. This was a key component to the need for a wireless server that would support more timely changes to the medication safety software library across the organization. The $253,000 wireless server cost was approved by the CNO through the capital approval process. The PI team planned for implementation for the following year. The purchase of the wireless server allowed for a simpler process for changes to the medication safety software. The pharmacist makes the necessary changes and sends the updates to the server. The server in turn updates the medication safety software on the pumps when the pump is turned on. The process is completed in several minutes as compared to the 80 man hours the process previously took to complete.
Study With the development of unit-based medication software libraries, Medication Safety Champions, education including super-user training, and adherence monitoring, the interdisciplinary team continued to observe and gather information to monitor for improvement. Improving Communication With Nurses and Programming Strategies While observing the changes, the PI team learned of additional challenges with the increased use of the medication safety software. Nurses advised that the programming process required additional work steps as compared with the weight-based programs. These included entering the patient weight first and then scrolling through the list of all formulary medications to find the prescribed medication. Nurses described scrolling through the medication list as cumbersome. They expressed that this contributed to work flow delays and increased the desire to bypass the medication safety software profiles. Although nurses felt that the changes to the software were an improvement, nurses requested further refinement of the medication safety software to increase ease of use.
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Staff Education Within the first month of the project do phase, 38.3% of the RN staff were educated. Within 2 months of the project do phase, 100% of the RN staff was educated, and the content was fully incorporated into nursing orientation. Medication Safety Champions The Medication Safety Champions provided the ongoing link between the nurse co-leader of the project and the nurses. The nurse co-leader met monthly during the Nursing Shared Governance Clinical Practice Council meeting to review adherence data, answer questions, and discuss any issues related to the medication safety software. Information about staff education, changes in technology, and adherence rates continue to be reported. Adherence Monitoring The team set an adherence goal of 100% when smart pumps are in use. The adherence rates were communicated with the nurses via the Education Coordinator of Nursing Products. The first adherence rate, reported at 1 month after the do phase, when staff education was completed was 68%, which was above the baseline of 28% but below the 100% goal. The CNO sent a follow-up e-mail encouraging the nurses to meet the medication safety software goal of 100%, resulting in an adherence rate above 85% within 1 week. Rates calculated monthly using the wireless server continued to range above 85%. Eight months after the implementation of the wireless server, a summation was shared with the nurses and managers and the Nursing Shared Governance Clinical Practice Council. Acquisition of Technology Two months after “Stump the Pump,” the PI team planned organization-wide implementation of new medication safety software libraries with standardized profiles as suggested by nurses in the Plan phase of the project. This programming strategy provided standardization between syringe and large volume infusion pumps. Installation of the wireless server for the pumps occurred at this time and the wireless server allowed for updates to the medication safety software simply by turning the pumps off and on again activating the changes. In addition to the updates, the server also allowed for efficient collection of CQI data. The collection of the data occurs at the beginning of each month by running a report that calculates by the unit profiles the total number of infusions programmed using the medication safety software by the total number of infusions. This allows for a more comprehensive assessment of the change, rather than a random audit of pumps in use at the time of the adherence check.
