Implementing an Obstetric Navigator Program

I N N O VAT I V E P R O G R A M S

Larson, E. M.

Proceedings of the 2012 AWHONN Convention

Igniting the Passion for Change through Web Conferencing Professional Issues

Barbara J. LaBranche, MBA, BSN, RN, Banner Health, Phoenix, AZ

Purpose for the Program large health care organization faced challenges educating large numbers of nurses and providers who worked various shifts, across various time zones, in multiple facilities, in six states. Classroom education with a live instructor became impossible as the health care organization faced economic constraints, and qualified instructors were stretched thin. With a goal of providing consistent, quality education, this health care organization searched for a better way to provide support and information to all perinatal staff.

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Jean Davis, MSN, MBA, HCM, RN, Banner Health, Phoenix, Proposed Change AZ Keywords education Web conferencing

Paper Presentation

To use Web conferencing services and large capacity bridge lines, with scripted training to provide education for nurses and providers in multiple facilities across the country

Implementation, Outcomes, and Evaluation With only 10 people available to provide the education, the group scheduled classes four times each day (including night shift) for 5 days. Experts were used to present the information remotely. The Web conferencing allows question and answer interaction, which is more effective than staff viewing a PowerPoint presentation on one’s own or completing a computerized module. The new education was implemented, including fetal heart rate tracing definitions, interpretations, and interventions as well as changes in the electronic medi-

cal record. The electronic medical record is used to hardwire best practice and adherence to specific policies and procedures aimed at improving patient outcomes. Clinical informatics coordinators and perinatal educators came together to provide this training. Instructions for connecting to the Web conference were sent to department leaders, educators, medical staff services, and informatics coordinators to communicate to end users. The outcome of using this method of providing education included reaching more than 400 staff and providers in just 1 week. Everyone who attended the training received the same information in a scripted format eliminating trainer bias. Nurses and providers had the opportunity to watch an expert navigate the electronic medical record. This format enabled real time question and answer opportunities, usually generating interactive thoughtful discussion. Attendees of the training received a link to a postquiz. The training attendance and postquiz were recorded and tracked in a database electronically. Implications for Nursing Practice The nurses all hear a consistent message, including the rationale for change. This type of training ignites passion in perinatal care and provides camaraderie in a large health care system by connecting perinatal nurses from small rural facilities with larger urban centers.

Birth of a Culture Change Enhances Safety during Second Stage of Labor Elsa M. Larson, RNC, BSN, Saint Elizabeth Regional Medical Center, Lincoln, NE Keywords second stage labor perinatal teamwork culture of safety

Professional Issues Paper Presentation

Purpose for the Program o identify signs of maternal or fetal stress during the second stage of labor and remove barriers to timely responses of care providers.

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Proposed Change To modify the culture in which experienced nurses independently manage nursing care during the second stage of labor. Implementation, Outcomes, and Evaluation Tested strategies were used that contribute to quality care: uniform processes, careful surveillance, team communication, and empowerment of each member of the team. The program consists of a group page to alert the entire team of the onset of the second stage of labor, identification

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of four essential assessments necessary for safe passage, and the inclusion of a designated experienced nurse to provide a second pair of eyes to the situation. The latter is critical as a single nurse may be caught up in the details of the situation and lose the greater perspective. The ability to safely monitor fetal status, adequacy of contractions, absence of tachysystole, and progress of descent can present challenges in long labors. This is especially true when competing priorities, such as complex birth plans, medical complications, or a very busy unit divert attention. The second pair of eyes enhances recognition of problems and hastens interventions through collegial communication. This collegiality imparts strength and confidence to the less experienced nurse in knowing when to speak up. Outcomes have been fewer incidents of unrecognized maternal or

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

fetal stress, improved teamwork, and greater nurse satisfaction. Implications for Nursing Practice Implications for nursing practice include knowing that working within uniform processes in a

strong teamwork environment enhances safety during a critical time in labor. Implications also include a sense of empowerment to support both laboring women and each other, especially during a prolonged second stage of labor.

New Infant Identification Program Improves Safety and Patient Satisfaction Purpose for the Program o comply with the National Center for Missing and Exploited Children’s recommendation for DNA sample identification of infants.

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Proposed Change MedStar Health decided to pilot the DNA Blood Spot program at Harbor Hospital to supplement its current infant safety method of infant and parent banding, employee name tags, umbilical cord detectors, foot printing, parent education, and locked units. Implementation, Outcomes, and Evaluation The National Center for Missing and Exploited Children states it is essential to have a sample of blood or saliva from every infant that is provided care until it is discharged. The preferred sample is blood because saliva contains bacteria and enzymes that eventually affect the DNA sample. The problem with this collection is that there are issues with the storage of the tubes of blood from each infant. However, the DNA Blood Spot program samples several drops of cord blood on a treated filter paper immediately after birth. The samples are are then placed in a special treated envelope for longterm preservation and storage. One advantage of the MedStar program is that it uses cord blood and the infant does not have to endure a heel stick. The MedStar procedure is done immediately

after delivery. Policies, procedures, staff education, provider education, parent education, and clinical competencies were all developed for the program. It was implemented at Harbor Hospital’s Birthing Center by the nursing education staff. Harbor Hospital uses a labor, delivery, recovery, and postpartum model, therefore, all staff were crosstrained. Information was shared with the providers at medical staff meetings and also through written communications. The outcomes that were measured were adherence rate for completion of the sampling and documentation and patient satisfaction. When audited there was 100% adherence to the sampling documentation and a significant increase in patient satisfaction scores related to recommending the hospital. An unexpected outcome was market differentiation because no other hospitals in the region were using this patient safety measure. Harbor Hospital has received a lot of positive press as a result of this program and has come to be known as the “safe harbor” for mothers to give birth their infants.

Vicki A. Lucas, RNC, BSN, MNEd, WHNP, PhD, PeriGen, Inc. and Vicki Lucas, LLC, Phoenix, MD Marion Kerns, RNC, BSN, MSN, Harbor Hospital, Brooklyn, MD Keywords infant security infant identification DNA sampling

Professional Issues Paper Presentation

Implications for Nursing Practice Patient identification is a nursing function and has the most profound implications for patient safety and security. A huge advantage of this program is the ability to give the parents the DNA sample for safe keeping for the future.

Camp Meeting or Revival? Developing and Coordinating Perinatal Leadership across a Multihospital System Purpose for the Program cquisition of new facilities into a health system required implementation of a nursing leadership structure for a women’s strategic service unit with administrative oversight of strategy and operations for perinatal services. Acquisition of individual community facilities presented challenges and opportunities for the strategic service unit to attain standardization of practice and qual-

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ity while promoting integration into a multihospital Lisa Smithgall, PhD, RNC, CPNP, NEA-BC, Mountain health system culture.

