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Development of a Unit-Based Practice Committee: A Form of Shared Governance
Development of a Unit-Based Practice Committee: A Form of Shared Governance KRISTIN ALT STYER, MS, RN, CPAN
S
hared governance is an organizational model that allows nurses to have control over their practice as well as influence in administrative areas.1 The benefits of shared governance, also known as collaborative governance or collaborative practice, have been published in the literature.1-4 Some of the benefits include increased staff morale, job satisfaction, staff member participation, and personal and professional development. According to the concept of shared governance, the process must originate from a leader who believes in the expertise and judgment of the staff members.5 In return, the staff members must be committed and flexible in participating in this process. Porter-O’Grady states that “leadership must be able to create a safe and developmental context for both staff and themselves so that . . . professional practice can truly evolve.”2
INITIATING A SHARED GOVERNANCE PROCESS Leaders at Brigham and Women’s Hospital (BWH) in Boston, Massachusetts, a 747-bed teaching hospital affiliated with Harvard Medical School,6 challenged staff nurses to implement a process based on shared governance but without the formal structure of traditional shared governance models. In February 2002, the nurse manager of the postanesthesia care unit (PACU) met with PACU staff members to share her vision: to formulate a staff-run, unit-based Clinical Practice Committee (CPC). The PACU at BWH is a 33-bed, phase 1 unit, with one nurse manager and four nurses-in-charge overseeing 75 nurses from diverse backgrounds and varying levels of experience. The PACU nurse manager’s original © AORN, Inc, 2007
proposal was to establish a small steering committee that would address practice issues and oversee long-term unit projects of the CPC. The initial steering committee would be composed of a chair, vice chair, and several other staff nurses who would be responsible for building a CPC of motivated and committed staff nurses. Subcommittees would be formed by staff nurses who wished to participate in short-term projects. The goal of this team was to afford staff nurses the opportunity to become more involved in their practice. RECRUITING VOLUNTEERS. The PACU nurse manager chose two staff nurses with committee experience to be the CPC steering committee chair and vice chair. The newly appointed chair then sent an e-mail to the PACU staff inviting individuals interested in joining the CPC or the steering committee to contact her. The initial response to this invitation was poor. The chair and vice chair
ABSTRACT NURSING LEADERS AT ONE FACILITY challenged staff nurses in the postanesthesia care unit (PACU) to implement a modified process of shared governance, a model that allows staff nurses to influence their practice. AS A RESULT OF THIS INITIATIVE, PACU nurses were able to collaborate with other perioperative staff members, ultimately increasing patient safety. SUCCESSES INCLUDED increased staff nurse participation in educational projects; increased interdisciplinary collaboration; personal and professional development for the nurses involved; and recognition from a highly esteemed, national organization. AORN J 86 (July 2007) 85-93. © AORN, Inc, 2007.
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The committee devised a simple plan in which they would address identified areas of concern by providing basic educational posters and handouts on those topics.
began to encourage individuals to join the group. Eventually, four additional staff nurses were added to the steering committee; however, there were not enough volunteers to form any subcommittees. The initial plan was then changed to concentrate on developing the steering committee into the CPC; subcommittees would be added at a later date. Based on the process of developing shared governance, in which it is essential to allow teams to develop themselves, the PACU nurse manager and one nurse-in-charge served in the roles of mentors and facilitators rather than as members of the committee. The mentors suggested that the committee start with a small project that could be accomplished in a timely manner. The team decided to set objectives for the committee, formulate a general strategy for working on projects, and develop a template that could be used for future endeavors. The committee met every other week to work toward these goals. REDEFINING THE COMMITTEE. Nearly six months into this process, the chair and vice chair expressed frustration with the committee’s negligible accomplishments. After meeting with the mentors, the committee members redefined the objectives for the committee. Drawing on the fundamentals of the nursing process, the committee performed a needs assessment by surveying the staff. The committee created an informal, self-administered questionnaire to be distributed to all PACU nurses. The questionnaire was voluntary and anonymous, and it took approximately five minutes to complete. The survey used a Likert-
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Styer
type scale and asked nurses questions on topics such as what practice issues they wanted to see addressed and what their experience and overall comfort was with certain patient populations. Demographic information that was collected included years of experience in both nursing and perianesthesia nursing. The survey was distributed to 55 nurses and had a 40% response rate (n = 22). The surveys not only provided the CPC with important information to define future projects, but also provided the entire PACU staff with updates on the committee’s goals and plan. EARLY PROJECTS. After the survey results were examined, the committee devised a simple plan: they would address each identified area of concern by providing basic educational posters and handouts on those topics. In addition, PACU leaders would suggest other projects to work on as the need arose. Projects during the ensuing months included reviewing and updating PACU guidelines, conducting research and educating staff members on specific patient populations with implications for postanesthesia care, and serving as a sounding board for unit issues (Table 1). A second strategy designed as a mode to educate staff members was the coordination of educational presentations. The committee drew on the expertise of their health care colleagues, including physicians, nurse practitioners, physician assistants, and nursing experts in their various specialties, and invited them to speak at formal, grand rounds-type forums. Topics included specific surgical procedures, types of anesthesia and their nursing implications, perioperative nursing issues, and national patient safety initiatives. These inservice programs were held in the PACU and proved to be informative and popular programs. More importantly, they provided an opportunity to create a network of collegial relationships between PACU staff members and these perioperative experts. As the comfort level of the committee members increased, the committee gained more autonomy and became less dependent on the mentors for guidance. Meetings became more formally structured, and agendas were developed and forwarded to the committee members
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in advance of the meeting. A process of ongoing evaluation was devised to help the committee members critique their activities and consider ways to improve their programs. After nearly two years of implementing randomly chosen projects, the CPC decided to create more structure for the education topics. Beginning in January 2004, the educational activities were based on a “Service of the Month” design. For example, when focusing on vascular patients, the posters and handouts included information such as medications or nursing implications pertinent to the vascular population, and the speaker for that month was a vascular surgeon. By focusing on specific topics, the committee members were able to coordinate efforts and delegate responsibilities to each other in advance.