Act Improving Communication With Nurses and Programming Strategies In response to the nurses concerns, the PI team identified additional modifications to the PI plan. The hospital
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C. Gavriloff
pharmacist made more than 100 changes to the software programming to increase ease of use. Changes included the addition of standard times for medications to be prepopulated and the removal from profiles of medications not normally administered in each unit. Subsequent audits using the wireless server showed that the adherence rates achieved by the organization exceeded the baseline and the national benchmark rate (p b .001) but did not result in the 100% goal adherence rate. One year after the project was initiated, the organization implemented medication safety software in two newly acquired units at geographically distant facilities. As a result, there was a 2% decrease in the overall adherence rates attributed to the adoption of the medication safety software for the year 2009. The following year, the adherence rate returned to an overall rate of 88%, a level congruent with the rates prior to implementation of the additional units (Figure 2). Additional PI plans with nurses continue to improve the medication safety profiles. These smaller plans allow nurses to modify the profiles to increase ease of use, match practice with the programming of the smart pumps, and address practice changes within the organization. Adherence Monitoring The PI team continues to monitor adherence monthly and communicates audit results by email to nurses, and the Nursing Shared Governance Clinical Practice Council. Results of the project were presented at the organization's annual pediatric nursing conference, to the hospital interdis-
Figure 2
ciplinary PI committee, and to the hospital interdisciplinary medication safety committee. Acquisition of Technology Limitations in the manufacturer's medication safety software led to the identification of future PI projects. The current medication safety software has reached the maximum number of unit-based profiles that can be programmed. The team has requested from the manufacturer the ability to increase the number of profiles within the software. In 2011, manufacturer software updates will allow the organization to increase the number of profiles. The improvement plan allows for pharmacy to individualize patient care areas for ease of finding specific medications. The varying parameters in the administration of clinical trial medications and chemotherapy protocols presents another challenge. In the pediatric population, a chemotherapy agent may be prescribed at a low dose in one chemotherapy protocol per diagnosis but may be prescribed at a high dose in another protocol. Current medication safety software does not have capacity to capture all the various parameters in chemotherapy administration. In addition to the maximum number of profiles, the organization has also reached the maximum number of medications that can be programmed into the smart pumps. Medication safety software projects identified for future PDSA cycles to address these issues include (a) increasing the number of unit-based profiles, (b) addressing the varying parameters for administration of clinical trial medications and chemotherapy protocols, and (c)
Nurse adherence to use of medication safety software by nursing division.
A PI Plan to Increase Nurse Adherence to Medication Safety Software identifying the prevention of medication errors in the organization. Ongoing efforts to fully integrate the functionality of medication safety software into the complex pediatric health care system will continue progression toward the organization's goal of 100% adherence when using the medication safety software.
Discussion The organization's implementation of a PI plan to increase nurse adherence was successful. The combined use of improving communication with nurses, programming strategies, Medication Safety Champions, staff education, adherence monitoring, and technology acquisition increased nursing adherence to a rate consistently above 85% with individual units intermittently reaching the 100% adherence rate goal. The PI team continues to work with nurses to further refine the medication safety software library, increase ease of use, and ensure programming strategies reflect nursing practice. Although the literature reports that medication errors are prevented by using medication safety software on IV infusions (Conroy et al., 2007; Larsen et al., 2005; Rosenthal, 2004), there is a gap in the literature specifically related to its use in pediatrics. The PI team chose to focus on increasing nurse adherence to using the medication safety software as an important step in the process. As has been noted in the literature, medication safety software cannot impact patient safety if nurses do not use the software when programming smart pumps (Birk, 2008; Cohen et al., 2007; Rothschild et al., 2005). Future projects are planned to identify if nursing adherence actually prevents errors in pediatric patients. For example, the project team plans to evaluate the CQI data previously collected to determine if using the medication safety software prevented medication errors within the organization. Staff education that focuses not only on the “how” to use the smart pumps but also on the “why” it is used is important to increase medication safety software adherence. Training only on how to use the technology does not assure sustained adherence to the technology's prescribed use. Nurses need to understand medication safety software to provide feedback. Communication between nurses and pharmacy provides ongoing evaluation of needed medication safety software revisions and refinements, which increases ease of use and reduces nuisance alarms. The PI team believes that support of the organization at all levels, commitment to interdisciplinary staff efforts, and vigilance to the change process are essential to successful use of medication safety software. Implementation of medication safety software is a monetary investment for an organization. Integrating use of the medication safety software requires constant refinement to fully realize a return on investment in terms of patient safety. Equally as important as the monetary investment to
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purchase the medication safety software technology is the realization of the investment in human capital of the interdisciplinary team that is needed to implement, enculturate, and sustain meaningful medication safety software use by nurses.
Acknowledgments The author wishes to thank Akron Children's Hospital staff Donna Blair, MSN, RN, CNP, B-C Center for Excellence in Nursing Education, and Aris Eliades, PhD, RN, CNS, Rebecca D. Considine Research Center, for assistance with manuscript preparation and review; and M. David Gothard, MS, Biostatistician, Rebecca D. Considine Research Center for statistical and benchmark comparison assistance.
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