States Health Alliance, Johnson City, TN

Catherine Ivory, RN, BC, Proposed Change To develop a nursing leadership model for a MSN, Mountain States Health Alliance, Johnson City, TN women’s strategic service unit to coordinate standardization of practice and quality for perinatal programs within a multihospital health system.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

http://jognn.awhonn.org

I N N O VAT I V E P R O G R A M S

LaBranche, B. J. and Sorensen, S.

Proceedings of the 2012 AWHONN Convention

Keywords centralized leadership standardization team development

Professional Issues Paper Presentation

Implementation, Outcomes, and Evaluation The organizational structure of the women’s strategic service unit was designed with resources across the health system to maximize efficiency and availability of limited resources in low-volume programs. Women’s strategic service unit nurse managers are brought together from across the health system regularly for the standardization of processes, policies, and quality initiatives to develop care practices that are consistently implemented in each program. Monthly meetings with the strategic service unit leadership team include the identification of population specific and regulatory issues for discussion and resolution, performance improvement activities, and implementation of health system initiatives. The women’s strategic service unit monthly leadership team meeting forums include rotation of on-site meetings throughout the health system facilities in addition to the use of interactive technology, including Web Ex, telephone conference calls, and video conference media to maximize resource utilization while promoting interaction and collaboration. The women’s strategic service unit system leadership structure has facilitated the development of a cohesive nursing leadership team with men-

toring and support for new members from existing members. Knowledge and experience shared in the women’s strategic service unit leadership team interactions resulted in the implementation of optimal processes and standardization of practices across the health system. The system structure for the management of the women’s strategic service unit facilitated the achievement of consistent outcomes across the health system perinatal programs for perinatal safety clinical measures, The Joint Commission Perinatal Core Measures, and women’s strategic service unit blueprint dashboard measures of quality. Implications for Nursing Practice Centralized women’s strategic service unit nursing leadership oversight and activities promoting collaboration and interaction of local nursing management supports the cohesive development of a team of nursing leaders within the specialty of women’s services. The centralized health system women’s strategic service unit structure promotes a support network for colleagues managing similar patient care delivery services for practice issues, population specific performance improvement activities, staff resource sharing, and mentoring and leadership development.

Safe Obstetric Care in a Rural Setting: Preparing for Low Frequency/High Risk Events Purpose for the Program very obstetric department works to provide safe outcomes for mothers and infants. Many Sherrill Sorensen, BSN, MHL, rural critical access hospitals provide low-volume, RN, Banner Health-Washakie low-risk obstetric care. However, they must be preMedical Center, Worland, WY pared to deal with any catastrophic event associated with increased maternal or neonatal morbidKeywords ity or mortality. And yet, they are challenged to simulation critical access find the best way to implement evidence-based rural facility care when these events happen so infrequently. low-frequency/high-risk events Large urban facilities have resources that may include clinical nurse specialists, nurse educators, nurse practitioners, and access to large ancillary Professional Issues services. But how does a facility hundreds of miles a large tertiary facility develop competency Paper Presentation from in their staff members? Barbara J. LaBranche, MBA, BSN, RN, Banner Health, Phoenix, AZ

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Proposed Change Improving patient outcomes requires use of evidence-based care, applying systems thinking, and increased training. This rural facility put together evidence-based protocols to facilitate emergent care for placenta abruption, extreme prematurity, and hemorrhage, all low-frequency occurrences that have been experienced with poor outcomes. The proposed changes included modifying the roll-specific functions and re-

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sponses, initiating the chain of communication, and redesigning unit and regular drills. Implementation, Outcomes, and Evaluation The first step included a root cause analysis of lowfrequency, high-risk events. From this, a protocol was developed, adapting to the unique resources and needs of this small facility. The next step was to test the protocol. Simulation with a simulation mannequin was used and every clinical staff member who provided obstetric care participated, including physicians. Revisions were made to the protocol and retested. In addition, clinical decision support was added to the electronic medical record to prompt the clinician to the appropriate actions and orders in a given situation. The electronic medical record also prompts for appropriate documentation to ensure a complete record. Implications for Nursing Practice Overall, staff readiness was improved by using simulation to define the process, educate, and assess competency. The use of simulation for ongoing team evaluation will continue to reinforce these skills so if the unthinkable happens, this nursing and medical staff will be prepared to ensure the most optimal outcome.

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Delta Interactive Solution to Collaborate Over Video for Education and Resources for Maternal Child Health Purpose for the Program he Mississippi Delta region is one of the most distressed areas of the nation. Health care providers fight to improve health disparities of its maternal, neonatal, and pediatric residents. This project will improve evidence-based educational opportunities in maternal child health for these rural health care providers using new and innovative technologies.

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Proposed Change To develop distance learning curricula that foster maternal child health leadership, competencies, and evidence-based practices, that specifically addresses topics relevant to maternal child health professionals in the Mississippi Delta region, including racially, ethnically, and culturally diverse themes. Increase attainment of maternal child health continuing education in the Mississippi Delta region through distance learning opportunities, which specifically target outreach among racially, ethnically, and culturally diverse maternal child health professionals. Increase understanding and comprehension of maternal child health evidencebased practices among participants in the Delta. Improve translation of maternal child health evidence-based practices into care provided by participants.

Implementation, Outcomes, and Evaluation The program began in July 2010 and has conducted 28 educational offerings through interactive video and has granted 278 continuing education hours to health care providers in the Mississippi Delta region in the first year. In August 2011, a new Web site, www.learnondemand.org, was launched to provide a forum for live streaming, content modules, and other Web-based educational materials for health care providers. Randomized surveys identified that nurses that utilize the learning opportunities are more likely to engage in evidence-based practice initiatives at their facility. One nurse stated “They [the nursing teleconferences] are invaluable and becoming a planned event in our unit.” In addition to nursing and medical continuing education, the program also provides educational opportunities for other health care providers, such as sonographers, genetic counselors, and multiple others. Two years of outcome data related to the current use of livestreaming, interactive video, enduring educational materials, and which is most beneficial to rural health care providers will be discussed.

Sarah Rhoads, DNP, APN, University of Arkansas for Medical Sciences, Little Rock, AR Barbara Smith, BSN, University of Arkansas for Medical Sciences, Little Rock, AR Keywords Mississippi Delta region telecommunication enduring educational materials health care providers evidence-based guidelines rural health care providers maternal child health health disparities Web-based continuing education multidisciplinary education

Professional Issues Paper Presentation

Implications for Nursing Practice Utilization of new and innovative technologies in continuing education can aid in dissemination of evidence-based practice implementation by rural health care providers.