SUCCESS
OF A
MAJOR PROJECT
TABLE 1
Clinical Practice Committee Accomplishments, 2002-2006 Minor accomplishments Updated guidelines for postanesthesia care unit (PACU) discharge, peripheral nerve blocks, infection control, and pain assessment Presented educational programs using multidisciplinary patient case studies and involving multiple speakers Provided staff members with updates and alerts on medications Created a “Statement of the Day” board with short, trivia-like statements pertaining to perianesthesia nursing Implemented “Service of the Month” programs, highlighting one type of surgical service (eg, vascular) in educational projects each month
Major accomplishments Presented posters at several American Society of PeriAnesthesia Nurses National Conferences and one AORN Congress Revised the PACU orientation manual Instituted multidisciplinary grand rounds-type forums Standardized the protocol for hand offs Developed resource manuals for staff nurses to consult when needed Conducted an orientation for incoming anesthesia residents on the
As time passed, staff inprotocol for hand offs volvement in CPC projects increased. A major project cian resident—and then brought back to the was to update the unit orientation manual. CPC to review for accuracy and compliance The committee chair consulted with PACU with institution-based practice. Then, in line preceptors (ie, nurses who are considered experts in their practice and orient new nurses in with the concept of shared input, the entire manual of 24 chapters was given to the PACU the PACU), who were deemed likely to have nursing leaders for their critique. The process the most vested interest in the content and was completed by a final structural edit from value of an orientation manual because they use the manual most often. Of the 15 identified the CPC chair and then publication. The whole process took more than two preceptors, seven agreed to assist in developyears to complete. This project was clearly the ing the new manual. most significant accomplishment of the group, Each individual volunteered to write a speand it involved the largest number of staff cific chapter, usually one pertaining to their nurses. The process of collaborating with particular specialty area. They were given physician residents helped promote teamwork guidelines to follow, including a writing forand nursing professionalism. Finally, this orimat and general timeline. After the chapter entation manual gained the CPC recognition was written, the draft was reviewed and editfrom the unit and those in hospital leadership ed by an external reviewer—usually a physiAORN JOURNAL •
87
Styer
JULY 2007, VOL 86, NO 1
roles. Recently, the committee, and specifically the orientation manual, was honored with national recognition from the Advisory Board Company for best practice.7 The Advisory Board Company is based in Washington, DC, and provides best practice research and analysis to health care organizations.8 The entire process of development is highlighted in the Advisory Board Company’s Nursing Executive Center’s publication Unlocking Nursing Excellence.9
BEYOND
THE
PACU
The CPC then began to expand education attempts beyond the PACU. The committee submitted two poster abstracts in the “Celebrate Successful Practices” category for presentation at the 2004 American Society of PeriAnesthesia Nurses (ASPAN) National Conference. Acceptance of these poster abstracts was a defining moment for the committee. This was the first time PACU nurses from BWH presented a poster at a conference, and it proved to be a positive experience. The posters, which were on the topics of creating a clinical practice committee and findings from random chart audits, were met with enthusiasm from conference participants. Positive evaluations from this external audience added to the credibility of the CPC and BWH’s process of shared governance. Since then, the CPC has presented 10 posters at ASPAN National Conferences and one poster at an AORN Congress. COLLABORATION WITH OTHER BWH AREAS. Two years into the shared governance process, PACU leaders asked the committee to expand and include staff nurses from BWH’s Day Surgery Unit (DSU), the ambulatory PACU. Perioperative issues are similar in both units, prompting a common area of interest. This expansion was a great opportunity for CPC members to share their experiences with another staff and incorporate these staff members into the committee. Experienced PACU members were teamed with DSU members for a project. As comfort levels increased through this mentoring effort, DSU members began taking on projects on their own. In 2006, in the continued spirit of perioperative teamwork, the committee welcomed a nurse practitioner from the BWH’s Weiner Center for Preoperative Evaluation.