Commitment to Putting New Mothers First: Implementing Bedside Report in the Family Birthing Center Purpose for the Program atient handoff has been identified as a time when the risk of ineffective communication contributes to errors and miscommunication. Accrediting organizations in the United States and Canada have identified the importance of an effective transfer of accountability process. Legislation and professional standards address privacy and the need to identify, assess, plan, implement, and evaluate care on an ongoing basis. Transfer of accountability episodes throughout the continuum of a woman’s inpatient experience provides opportunities for providers to exchange important and relevant information about the woman and include her in the interaction. Bedside report in the perinatal setting places the woman and her family in the center of the process and has been

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demonstrated to improve provider-to-provider and patient-to-provider communication, improve nurse efficiency at shift change, improve patient satisfaction with care, and improve nurse satisfaction. On our unit, chart audits uncovered concerns and when seeking the root cause of the issues identified, the shift handover report was identified as one system issue contributing to near misses and adverse events.

Ann C. Holden, RN, BScN, MSc, PNC, St. Joseph’s Health Centre, Toronto, ON

Proposed Change Shift report traditionally took place in the nurse’s station. There was no standard format for report and the quality and value of information exchanged varied widely. The proposed change moved the shift report and all transfers of accountability to the bedside.

Professional Issues Paper Presentation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Keywords transfer of accountability bedside report patient-centered care patient safety

http://jognn.awhonn.org

Lane, A., Rosenberg, R., Mendoza, R., and DelaRosa, D.

I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Implementation, Outcomes, and Evaluation Utilizing recommendations from evidence-based literature and the shared experiences of a peer hospital, our unit implemented the bedside transfer of accountability initiative using role-play, a report prompt tool, and addressing questions and concerns. When the off-going and on-coming nurses exchange information about the woman at the bedside it provides an opportunity to use visual cues, including verification of the patient’s identification, intake and output, the status of dressings and drainage devices, and pain management. It also enables the on-coming nurse to gather information from the off-going nurse. Each patient

and her family are provided with the opportunity to be partners in her care and contribute information or clarification. Patient rounds data, risk audits, and nurse feedbacks have revealed positive outcomes, including improved quality of communication, documentation, and both patient and staff satisfaction. Implications for Nursing Practice Implementing change can be challenging in any unit culture. In this presentation, we will share our strategies and experiences as a learning opportunity for others considering implementation of bedside report.

Implementation of a Bar-Coded Label System for the Management of Expressed Breast Milk Anna Lane, BSN, RN-C, Purpose for the Program Northern Westchester Hospital, reastfeeding promotes the mother–infant reMount Kisco, NY Relinie Rosenberg, BS, MS, Northern Westchester Hospital, Mount Kisco, NY Rosabel Mendoza, BSN, RN-C, Northern Westchester Hospital, Mount Kisco, NY Diwata DelaRosa, BSN, RN-C, Northern Westchester Hospital, Mount Kisco, NY Keywords expressed breast milk shared governance bar-coded labels parental confidence patient safety

Professional Issues Paper Presentation

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lationship and provides the best nutritional support for the infant. For infants born with medical needs who require admission to the nursery or neonatal intensive care unit, breast milk may be expressed and stored until the time of administration. The Northern Westchester Neonatal Intensive Care Unit/Nursery Nursing Shared Governance Council identified an opportunity to improve practice and meet quality standards to decrease the potential for administration errors.

milk. The parent receives the bar-coded labels from the nurse after the two patient identifiers, name and date of birth, are verified. It is the responsibility of the parent to label each expressed breast milk container with a bar-coded label and date and time of pumping. The nurse is accountable for scanning the expressed breast milk into the electronic medication record at the bedside.

Proposed Change To replace handwritten labels for identification of stored expressed breast milk, which have to be verified by two nurses, with electronically scanned bar-coded labels. Utilizing the existing electronic medical records system in an adaptive manner provided increased time for the delivery of patient care.

A corresponding policy was approved and distributed, and a staff competency tool was completed prior to implementation of the new process. The process was well received. An initial audit of stored expressed breast milk administration over 4 weeks indicated 92% adherence to the process. The adherence goal for this initiative is 100%. The staff has been provided with ongoing education and support, and the unit has remained error free. The Nursing Shared Governance Council is reviewing expressed breast milk warming practices to further enhance management of expressed breast milk.

Implementation, Outcomes, and Evaluation Through an interdisciplinary approach, a process was developed to incorporate aspects of medication administration and bar-coded label use to improve the efficacy of stored expressed breast milk administration. A workflow algorithm defines the system’s steps and user accountabilities. A physician’s order initiates the process and generates the first bar-coded expressed breast milk label. Parental involvement is essential to the appropriate identification of stored expressed breast

Implications for Nursing Practice Neonatal nurses are strong advocates for the smallest of patients. The implementation of the electronic bar-coded label process in expressed breast milk management supports practice change to improve the quality of infant care, increase parental confidence, and secure patient safety. The use of this technological advancement can be applied to other instances of body fluid verification, such as blood administrations, to prevent errors.

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Igniting the Midnight Shift Passion for Breastfeeding Support: A Unique Educational Opportunity for the Mother-Baby Nurse Purpose for the Program ealthy People 2020 has set the goal of improving breastfeeding rates nationally. In an effort to meet these goals, breastfeeding education for staff nurses is imperative. Lactation consultants have the responsibility to not only work directly with patients but to also provide education to all postpartum nurses. Many facilities do not offer lactation consultant services during the overnight shift, which presents a unique challenge to educating staff nurses who work this shift. The purpose of this program was to provide an appropriately targeted program that met the overnight postpartum nurses’ educational needs.

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Proposed Change A comprehensive breastfeeding educational program was developed to improve breastfeeding knowledge, attitudes, and beliefs of postpartum nurses. Empowering postpartum nurses with exceptional, evidence-based education improves their confidence in providing breastfeeding support. With superior support from postpartum nurses, new mothers can avoid the many breastfeeding problems that lead to early cessation. Implementation, Outcomes, and Evaluation To understand the perceived educational needs of the overnight shift, a committee of hospital-based lactation consultants was formed. The members of this committee carried out face-to-face interviews with staff nurses during five different overnight

shifts. The identified educational needs were used to develop a Midnight Education program, which included the topics of proper latch and positioning, reason for supplementation, how to evaluate a feeding, community lactation resources, pumping, soothing a crying infant, and skin-toskin contact to promote breastfeeding success. Tools used to deliver information included posters, videos, lactation consultant question and answer session, and pocket reference cards. The committee recruited the 18-member lactation department to participate in the development of the posters, pocket reference cards, and scenarios. Continuing education credit was obtained for participants. To engage participants, a fun theme was incorporated into the program with games, prizes, themed food, and decorations. Interactive breastfeeding scenarios were used to evaluate participants’ comprehension of the presented information. A follow-up e-mail survey was sent to participants to determine the program’s effect on nursing practice. Implications for Nursing Practice Developing an educational program to meet a specific shift’s needs takes careful planning. Making initial face-to-face contact establishes buyin and allows proper assessment of educational needs. A team approach can create a more comprehensive program in a timely manner. Reaching more postpartum nurses intensifies breastfeeding support for patients and, thereby, improves breastfeeding outcomes.

Rebecca L. Hayman, BSN, PCE, IBCLC, Christiana Care Health Services, Newark, DE Mary Ann Crosley, BSN, RN, IBCLC, Christiana Care Health Services, Newark, DE Lydia Henry, MSN, RNC-OB, CCE, IBCLC, Christiana Care Health System, Newark, DE Mindy Schrier Neff, RN, MSN, CPNP, IBCLC, CPCE, Christiana Care Health System, Wilmington, DE Debra A. Otto, RN, BSN, CCE, IBCLC, Christiana Care Health Services, Newark, DE Keywords breastfeeding education nursing education breastfeeding support

Professional Issues Poster Presentation

Journey to Green: Quest for Chemical-Free Products Purpose for the Program tudies show that some chemicals in personal care products can have negative effects on human health, such as increases in cancer, allergies, and hormone disruption. Multiple personal care products are used in our institution. Our quest was to identify chemical-free personal care products for use in the perinatal areas of our tertiary center.

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Proposed Change Our goal was to define a process for moving to healthier infant care products through the use of current, evidence-based research on chemicals

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and their effects on health. Our challenge was Lisa M. Trefz, MSN, RNC-OB, to increase awareness of chemical-free product IBCLC, Miami Valley Hospital, Dayton, OH used by patients, staff, and the community.

Implementation, Outcomes, and Evaluation A “green team,” consisting of nurses, a pediatrician, maternity director, pharmacist, and a patient care technician, representing the perinatal areas was established. Stakeholders, including sourcing, marketing, administration, legal, and infection control were consulted. Organizational and green team goals were aligned. Current, evidence-based research was reviewed. Infant

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Anne E. R. Brower, BA, RN, IBCLC, ICCE, CD, Miami Valley Hospital, Dayton, OH Keywords chemical-free personal care products chemical exposure environmental hazards

Professional Issues Poster Presentation http://jognn.awhonn.org

Leist-Smith, M., Green, D., Lipke, J., Jordan, L. and Nurre, M.

I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

skin care products used in the hospital were evaluated. Parents and staff were surveyed and results indicated a desire for chemical-free products for self and infants. New product evaluation criteria were established. A new chemical-free personal care product was selected, presented, and approved. Education of staff, physicians, and patients regarding need for replacement product, healthy product choices, cost and practice effect, and resource information was completed. The new product will be used in care of infants and samples will be sent home with the fami-

lies. The evaluation of the acceptance of the new product will be conducted through the postpartum survey.

Implications for Nursing Practice Changing to chemical-free products will position our organization as a community leader, setting a health standard to decrease environmental exposure to parents, families, and staff. We plan to move toward identifying other environmentally safe products and practices in our health care setting.

Advancing the Educational Training of Perinatal Patient Care Assistants Purpose for the Program atient care assistants are vital components of the health care team and the delivery of paDonna Green, RN, BSN, PhD, tient care. Providing patient care assistants with Student, Mercy Health Partners, the appropriate education and skills increases Fairfield, OH their knowledge, job satisfaction, and improves patient care. To achieve this, a patient care asJennifer Lipke, RN, MSN, student, Mercy Health Partners, sistant education project was implemented to fill Fairfield, OH an identified practice gap between the knowledge Lora Jordan, RN, PNP, Mercy levels of patient care assistants and rationales surrounding their delivery of nurse delegated newHealth Partners, Fairfield, OH born care tasks. Patient care assistants support Melissa Nurre, RN, CRNP, nursing staff in assessing and carrying out physiMercy Health Partners, cian orders, such as newborn vital signs and lab Fairfield, OH specimens. Marie Leist-Smith, RN, MSN, Mercy Health Partners, Fairfield, OH

Keywords professional education team training STABLE patient care assistants employee satisfaction

Professional Issues Poster Presentation

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Proposed Change The training project provided patient care assistants with a modified version of the neonatal education program, Sugar, Temperature, Airway, R ) Blood pressure, Labs, Emotions (S.T.A.B.L.E program, and with basic pathophysiology regarding neonatal care, rationales for interventions, lab testing, and the capability to answer basic parental questions surrounding the delegated newborn nursing tasks. Implementation, Outcomes, and Evaluation R The modified S.T.A.B.L.E program was offered through a 4-hour program. Concept mapping and case studies were utilized to reinforce information R proand facilitate deeper learning. S.T.A.B.L.E gram increased the patient care assistants confidence, competence, and commitment to the delivery of thorough and high-quality care. Providing

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R propatient care assistants with the S.T.A.B.L.E gram knowledge fostered critical thinking, teamwork, and professional development. Cooperative practice and knowledgeable dialogue between nurses and patient care assistants strengthened workplace and patient relationships. The education program will be evaluated using immediate, short- and long-term outcome measures. Outcomes for patient care assistants were assessed with a self-reported questionnaire given to the staff members precourse and 4 to 6 weeks following the course to examine their perceived levels of self-efficacy, satisfaction, and use of the newborn care information. To assess changes in knowledge levels, patient care assistants were given precomprehension and postcomprehension tests along with a developed course evaluation tool. Longterm outcome measures of this educational intervention will include increased communication, decrease in adverse newborn events, and increased employee satisfaction.

Implications for Nursing Practice It was identified that patient care assistants, nurses, patients, and their families would benefit from providing patient care assistants with basic pathophysiology knowledge related to newborn care and interventions. This knowledge base will assist patient care assistants in their professional abilities to address parental newborn concerns and integrate a higher level of comprehension into their patient care. Providing patient care assistants with educational building blocks for success was undertaken to improve patient and nurse relationships.

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Igniting Change in Implementation of Nursing and Medical Practice to Increase Exclusive Breast Milk Feeding Purpose for the Program uidelines support exclusive breast milk feeding starting within the first hour of life. This goal ignited passion for change at this 550-bed community teaching hospital with 3,200 births per year, which fueled ideas to meet the Joint Commission’s standards and to provide patients with evidence-based practice, while increasing our rate of exclusive breast milk feeding.

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Proposed Change A multifaceted, multidisciplinary approach to change the culture of the entire family care service focused on medical and nursing staff interventions, processes for care, environmental changes, and maternal education. We started with an exclusive breast milk feeding rate of 32% and a goal of 50%. Our initiation rate was 79% proving patient interest but illustrating the need for changes targeted at sustaining exclusive breast milk feeding. Implementation, Outcomes, and Evaluation Pediatricians were included in education and signed a contract agreeing to support exclusive breast milk feeding. Lactation consultants worked with pediatricians regarding discharge planning and with obstetricians for management of mastitis, engorgement, inadequate supply, and pain. Nurses and lactation consultants formed a breastfeeding committee to discuss concerns and roadblocks. They developed consents for mothers to sign for formula supplementation and encouraged mothers to provide expressed breast milk instead of formula. To expand lactation consultant ser-

vices, all lactation consultants carried phones with coverage on a daily basis, inclusive of all shifts. Staff and mothers were dissuaded from providing pacifiers except during painful procedures. Lactation consultant triage practice was developed starting in labor and delivery to follow high-risk infants from birth to discharge. Labor and delivery nurses started routine breastfeeding education on admission, and now provide expressed breast milk to infants unable to breastfeed. Staff was updated on exclusive breast milk feeding rates routinely. Readmission rates of newborns fell after implementation of strategies. Nursing orientation in all obstetric areas now includes 8 hours with a lactation consultant. We stopped providing formula gift bags to exclusive breast milk feeding patients. An outpatient lactation clinic was opened to assist with follow-up care. This clinic is open daily inclusive of weekends and holidays to ensure that feeding, infant, and maternal assessments can be readily accomplished. The clinic is open to the community, and it rents breast pumps and sells breastfeeding supplies. Education and support increased and continues for staff, physicians, and the community. Deviation from the policy is not tolerated by nursing or medical directors. Our current initiation rate is 83% and the exclusive breast milk feeding rate is 68%.