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Members of the CPC also began participating in hospital-wide committees and task forces. An interdisciplinary task force was formed to address the Joint Commission’s National Patient Safety Goal on effective patient hand offs.10 The CPC chair was asked to participate in this task force along with other perianesthesia nurses and representatives from the anesthesia department and OR nursing department; their charge was to decide how best to address hand-off procedures. The task force met several times and worked together to standardize the procedure for effective hand offs. As a result of the task force’s work, all members of these disciplines have a small laminated card that outlines the formalized reporting process; this card is located on the back of their identification badges for easy reference. This task force helped formulate a safe, standard practice for hand offs and also gave members an opportunity for interdisciplinary teamwork and the building of collegial relationships. This collaboration gave the CPC an opportunity to discuss ideas to improve teamwork and spirit within the departments of anesthesiology and perianesthesia nursing. Members of the committee discussed with residency directors (ie, staff physicians responsible for guiding new residents) ways to create more positive interactions. As a result, in July 2005, the interdisciplinary team of CPC members and residency directors held “meet and greet” luncheons, which provided open forums for communication between the perianesthesia nurses and new anesthesiologists. All incoming residents were presented with laminated cards outlining the specifics of a detailed hand-off report that should be given to the PACU nurses when a patient arrives in PACU from the OR. Working collaboratively and sharing resources with the anesthesiology department proved to be a positive experience for all involved. This partnership not only improved the safety of hand offs, but also improved relationships and teamwork across disciplines. PERSONAL AND PROFESSIONAL GROWTH. In addition to opportunities to improve interdepartmental collaboration, another benefit of serving on this type of committee is the promotion of
JULY 2007, VOL 86, NO 1
personal and professional development.3 The CPC members took advantage of hospitalprovided offerings that were related to committee projects. These offerings included advanced computer classes for PowerPoint presentations, classes for advanced poster development skills, and evidence-based practice workshops.
Styer
tient care will always take precedence, and meetings may need to be rescheduled to a later time or a different day. Fortunately, rescheduling happens infrequently with this committee. In addition, there are times when a staff nurse may request time away from the unit to work on a project for the committee, but subsequently he or she might have to postpone working on the project to accommodate the needs of the INCREASED EXPECTATIONS unit. Although these delays may be disappointWith each successfully completed project ing, it is understood that dedication to patients came greater expectations from the committee is a core value of the committee. members as well as nursing leaders. CommitA third challenge, which was perhaps the tee members continue to look biggest hurdle, was gaining for new and better ways to buy-in from the other staff educate staff members and nurses. Although there was a improve patient care. One sigpositive response to the orienPerhaps the biggest nificant outcome of this protation manual as well as incess was the development of creased staff nurse participachallenge for the resource binders that staff tion in many projects and use members can use for referof the committee as a reClinical Practice ence. These binders are useful source, hesitancy still exists particularly when nurses are on the part of staff members Committee was gaining caring for high-risk, lowto fully share in this process frequency patients, such as of shared governance. Many buy-in from staff nurses those undergoing extrapleural staff members still admit that pneumonectomies with intrathey have only a vague unwho continually operative heated chemotheraderstanding of what commithesitated to fully share py or craniotomies with ventee members do at meetings triculostomy drains. or during time off the unit. in the process of In addition, the educationOne strategy to address this al presentations program has challenge is to improve comshared governance. been revised. Now, educamunication with the staff. tional presentations are often Minutes from each CPC meetmultidisciplinary case studies ing now are sent to the entire with participation from severstaff electronically. At unit al speakers. All presentations staff meetings, time is allotted are part of an ongoing educational series, with on the agenda to update the PACU staff on continuing education contact hours available CPC projects as well as consistently request for attendance. In 2006, the committee secured volunteers for projects. hospital funding for audiovisual equipment and now consistently videotapes presentaMOVING FORWARD tions so that nurses unable to attend a presenThe original vision to have a steering comtation are able to benefit by watching the mittee for the CPC that would lead and coorvideo at another time. dinate PACU staff education has finally come to fruition. Since that initial group formed SHARED GOVERNANCE CHALLENGES with six members, the CPC steering commitOne challenge for a staff-run committee is tee has grown to 10 members and has formed finding the time to have regularly scheduled more than six subcommittees or task forces, meetings. The needs of the unit to provide paincluding two standing subcommittees.
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TABLE 2
Clinical Practice Committee (CPC) Subcommittees and Liaisons Subcommittees Chart Audit Team* Infection Control Team* Hand Off Committee
Liaisons** Intensive Care Unit Committee liaison Pain Committee liaison Skin Integrity Committee liaison * Standing subcommittees ** Liaisons from the CPC are on hospital-wide committees.
Examples of subcommittees that grew out of the CPC steering committee are the Chart Audit Team and the Infection Control Team. In addition, liaisons represent the PACU on hospital-wide committees. These teams and liaisons (Table 2) report their progress and findings to the CPC and work in conjunction with the CPC steering committee to determine what information should be disseminated to the PACU staff. The number of nurses who have completed a project or are currently participating in quality improvement and practice issues has increased to 18. MEASURING SUCCESS. Although many of the committee’s accomplishments were considered successful by staff or those in leadership roles and have received informal, positive feedback, there has been little objective measurement of the committee’s success. Brooks4 and Porter-O’Grady2 emphasize the need to measure the benefits of shared governance models. One way to measure the success of the CPC’s programs is to examine the data collected from medical chart audits. Analyzing these data could allow the CPC to conduct benchmarking, measure effectiveness of the CPC programs, and offer staff more concrete
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feedback on their documentation skills and clinical practice.