Charla S. Payne, RNC, IBCLC, The Christ Hospital, Cincinnati, OH Keywords exclusive breast milk feeding lactation

Professional Issues Poster Presentation

Implications for Nursing Practice Multiple factors fueled the fire and increased passion for change. Although many were reluctant to embrace this change, the passionate nurses involved sparked the fire for improvement.

Reigniting Our Passion to Deliver an Extraordinary Patient Experience Purpose for the Program n July 2008, our obstetric Press Ganey patient satisfaction raw score hit an all-time low of 86.5. We were frustrated and discouraged and knew there were many contributing factors, including an outdated physical space, unengaged obstetric staff, and lack of amenities for our patients and families. Despite brainstorming regarding the possible fixes and discussions with staff in monthly meetings, our scores stayed low.

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Kimberly J. Pickens, RN, MS, Proposed Change In 2009, we formed a multidisciplinary team con- NE-BC, The Christ Hospital, sisting of the obstetric nursing divisional director, Cincinnati, OH nurse managers, and representatives from patient relations, nutrition, environmental services, and research. We invited a member of our hospital family advisory council to give a patient perspective. Objectives were established for igniting the passion in our staff to make the patient experience extraordinary.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

http://jognn.awhonn.org

I N N O VAT I V E P R O G R A M S

Brenneman, A. and Schad, J.

Proceedings of the 2012 AWHONN Convention

Amy Risola, RN, C-EFM, BSN, The Christ Hospital, Cincinnati, OH Claudia Hulley, RN, BSN, NE-BC, The Christ Hospital, Cincinnati, OH Keywords patient satisfaction family-centered care patient experience

Professional Issues Poster Presentation

Implementation, Outcomes, and Evaluation We seized opportunities to enhance our facility with minimal expense. Flat screen televisions and decor updates were necessary, but the real challenge was engaging the staff to provide excellent customer service, a cultural shift. Although our hospital leadership had been rounding on inpatient units on day 2 of their stay for years (maternity patients were excluded), we began rounding on these patients daily to get feedback. We systematically identified opportunities for improvement and implemented them at a rapid pace. The opening of an outpatient lactation center, which included pump rental and retail breastfeeding supplies, the afternoon magic cookie moment, and free meal ticket for the patient’s significant other were the initiatives implemented on the family unit. Bedside reporting, room readiness, and lateral accountability initiatives were started in the labor and

delivery unit. Patient satisfaction scores became a standing agenda item at the obstetrician physician monthly staff meeting as well as tips on how to improve. Each member of our interdisciplinary group led an initiative on a narrow time line. As a result, we have reached our all-time high patient satisfaction score of 91.3, exceeding many units in our facility. Implications for Nursing Practice We tell our families that we want to be the best maternity unit in our city. When asked what we could have done better, we now get few suggestions. As a result, our newly engaged staff are passionate about offering our patients a truly memorable and personalized experience. We are proud of our accomplishments but recognize that we must continuously look for ways to improve. As nurses we proved that when we collaborate with our partners in care, everyone wins.

Igniting Passion and Renewing Commitment through Women’s Health Joint Dynamics Alicia Brenneman, BSN, RNC, Purpose for the Program Grant Medical Center orking in a stressful environment can deOhioHealth, Columbus, OH Jane Schad, BSN, RNC, Grant Medical Center OhioHealth, Columbus, OH Keywords building working relationships unhealthy work environment improve communication

Professional Issues Poster Presentation

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crease staff satisfaction and also decrease patient safety and satisfaction. The purpose of this program was to improve staff communication between units. The Joint Commission has determined that a breakdown in communication is one of the leading causes of error. A Women’s Health Joint Dynamics committee was formed among the women’s health units. It was implemented with the intention of improving unit relationships with communication and collaboration due to unhealthy relationships between the women’s health units. The units seemed to be suffering from an old history of not being able to get along. The team identified communication as the main factor in their dissatisfaction and therefore is working on ways to improve communication between team members. The goal of the Women’s Health Joint Dynamics committee is to identify and solve professional practice issues by incorporating the use of evidence-based practice to improve unit relationships and communication, facilitate the development of agreeable working relationships, and increase patient safety and satisfaction.

Proposed Change To collaborate on a regular basis to address the dynamics of unhealthy relationships between units

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and work together to improve relationships. The committee will work together on projects, considering input from staff, to increase awareness and opportunities for process improvement ideas. This process involves staff in making improvements that will directly benefit them. Implementation, Outcomes, and Evaluation Presently, the committee meets once per month to discuss where there may be a professional issue and how to solve it using evidence-based practice. The first project the group implemented was a bedside report between each other on individual units and also between units when transporting patients to other women’s health units. The implementation had a rocky start, but with communication and education it rolled out with positive outcomes. All of the patients were called at home for follow-up and asked about the bedside report. All but a few of the follow-up comments were positive. The staff also was asked about bedside report, and the majority felt that it helped increase communication and relationships. Implications for Nursing Practice This collaboration has shown to improve collegial relationships and empower nurses to make decisions that affect their satisfaction in the workplace. With improved staff relationships patient safety and satisfaction will continue to become stronger.

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Exploring the Impact of a Family-Centered Maternity Care Program on Staff Attitudes and Patient Satisfaction Purpose for the Program ur obstetric service implemented a familycentered maternity care program in 2010. Our facility was known in the region for being very high-tech and medicalized and a place where patients would want to give birth if they had high-risk pregnancies or desired induction and epidural. Families who sought a low intervention, nonmedicalized birth often went elsewhere. We simultaneously suffered a downturn in births. Some of this was attributable to the economic situation, but also we felt our patients may be going to facilities that offered a different birth experience than the one we were providing. Additionally, we were seeing an increase in emergent admissions from nearby lay midwife-run birthing centers. We wanted to offer our patients the opportunity to give birth the way they wanted to but within easy access to our obstetric operating rooms and the neonatal intensive care unit if the need arose.