THE SHARED GOVERNANCE JOURNEY Staff nurses must become more active in ensuring quality patient care. Nurses must own their practice. If nurses are to keep pace with the practice and technological advances in health care, they need to become more involved in their practice and in shaping their work environment. The CPC is an example of how nurses can influence patient outcomes in their unit and improve the quality of care they provide. These accomplishments would not have been possible, however, without the support of those in PACU leadership positions. These leaders were committed to the purpose of the committee and were able to coordinate time away from the unit for committee members. In addition, they challenged the committee to continue to grow in its scope and promoted the committee to the PACU staff and throughout the hospital. Clearly, this process involved a team approach to achieve real success. Hess calls shared governance “a journey, not a destination”;1 the success of this committee also has been one of ongoing growth, evaluation, and restructuring. The accomplishments of the committee have benefited many people; such benefits include building interdisciplinary collaboration and providing committee members with opportunities for personal and professional growth. More importantly, the work of the CPC has helped keep staff nurses current in their practice and has provided them with the resources they need, resulting in patients receiving excellent patient care from a nursing staff that is practicing the highest level of care. Acknowledgment: The author thanks Ellen E. Sullivan, BSN, RN, CPAN, nurse-in-charge, Brigham and Women’s Hospital, Boston, MA, and Michelle A. Beauchesne, DNSc, CPNP, associate professor and director, Pediatric Nurse Practitioner Program, Northeastern University, Boston, for their review of this article. Editor’s note: PowerPoint is a registered trademark of Microsoft Corp, Redmond, WA.
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REFERENCES 1. Hess RG Jr. From bedside to boardroom—nursing shared governance. Online J Issues Nurs. 2004;9(1). http://www.nursingworld.org/ojin/topic23/tpc23 _1.htm. Accessed May 9, 2007. 2. Porter-O’Grady T. Overview and summary: shared governance: is it a model for nurses to gain control over their practice? Online J Issues Nurs. 2004;9(1). http://www.nursingworld.org/ojin /topic23/tpc23ntr.htm. Accessed May 9, 2007. 3. Scott L, Caress AL. Shared governance and shared leadership: meeting the challenges of implementation. J Nurs Manag. 2005;13(1):4-12. 4. Brooks BA. Measuring the impact of shared governance. Online J Issues Nurs. 2004;9(1). http:// www.nursingworld.org/ojin/topic23/tpc23_1a .htm. Accessed May 9, 2007. 5. Kerfoot K. Establishing guardrails in leadership. Nurs Econ. 2005;23(6):334-335. 6. Welcome to Partners HealthCare: dedicated to patient care, teaching and research. Partners HealthCare System. http://www.partners.org/. Published 2005. Accessed May 9, 2007.
7. Advisory board recognizes BWH nurses. BWH Nurse [serial online]. May 2006. http://www.brig hamandwomens.org/publicaffairs/publications /DisplayNurse.aspx?issueDate=5/1/2006%2012:00 :00%20AM. Accessed May 9, 2007. 8. In brief. The Advisory Board Company. http:// www.advisoryboardcompany.com/public/inbrief .asp. Published 2002. Accessed May 9, 2007. 9. The Advisory Board Company. Unlocking Unit Excellence: Executive Summary. Washington, DC: The Advisory Board Company; 2004. 10. 2006 Critical Access Hospital and Hospital National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/PatientSafety /NationalPatientSafetyGoals/06_npsg_cah.htm. Accessed May 10, 2007.
Kristin Alt Styer, MS, RN, CPAN, is a staff nurse and chair of the postanesthesia care unit Clinical Practice Committee, Brigham and Women’s Hospital, Boston, MA.
What Does Your Facility Do About Surgical Smoke?
A
ORN and researchers at Duke University and Medical Center, Durham, North Carolina, are partnering in a project to determine how AORN members and their facilities currently protect staff members against the dangers of surgical smoke. The hazard posed to health care workers and patients by surgical smoke has been well documented for many years. Emerging guidance from the US government, industry, and professional organizations reflects a growing consensus on appropriate control measures to address this haz-
ard. No comprehensive data exist, however, regarding the extent to which these recommended control measures have been implemented. You can help to fill this knowledge gap by completing a brief, anonymous, web-based survey. This benchmarking survey is designed to measure the extent of control measures used during procedures that produce surgical smoke. Please take a few minutes to visit http://www.safety.duke.edu/radsafety/smoke/ to participate in this important survey.
Aspirin Not Recommended for Colorectal Cancer Prevention
P
eople who have an average risk for developing colorectal cancer, including those with a family history of the disease, should not take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for prevention of colorectal cancer, according to a March 5, 2007, news release from the Agency for Healthcare Research and Quality. Colorectal cancer is the third most common type of cancer and is the second leading cause of cancer-related death in the United States. After conducting a rigorous, impartial assessment of the latest available evidence, the US Preventive Services Task Force found that the potential risks of taking aspirin and NSAIDs (eg, stroke, intestinal bleeding, kidney failure) outweighed the potential benefits in regard to colorectal cancer prevention.
Patients taking these medications for other reasons, however, should consult with their physicians to discuss the potential benefits and risks. For example, the task force found that taking low doses of aspirin (ie, less that 100 mg) may reduce the risk of heart disease but does not reduce the rate of colorectal cancer. The task force therefore recommends exercising caution if using this kind of therapy for colorectal cancer prevention alone and encourages screening for colorectal cancer for all men and women ages 50 years and older. Task Force Recommends Against Use of Aspirin and NonSteroidal Anti-Inflammatory Drugs to Prevent Colorectal Cancer [news release]. Rockville, MD: Agency for Healthcare Research and Quality; March 5, 2007.
AORN JOURNAL •
93
S
hared governance is an organizational model that allows nurses to have control over their practice as well as influence in administrative areas.1 The benefits of shared governance, also known as collaborative governance or collaborative practice, have been published in the literature.1-4 Some of the benefits include increased staff morale, job satisfaction, staff member participation, and personal and professional development. According to the concept of shared governance, the process must originate from a leader who believes in the expertise and judgment of the staff members.5 In return, the staff members must be committed and flexible in participating in this process. Porter-O’Grady states that “leadership must be able to create a safe and developmental context for both staff and themselves so that . . . professional practice can truly evolve.”2
INITIATING A SHARED GOVERNANCE PROCESS Leaders at Brigham and Women’s Hospital (BWH) in Boston, Massachusetts, a 747-bed teaching hospital affiliated with Harvard Medical School,6 challenged staff nurses to implement a process based on shared governance but without the formal structure of traditional shared governance models. In February 2002, the nurse manager of the postanesthesia care unit (PACU) met with PACU staff members to share her vision: to formulate a staff-run, unit-based Clinical Practice Committee (CPC). The PACU at BWH is a 33-bed, phase 1 unit, with one nurse manager and four nurses-in-charge overseeing 75 nurses from diverse backgrounds and varying levels of experience. The PACU nurse manager’s original © AORN, Inc, 2007
proposal was to establish a small steering committee that would address practice issues and oversee long-term unit projects of the CPC. The initial steering committee would be composed of a chair, vice chair, and several other staff nurses who would be responsible for building a CPC of motivated and committed staff nurses. Subcommittees would be formed by staff nurses who wished to participate in short-term projects. The goal of this team was to afford staff nurses the opportunity to become more involved in their practice. RECRUITING VOLUNTEERS. The PACU nurse manager chose two staff nurses with committee experience to be the CPC steering committee chair and vice chair. The newly appointed chair then sent an e-mail to the PACU staff inviting individuals interested in joining the CPC or the steering committee to contact her. The initial response to this invitation was poor. The chair and vice chair
ABSTRACT NURSING LEADERS AT ONE FACILITY challenged staff nurses in the postanesthesia care unit (PACU) to implement a modified process of shared governance, a model that allows staff nurses to influence their practice. AS A RESULT OF THIS INITIATIVE, PACU nurses were able to collaborate with other perioperative staff members, ultimately increasing patient safety. SUCCESSES INCLUDED increased staff nurse participation in educational projects; increased interdisciplinary collaboration; personal and professional development for the nurses involved; and recognition from a highly esteemed, national organization. AORN J 86 (July 2007) 85-93. © AORN, Inc, 2007.
JULY 2007, VOL 86, NO 1 • AORN JOURNAL • 85
JULY 2007, VOL 86, NO 1
The committee devised a simple plan in which they would address identified areas of concern by providing basic educational posters and handouts on those topics.
began to encourage individuals to join the group. Eventually, four additional staff nurses were added to the steering committee; however, there were not enough volunteers to form any subcommittees. The initial plan was then changed to concentrate on developing the steering committee into the CPC; subcommittees would be added at a later date. Based on the process of developing shared governance, in which it is essential to allow teams to develop themselves, the PACU nurse manager and one nurse-in-charge served in the roles of mentors and facilitators rather than as members of the committee. The mentors suggested that the committee start with a small project that could be accomplished in a timely manner. The team decided to set objectives for the committee, formulate a general strategy for working on projects, and develop a template that could be used for future endeavors. The committee met every other week to work toward these goals. REDEFINING THE COMMITTEE. Nearly six months into this process, the chair and vice chair expressed frustration with the committee’s negligible accomplishments. After meeting with the mentors, the committee members redefined the objectives for the committee. Drawing on the fundamentals of the nursing process, the committee performed a needs assessment by surveying the staff. The committee created an informal, self-administered questionnaire to be distributed to all PACU nurses. The questionnaire was voluntary and anonymous, and it took approximately five minutes to complete. The survey used a Likert-
86 • AORN JOURNAL
Styer
type scale and asked nurses questions on topics such as what practice issues they wanted to see addressed and what their experience and overall comfort was with certain patient populations. Demographic information that was collected included years of experience in both nursing and perianesthesia nursing. The survey was distributed to 55 nurses and had a 40% response rate (n = 22). The surveys not only provided the CPC with important information to define future projects, but also provided the entire PACU staff with updates on the committee’s goals and plan. EARLY PROJECTS. After the survey results were examined, the committee devised a simple plan: they would address each identified area of concern by providing basic educational posters and handouts on those topics. In addition, PACU leaders would suggest other projects to work on as the need arose. Projects during the ensuing months included reviewing and updating PACU guidelines, conducting research and educating staff members on specific patient populations with implications for postanesthesia care, and serving as a sounding board for unit issues (Table 1). A second strategy designed as a mode to educate staff members was the coordination of educational presentations. The committee drew on the expertise of their health care colleagues, including physicians, nurse practitioners, physician assistants, and nursing experts in their various specialties, and invited them to speak at formal, grand rounds-type forums. Topics included specific surgical procedures, types of anesthesia and their nursing implications, perioperative nursing issues, and national patient safety initiatives. These inservice programs were held in the PACU and proved to be informative and popular programs. More importantly, they provided an opportunity to create a network of collegial relationships between PACU staff members and these perioperative experts. As the comfort level of the committee members increased, the committee gained more autonomy and became less dependent on the mentors for guidance. Meetings became more formally structured, and agendas were developed and forwarded to the committee members
Styer
JULY 2007, VOL 86, NO 1
in advance of the meeting. A process of ongoing evaluation was devised to help the committee members critique their activities and consider ways to improve their programs. After nearly two years of implementing randomly chosen projects, the CPC decided to create more structure for the education topics. Beginning in January 2004, the educational activities were based on a “Service of the Month” design. For example, when focusing on vascular patients, the posters and handouts included information such as medications or nursing implications pertinent to the vascular population, and the speaker for that month was a vascular surgeon. By focusing on specific topics, the committee members were able to coordinate efforts and delegate responsibilities to each other in advance.