Implementation, Outcomes, and Evaluation The physicians and nursing staff underwent training and new practices were implemented on all obstetric services. Changes were seen in physician order sets, policies and procedures, and nursing documentation. A nursing attitude survey was offered to all staff prior to the start of the program and 12 months after the start of the program. Results demonstrated a shift in most of the indicators toward a more family-centered maternity care attitude. A targeted patient satisfaction survey also was given to all patients over a 4-week period who delivered a normal newborn (non-neonatal intensive care unit admission) about a month after implementation of the program and again 8 months after implementation. The patient satisfaction survey demonstrated continued improvements of our patients’ experience. Our facility is planning on offering a follow-up patient survey in April 2012 to determine if we have achieved further gains.

Proposed Change We are endeavoring to make a family-centered maternity care culture change within our facility, initiating with our physician’s offices and clinics and continuing through our childbirth education programs and hospital services. All services that interact with the obstetric services are affected in some way.

Implications for Nursing Practice Our journey through this program has challenged all of our care providers to examine their practices. Through these efforts we have seen changes in our marketing, childbirth and lactation services, office and clinic practices, as well as all of the inpatient services that interact with our maternity patients and their infants.

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Anita DeWeese, MSN, RNC-NIC, Greenville Hospital System, Easley, SC Janice T. Negron, RN, MN, FNP, Greenville Hospital System University Medical Center, Greenville, SC

Keywords family-centered maternity care labor support patient satisfaction

Professional Issues Poster Presentation

Changing Nursing Care Practices and Improving Breastfeeding Outcomes: Implementing a Comprehensive Breastfeeding Nursing Education Program. What Is the Impact? Purpose for the Program he poster presentation will demonstrate the results of improving breastfeeding education for nurses and the effect on the supplementation rates at Jersey Shore University Medical Center. Based on the Centers for Disease Control and Prevention’s results of the Maternity Practices in Infant Nutrition and Care survey, it was determined that there was an opportunity for improvement in our existing hospital practices. Hospital administration determined that seeking Baby-

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Friendly designation would improve the quality of care that we provide to mothers and infants in our community. In meeting the requirements for the designation, a comprehensive breastfeeding education program was put into place. As a result, our data collection on maternity practices, such as skin-to-skin care at delivery, exclusive breastfeeding rates, and formula supplementation showed significant improvement in all three practices after the educational program was implemented.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Joyce McKeever, RN, MS, LCCE, IBCLC, Jersey Shore University Medical Center, Neptune, NJ

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Susdorf, S. and Curtis, K.

Proceedings of the 2012 AWHONN Convention

Roselyn Young, MSN, RNC, Jersey Shore University Medical Center, Neptune, NJ Barbara Lechner, RN, Jersey Shore University Medical Center, Neptune, NJ Keywords supplementation rates nurse education and breastfeeding rates

Professional Issues Poster Presentation

Proposed Change To improve breastfeeding skills and change nursing process related to maternity practices that support breastfeeding. This educational program will ultimately help to ensure breastfeeding success and increase the duration of exclusive breastfeeding. Implementation, Outcomes, and Evaluation The comprehensive breastfeeding education program and strategies for implementing improved maternity care practices will be described, and

results of improved maternity care practices will be demonstrated. Ongoing evaluation of our exclusive breastfeeding rate will help to determine the long-term success of the educational program as determined by our electronic birth certificate data. Implications for Nursing Practice Long-standing nursing practices can be changed and improved through education and awareness of current evidence-based standards and research.

Implementing Lactation Services Support from Hospital to Clinic Signe Susdorf, RN, Gundersen Lutheran Medical Center, La Crosse, WI Kathleen Curtis, MS, RN, Gundersen Lutheran, La Crosse, WI Keywords lactation consultant breastfeeding revenue continuum ICD9 codes

Professional Issues Poster Presentation

Purpose for the Program ur goal was to expand our inpatient lactation consultant services to our two outpatient clinics where mothers with complex breastfeeding problems could schedule appointments with a lactation consultant. We needed to accomplish this without increasing full-time equivalents. We have two full-time equivalent international board certified lactation consultants for 1,600 deliveries per year.

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Proposed Change Prior to 2008, lactation consultants would see patients on the postpartum unit and make followup phone calls to support breastfeeding women. The problem that continued to arise was how to get this information to either the mother’s or infant’s medical record for the continuum of care. Patients were calling the lactation consultants more often requesting visits, and the medical staff were requesting the lactation consultants to see their patients for complex breastfeeding issues. Implementation, Outcomes, and Evaluation Beginning in 2008, we shifted 16 international board certified lactation consultant hours per week to the two outpatient pediatric clinics. This provided lactation services two afternoons per week in each clinic. These visits were considered a nurse-only visit. By 2009, we expanded to three afternoons per week in each clinic. The need to open more lactation clinic hours became obvious as the number of patient appointments increased. Today, lactation consultants are

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in the hospital from 7:30 a.m. to 11:30 a.m. seven days a week and in two outpatient clinics from 12:00 p.m. to 4:00 p.m. Monday through Friday. Gundersen Lutheran is an integrated health system and, therefore, the lactation consultants can work in both the clinic and the hospital setting. In March of 2010, we began using the International Classification of Diseases-Ninth Clinical Modification codes and diagnoses for billing for the lactation consultant visits. The number of outpatient appointments for lactation consultants increased from 444 in 2008 to 756 in 2010. Between March and December of 2010 there was almost $30,000 billed for lactation consultation visits. Implications for Nursing Practice All of our lactation consultants are registered nurses. The visits are billed under a physician order. Physicians are present in the clinics for consultation. Seeing a lactation consultant for complex breastfeeding problems has opened up the physicians’ schedules for more appropriate patients. We anticipate increased duration of breastfeeding due to ongoing, accessible lactation consultant services. Data suggest that patient education and support by international board certified lactation consultants promotes a longer duration of breastfeeding when utilized in a primary care setting. With the implementation of Epic for our electronic medical record in August 2011, we will now be able to begin tracking more precise data for duration of breastfeeding.

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It Takes a Village: Commitment to Teamwork Improves Patient Safety Purpose for the Program eamwork and effective communication have a profound effect on patient care; in the delivery room this means the best possible care for mothers and infants. With that goal in mind, our obstetrics team implemented a crew resource management initiative. Although the principles of crew resource management are relatively new to the health care environment, the literature supports the value of training health care teams in the principles of crew resource management.