SUCCESS
OF A
MAJOR PROJECT
TABLE 1
Clinical Practice Committee Accomplishments, 2002-2006 Minor accomplishments Updated guidelines for postanesthesia care unit (PACU) discharge, peripheral nerve blocks, infection control, and pain assessment Presented educational programs using multidisciplinary patient case studies and involving multiple speakers Provided staff members with updates and alerts on medications Created a “Statement of the Day” board with short, trivia-like statements pertaining to perianesthesia nursing Implemented “Service of the Month” programs, highlighting one type of surgical service (eg, vascular) in educational projects each month
Major accomplishments Presented posters at several American Society of PeriAnesthesia Nurses National Conferences and one AORN Congress Revised the PACU orientation manual Instituted multidisciplinary grand rounds-type forums Standardized the protocol for hand offs Developed resource manuals for staff nurses to consult when needed Conducted an orientation for incoming anesthesia residents on the
As time passed, staff inprotocol for hand offs volvement in CPC projects increased. A major project cian resident—and then brought back to the was to update the unit orientation manual. CPC to review for accuracy and compliance The committee chair consulted with PACU with institution-based practice. Then, in line preceptors (ie, nurses who are considered experts in their practice and orient new nurses in with the concept of shared input, the entire manual of 24 chapters was given to the PACU the PACU), who were deemed likely to have nursing leaders for their critique. The process the most vested interest in the content and was completed by a final structural edit from value of an orientation manual because they use the manual most often. Of the 15 identified the CPC chair and then publication. The whole process took more than two preceptors, seven agreed to assist in developyears to complete. This project was clearly the ing the new manual. most significant accomplishment of the group, Each individual volunteered to write a speand it involved the largest number of staff cific chapter, usually one pertaining to their nurses. The process of collaborating with particular specialty area. They were given physician residents helped promote teamwork guidelines to follow, including a writing forand nursing professionalism. Finally, this orimat and general timeline. After the chapter entation manual gained the CPC recognition was written, the draft was reviewed and editfrom the unit and those in hospital leadership ed by an external reviewer—usually a physiAORN JOURNAL •
87
Styer
JULY 2007, VOL 86, NO 1
roles. Recently, the committee, and specifically the orientation manual, was honored with national recognition from the Advisory Board Company for best practice.7 The Advisory Board Company is based in Washington, DC, and provides best practice research and analysis to health care organizations.8 The entire process of development is highlighted in the Advisory Board Company’s Nursing Executive Center’s publication Unlocking Nursing Excellence.9
BEYOND
THE
PACU
The CPC then began to expand education attempts beyond the PACU. The committee submitted two poster abstracts in the “Celebrate Successful Practices” category for presentation at the 2004 American Society of PeriAnesthesia Nurses (ASPAN) National Conference. Acceptance of these poster abstracts was a defining moment for the committee. This was the first time PACU nurses from BWH presented a poster at a conference, and it proved to be a positive experience. The posters, which were on the topics of creating a clinical practice committee and findings from random chart audits, were met with enthusiasm from conference participants. Positive evaluations from this external audience added to the credibility of the CPC and BWH’s process of shared governance. Since then, the CPC has presented 10 posters at ASPAN National Conferences and one poster at an AORN Congress. COLLABORATION WITH OTHER BWH AREAS. Two years into the shared governance process, PACU leaders asked the committee to expand and include staff nurses from BWH’s Day Surgery Unit (DSU), the ambulatory PACU. Perioperative issues are similar in both units, prompting a common area of interest. This expansion was a great opportunity for CPC members to share their experiences with another staff and incorporate these staff members into the committee. Experienced PACU members were teamed with DSU members for a project. As comfort levels increased through this mentoring effort, DSU members began taking on projects on their own. In 2006, in the continued spirit of perioperative teamwork, the committee welcomed a nurse practitioner from the BWH’s Weiner Center for Preoperative Evaluation.
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Members of the CPC also began participating in hospital-wide committees and task forces. An interdisciplinary task force was formed to address the Joint Commission’s National Patient Safety Goal on effective patient hand offs.10 The CPC chair was asked to participate in this task force along with other perianesthesia nurses and representatives from the anesthesia department and OR nursing department; their charge was to decide how best to address hand-off procedures. The task force met several times and worked together to standardize the procedure for effective hand offs. As a result of the task force’s work, all members of these disciplines have a small laminated card that outlines the formalized reporting process; this card is located on the back of their identification badges for easy reference. This task force helped formulate a safe, standard practice for hand offs and also gave members an opportunity for interdisciplinary teamwork and the building of collegial relationships. This collaboration gave the CPC an opportunity to discuss ideas to improve teamwork and spirit within the departments of anesthesiology and perianesthesia nursing. Members of the committee discussed with residency directors (ie, staff physicians responsible for guiding new residents) ways to create more positive interactions. As a result, in July 2005, the interdisciplinary team of CPC members and residency directors held “meet and greet” luncheons, which provided open forums for communication between the perianesthesia nurses and new anesthesiologists. All incoming residents were presented with laminated cards outlining the specifics of a detailed hand-off report that should be given to the PACU nurses when a patient arrives in PACU from the OR. Working collaboratively and sharing resources with the anesthesiology department proved to be a positive experience for all involved. This partnership not only improved the safety of hand offs, but also improved relationships and teamwork across disciplines. PERSONAL AND PROFESSIONAL GROWTH. In addition to opportunities to improve interdepartmental collaboration, another benefit of serving on this type of committee is the promotion of
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personal and professional development.3 The CPC members took advantage of hospitalprovided offerings that were related to committee projects. These offerings included advanced computer classes for PowerPoint presentations, classes for advanced poster development skills, and evidence-based practice workshops.
Styer
tient care will always take precedence, and meetings may need to be rescheduled to a later time or a different day. Fortunately, rescheduling happens infrequently with this committee. In addition, there are times when a staff nurse may request time away from the unit to work on a project for the committee, but subsequently he or she might have to postpone working on the project to accommodate the needs of the INCREASED EXPECTATIONS unit. Although these delays may be disappointWith each successfully completed project ing, it is understood that dedication to patients came greater expectations from the committee is a core value of the committee. members as well as nursing leaders. CommitA third challenge, which was perhaps the tee members continue to look biggest hurdle, was gaining for new and better ways to buy-in from the other staff educate staff members and nurses. Although there was a improve patient care. One sigpositive response to the orienPerhaps the biggest nificant outcome of this protation manual as well as incess was the development of creased staff nurse participachallenge for the resource binders that staff tion in many projects and use members can use for referof the committee as a reClinical Practice ence. These binders are useful source, hesitancy still exists particularly when nurses are on the part of staff members Committee was gaining caring for high-risk, lowto fully share in this process frequency patients, such as of shared governance. Many buy-in from staff nurses those undergoing extrapleural staff members still admit that pneumonectomies with intrathey have only a vague unwho continually operative heated chemotheraderstanding of what commithesitated to fully share py or craniotomies with ventee members do at meetings triculostomy drains. or during time off the unit. in the process of In addition, the educationOne strategy to address this al presentations program has challenge is to improve comshared governance. been revised. Now, educamunication with the staff. tional presentations are often Minutes from each CPC meetmultidisciplinary case studies ing now are sent to the entire with participation from severstaff electronically. At unit al speakers. All presentations staff meetings, time is allotted are part of an ongoing educational series, with on the agenda to update the PACU staff on continuing education contact hours available CPC projects as well as consistently request for attendance. In 2006, the committee secured volunteers for projects. hospital funding for audiovisual equipment and now consistently videotapes presentaMOVING FORWARD tions so that nurses unable to attend a presenThe original vision to have a steering comtation are able to benefit by watching the mittee for the CPC that would lead and coorvideo at another time. dinate PACU staff education has finally come to fruition. Since that initial group formed SHARED GOVERNANCE CHALLENGES with six members, the CPC steering commitOne challenge for a staff-run committee is tee has grown to 10 members and has formed finding the time to have regularly scheduled more than six subcommittees or task forces, meetings. The needs of the unit to provide paincluding two standing subcommittees.
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TABLE 2
Clinical Practice Committee (CPC) Subcommittees and Liaisons Subcommittees Chart Audit Team* Infection Control Team* Hand Off Committee
Liaisons** Intensive Care Unit Committee liaison Pain Committee liaison Skin Integrity Committee liaison * Standing subcommittees ** Liaisons from the CPC are on hospital-wide committees.
Examples of subcommittees that grew out of the CPC steering committee are the Chart Audit Team and the Infection Control Team. In addition, liaisons represent the PACU on hospital-wide committees. These teams and liaisons (Table 2) report their progress and findings to the CPC and work in conjunction with the CPC steering committee to determine what information should be disseminated to the PACU staff. The number of nurses who have completed a project or are currently participating in quality improvement and practice issues has increased to 18. MEASURING SUCCESS. Although many of the committee’s accomplishments were considered successful by staff or those in leadership roles and have received informal, positive feedback, there has been little objective measurement of the committee’s success. Brooks4 and Porter-O’Grady2 emphasize the need to measure the benefits of shared governance models. One way to measure the success of the CPC’s programs is to examine the data collected from medical chart audits. Analyzing these data could allow the CPC to conduct benchmarking, measure effectiveness of the CPC programs, and offer staff more concrete
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feedback on their documentation skills and clinical practice.