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Proposed Change The goal of the initiative was to improve patient care through improved communication between and among disciplines; situation monitoring throughout the continuum of care; and mutual support and respect among care givers and effective team leadership. Implementation, Outcomes, and Evaluation A mandatory crew resource management training program was presented to all staff members of labor and delivery, all attending anesthesiologists and obstetricians, nursing leadership, the neonatology director, and neonatal nurse practitioners. Through team meetings and debriefings, we identified areas in which patient care could be improved. For example, a team debriefing that followed a stat cesarean birth precipitated several

changes. Among these changes was a revision of the method used to track calls from physicians’ offices as well as the information recorded by nursing staff regarding the location of covering physicians. This translated into the nursing staff being aware of the physician’s plan of care for each patient even before that patient’s arrival in labor and delivery. It also triggered a collaborative effort between the departments of anesthesia and nursing education to provide in-service education to labor and delivery nursing staff and to review the nurse’s role in assisting with general anesthesia. Medical records of mothers and newborns were analyzed to determine the incidence and significance of the 10 adverse outcomes identified by Mann et al. prior to and following crew resource management training.

Anne Shea-Lewis, RN, BS, MBA, St. Charles Hospital, Port Jefferson, NY Keywords teamwork safety communication

Professional Issues Poster Presentation

Implications for Nursing Practice Expecting health care professionals to work as a team has enhanced performance and improved outcomes for mother and infant. Improved communication with the nurses on the maternity unit has smoothed the transition of patient care between departments. Since the completion of training and initiation of team meetings, we realized a significant improvement in both the incidence and severity of adverse outcomes following the crew resource management training as well as a significant improvement in employee satisfaction.

Obstetric Emergencies in a Children’s Hospital Purpose for the Program he special delivery unit in the Children’s Hospital of Philadelphia is designed to perform fetal surgery and deliver fetuses with known anomalies. Because of the low volume, staff are challenged with maintaining obstetric emergency competencies and learning to run adult emergencies within a children’s hospital. The purpose was to provide the interdisciplinary staff with realistic obstetric emergency situations to identify educational opportunities using simulation and debriefing and to identify barriers to providing appropriate care. This learning modality was selected so that staff could practice in a team environment that best portrays an obstetric emergency.

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Proposed Change To use multidisciplinary simulation for team education rather than the annual obstetric-competencies education day provided in a lecture format for nurses. With this change, physicians, midwives, and nurses will work together as a team and focus on team dynamics as well as clinical objectives. Implementation, Outcomes, and Evaluation The simulation program was implemented by creating a multidisciplinary planning team, in coordination with the hospital simulation team, to prioritize the highest risk, low-volume obstetric emergencies. To select these topics, the group took into consideration information from risk management, Joint Commission recommendations, and problem-prone areas. Scenarios were cre-

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Karen L. King, MSN, RNC, The Children’s Hospital of Philadelphia, Philadelphia, PA Joanna L. Horst, MSN, RNC, NEA-BC, The Children’s Hospital of Philadelphia, Philadelphia, PA Michelle Olkkola, MSN, RN, The Children’s Hospital of Philadelphia, Philadelphia, PA Keywords simulation obstetric emergency team training

Professional Issues Poster Presentation

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Hall, K. A. and Moran, K. M.

Proceedings of the 2012 AWHONN Convention

ated combining that information with the simulation model capabilities. Time was scheduled to ensure that all members of the obstetric team were able to attend one simulation. Each simulation lasted 4 hours and included the simulation of a maternal code, shoulder dystocia, postpartum hemorrhage, and fire in the operating room. After completing the simulations, staff feedback and evaluations were reviewed. The need for more frequent simulations and the need for easier access to supplies during a postpartum hemorrhage were identified. As a result, simulations are now being planned for twice a year and a postpartum hemorrhage cart was created.

Implications for Nursing Practice There are many positive implications for using simulation as a learning modality. It provides education on clinical skills and promotes team communication skills that are vitally important in an emergency. Additional implications are the ability to identify process issues and make changes that could quickly affect practice. Simulation also offers the opportunity to practice skills in a nonthreatening atmosphere where questioning practice is an expectation and making mistakes has no adverse effects on the patient.

Collaboration between Nursing Units to Affect Breastfeeding Outcomes Karen A. Hall, BSN, RNC-NIC, ICCE, IBCLC, Christiana Care, West Grove, PA Kathleen M. Moran, BSN, RNC-NIC, RN11, Christiana Care, Newark, DE Keywords breast milk pumping mentoring premature infant

Professional Issues Poster Presentation

Purpose for the Program Discussions between the staff nurses in the neonatal intensive care unit and the parent education and lactation services resulted in an interest in improving breastfeeding outcomes in a level III neonatal intensive care unit after attending a professional conference. Exclusive breastfeeding for the first 6 months of life continuing for 1 year or more is recommended by the American Academy of Pediatrics. Although the ill or premature infant may benefit most from its mother’s own milk, obstacles leading to successful breastfeeding can occur when mothers and infants are separated during hospitalization. Mentoring provides a safe environment in which new skills can be developed and transferred into actual practice. Proposed Change This collaborative effort between managers, physicians, neonatal intensive care unit (NICU) staff nurses, nurse lactation consultants, and nurse research facilitator/neonatal nurse practitioner seeks to enhance communication between members of both departments and explore clinical pathways to help vulnerable infants to receive their mother’s milk. Implementation, Outcomes, and Evaluation A written plan was submitted and approved by managers from both units. Three key members

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were selected from each department to meet on a monthly basis. The first project was to improve the NICU staff nurses’ knowledge and skills necessary for initiation of lactation and pumping of breast milk. Key members from parent education and lactation services taught breast milk pumping skills to key members from the NICU. A pretest of five basic questions on breast milk pumping was developed and administered to the NICU staff. A computer-based program consisting of an educational slide presentation was developed by the team and sent to the NICU staff. The pretest had a 17.2% response rate from the NICU staff on five basic questions. Two questions were answered correctly by 50% of the staff and three questions were answered correctly by 80%. The goal is for 90% of the staff to correctly answer all five basic questions. The posttest had a 8.6% response rate, three questions were answered correctly by 90%, and two questions were answered correctly by 60% of the staff. Support for education by managers on infant nutrition and breastfeeding should be developed for NICU staff, especially for nurses considering a clinical ladder. Prospectively, factors associated with breastfeeding outcomes may be investigated.

Implications for Nursing Practice This pilot project can be expanded to other maternal–child units in the hospital system.

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See One, Do One, Teach One? A Better Way to Teach Vaginal Exam/Cervical Assessment Purpose for the Program n a high-risk obstetric department that had 3,600 newborns in 2010, vaginal exams for cervical assessment were routinely performed by residents, attending physicians, and physician assistants employed by the teaching service. Nurse managers in the department were anxious to change this practice, citing the need for labor and delivery nurses to be an active participant in the planning of their patients’ care. This practice also would be an integral part of the Team Performance Plus concept that was being initiated at the hospital.