THE SHARED GOVERNANCE JOURNEY Staff nurses must become more active in ensuring quality patient care. Nurses must own their practice. If nurses are to keep pace with the practice and technological advances in health care, they need to become more involved in their practice and in shaping their work environment. The CPC is an example of how nurses can influence patient outcomes in their unit and improve the quality of care they provide. These accomplishments would not have been possible, however, without the support of those in PACU leadership positions. These leaders were committed to the purpose of the committee and were able to coordinate time away from the unit for committee members. In addition, they challenged the committee to continue to grow in its scope and promoted the committee to the PACU staff and throughout the hospital. Clearly, this process involved a team approach to achieve real success. Hess calls shared governance “a journey, not a destination”;1 the success of this committee also has been one of ongoing growth, evaluation, and restructuring. The accomplishments of the committee have benefited many people; such benefits include building interdisciplinary collaboration and providing committee members with opportunities for personal and professional growth. More importantly, the work of the CPC has helped keep staff nurses current in their practice and has provided them with the resources they need, resulting in patients receiving excellent patient care from a nursing staff that is practicing the highest level of care. Acknowledgment: The author thanks Ellen E. Sullivan, BSN, RN, CPAN, nurse-in-charge, Brigham and Women’s Hospital, Boston, MA, and Michelle A. Beauchesne, DNSc, CPNP, associate professor and director, Pediatric Nurse Practitioner Program, Northeastern University, Boston, for their review of this article. Editor’s note: PowerPoint is a registered trademark of Microsoft Corp, Redmond, WA.
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REFERENCES 1. Hess RG Jr. From bedside to boardroom—nursing shared governance. Online J Issues Nurs. 2004;9(1). http://www.nursingworld.org/ojin/topic23/tpc23 _1.htm. Accessed May 9, 2007. 2. Porter-O’Grady T. Overview and summary: shared governance: is it a model for nurses to gain control over their practice? Online J Issues Nurs. 2004;9(1). http://www.nursingworld.org/ojin /topic23/tpc23ntr.htm. Accessed May 9, 2007. 3. Scott L, Caress AL. Shared governance and shared leadership: meeting the challenges of implementation. J Nurs Manag. 2005;13(1):4-12. 4. Brooks BA. Measuring the impact of shared governance. Online J Issues Nurs. 2004;9(1). http:// www.nursingworld.org/ojin/topic23/tpc23_1a .htm. Accessed May 9, 2007. 5. Kerfoot K. Establishing guardrails in leadership. Nurs Econ. 2005;23(6):334-335. 6. Welcome to Partners HealthCare: dedicated to patient care, teaching and research. Partners HealthCare System. http://www.partners.org/. Published 2005. Accessed May 9, 2007.
7. Advisory board recognizes BWH nurses. BWH Nurse [serial online]. May 2006. http://www.brig hamandwomens.org/publicaffairs/publications /DisplayNurse.aspx?issueDate=5/1/2006%2012:00 :00%20AM. Accessed May 9, 2007. 8. In brief. The Advisory Board Company. http:// www.advisoryboardcompany.com/public/inbrief .asp. Published 2002. Accessed May 9, 2007. 9. The Advisory Board Company. Unlocking Unit Excellence: Executive Summary. Washington, DC: The Advisory Board Company; 2004. 10. 2006 Critical Access Hospital and Hospital National Patient Safety Goals. The Joint Commission. http://www.jointcommission.org/PatientSafety /NationalPatientSafetyGoals/06_npsg_cah.htm. Accessed May 10, 2007.
Kristin Alt Styer, MS, RN, CPAN, is a staff nurse and chair of the postanesthesia care unit Clinical Practice Committee, Brigham and Women’s Hospital, Boston, MA.
What Does Your Facility Do About Surgical Smoke?
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ORN and researchers at Duke University and Medical Center, Durham, North Carolina, are partnering in a project to determine how AORN members and their facilities currently protect staff members against the dangers of surgical smoke. The hazard posed to health care workers and patients by surgical smoke has been well documented for many years. Emerging guidance from the US government, industry, and professional organizations reflects a growing consensus on appropriate control measures to address this haz-
ard. No comprehensive data exist, however, regarding the extent to which these recommended control measures have been implemented. You can help to fill this knowledge gap by completing a brief, anonymous, web-based survey. This benchmarking survey is designed to measure the extent of control measures used during procedures that produce surgical smoke. Please take a few minutes to visit http://www.safety.duke.edu/radsafety/smoke/ to participate in this important survey.
Aspirin Not Recommended for Colorectal Cancer Prevention
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eople who have an average risk for developing colorectal cancer, including those with a family history of the disease, should not take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for prevention of colorectal cancer, according to a March 5, 2007, news release from the Agency for Healthcare Research and Quality. Colorectal cancer is the third most common type of cancer and is the second leading cause of cancer-related death in the United States. After conducting a rigorous, impartial assessment of the latest available evidence, the US Preventive Services Task Force found that the potential risks of taking aspirin and NSAIDs (eg, stroke, intestinal bleeding, kidney failure) outweighed the potential benefits in regard to colorectal cancer prevention.
Patients taking these medications for other reasons, however, should consult with their physicians to discuss the potential benefits and risks. For example, the task force found that taking low doses of aspirin (ie, less that 100 mg) may reduce the risk of heart disease but does not reduce the rate of colorectal cancer. The task force therefore recommends exercising caution if using this kind of therapy for colorectal cancer prevention alone and encourages screening for colorectal cancer for all men and women ages 50 years and older. Task Force Recommends Against Use of Aspirin and NonSteroidal Anti-Inflammatory Drugs to Prevent Colorectal Cancer [news release]. Rockville, MD: Agency for Healthcare Research and Quality; March 5, 2007.
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