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Proposed Change The original request was to have the residents teach the nurses and then observe the nurses performing the skill. Implementation, Outcomes, and Evaluation Cervical models were made, using directions from a Web site dedicated to education for residents and medical students. An instructional video was also available on this site to provide didactic content for the learners. The simulation lab at the health system was able to purchase a teaching model to also be used in this program. Nursing

staff are assigned to this monthly course and are taught by staff experienced in vaginal exams. The nurses view the video, look at models of a cervix at various dilatations, and practice the exams on a clay model that is placed in a paper bag. All of these models have various degrees of dilatation and effacement. The nursing staff are required to be signed off on three patient exams by a physician or resident. A checklist is given to the educator as proof of skill, which is a required competency for 2012. These staff will then be expected to perform exams on their patients. Pre- and posteducation surveys are being completed by staff to determine effectiveness of the training. When all staff have completed the course, there will be an evaluation of how this practice has changed patient outcomes. This course also has been utilized in the simulation lab by the new obstetric residents who entered the hospital’s program in July, 2011.

Monica C. Kraynek, MS, RNC-LRN, RN-BC, The Western Pennsylvania Hospital, Pittsburgh, PA Keywords cervical assessment simulation nursing skills competency

Professional Issues Poster Presentation

Implications for Nursing Practice This program shows how health care disciplines can share knowledge about teaching practices and ensure better communication among health care providers.

Staff-Designed Labor and Delivery Practice Improvement Purpose for the Program ursing leaders and staff identified nursing practice in the labor and delivery unit as complex with many variables influencing workload and productivity. Observation of clinical practice reinforced the dynamic nature of the unit with high-risk patient presentations and comorbidities requiring multitasking, critical thinking, and expert care. Staff nurses described inefficiencies and discrepancies that added to nursing workload and interfered with clinical care. Themes and patterns emerged in their observations, which represented eight areas for improvement.

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Proposed Change Eight staff performance improvement groups were formed to address the issues. Implementation, Outcomes, and Evaluation Eight groups were constructed with two to three staff nurse members, a staff nurse as chair, a lead-

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ership resource, and a facilitator. Each group was given a charge, data and drivers for their work, education and support for performance improvement processes, and a time line. The course for each group was complicated and took longer than planned. Motivation and commitment prevailed to produce a recommendation for pilot implementation of practice change in six of the groups and ongoing progress toward the goals for the other two. The workload and allocation of resources group developed a nurse-driven patient acuity/complexity scoring system for pilot and integration with the institution’s QuadraMed patient classification system. The postdelivery length of stay group validated activities that occur between the delivery and the transfer to the postpartum unit for vaginal and cesarean births and proposed improvements. The induction group collected and analyzed data to describe utilization patterns and proposed redistribution of work and resources. The communication and collaboration group conducted extensive

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Bonnell W. Glass, RN, MN, The Center for Perinatal Practice, Natick, MA Barbara C. Wallace, RNC, MSN, MPH, EdD, Brigham and Women’s Hospital, Boston, MA Keywords practice workload productivity innovation empowerment outcomes

Professional Issues Poster Presentation

http://jognn.awhonn.org

Garrison, C. S., Haynes, M. J. and Newhouse, L.

I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

on-unit analysis of communication behaviors and designed an intervention for daily interdisciplinary rounds. The environment of care group identified labor and delivery room readiness as a problem, collected data, and worked with support departments to construct a reliable system for equipment and supplies. The professional growth and development group assessed staff needs and designed an education, mentoring, and accountability program using expertise and resources from within the staff. The work of the documentation group and outcomes group is ongoing. The documentation group is evaluating elements of nursing documentation that influence perinatal outcomes, including those in the new electronic medical record. The outcomes group is identifying evaluation methods

for perinatal outcomes, patient and staff satisfaction, regulatory compliance, and financial indicators. Implications for Nursing Practice Best practice innovations come from the clinicians. Staff performance improvement groups will continue to monitor the results of their implementations and look for opportunities for other practice improvements. We will move toward identifying strategies that strengthen interdisciplinary, collegial, and collaborative practice. The work of the eight performance improvement groups has built a foundation for continuing development of clinician-driven practice improvements to ensure successful outcomes for mother, infant, and family.

An Unusual Journey for Patient Safety: The Partnership between a Level I Community Hospital and a Level III Birthing Center Connie S. Garrison, MSN, Purpose for the Program RNC-LRN, NE-BC, Riverside small community hospital located in the Methodist Hospital, Columbus, Midwest identified several opportunities OH

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Mary J. Haynes, RN, Grady Memorial Hospital, Delaware, OH Linda Newhouse, MSN, RNC, WHNP, Riverside Methodist Hospital, Columbus, OH Keywords collaboration standardization outcomes

Professional Issues Poster Presentation

to improve patient outcomes in the obstetric population. Because it was a small community level I facility that delivered approximately 400 infants per year, the hospital had limited resources.

Proposed Change One advantage to being part of a health care system is the ability to utilize additional resources. The level I facility worked in collaboration with the health care system’s level III maternity center to standardize nursing practice and improve patient outcomes. This collaborative effort brought the experience and resources of the level III maternity center’s program into the level I community hospital. Implementation, Outcomes, and Evaluation The first step in merging these programs was to standardize nursing education and validate nurse competency. Policies and procedures were reviewed to ensure adherence to those used at the level III facility and also with maternity licensure requirements. Remote monitoring was put in place to enhance peer review and peer coaching opportunities. Chain of command policies were reviewed. Nursing staff from the level III facility were assigned to be present during the night shift at the

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level I facility with the purpose of mentoring and teaching. Staff nurses at the level I facility rotate on a quarterly basis to the level III facility to gain exposure to a variety of patient conditions and treatments. An obstetric multidisciplinary committee consisting of nurses and physicians from both facilities meets monthly. All high-risk patients seen by physicians or at the clinic within the level I facility are reviewed monthly by the level III maternal–fetal medicine physicians. Nurses successfully validated their nursing skills and critical thinking ability. There is an increase in the number of nurses holding certification and memberships in professional nursing organizations. The assessment of the highrisk patient improved and referrals to the level III facility increased. Physician–nurse communication and the communication with other disciplines improved. There is enhanced utilization of medical peer review and the Press Ganey scores are higher. There have been no sentinel events or serious safety events since the collaboration was initiated. Implications for Nursing Practice Utilization of level III maternity center resources can help small community hospitals standardize practice and, thereby, improve patient safety and outcomes. Collaborative efforts between hospitals in a system can provide valuable learning opportunities for all involved.

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Partnering: A Metro Health Department and Community Hospital Collaboration. Implementation of an Outpatient Lactation Clinic Purpose for the Program his project focused on an innovative collaboration between a metro health department and a community hospital to create a free outpatient lactation clinic for breastfeeding support. The Louisville Metro Health Department was awarded a 2-year, $7.9 million “Communities Putting Prevention to Work” grant from the U.S. Department of Health and Human Services. The project focused on policy, environmental, and systems changes to address risk factors for obesity by improving access to healthy foods and increasing access to physical activity. Breastfeeding is the first step in accessing healthy nutrition to prevent obesity and other chronic diseases. The grant provided salary dollars for the international board certified lactation consultants staff and inkind donations of space, supplies, office materials, and staff benefits were provided by the hospital. Baptist Hospital East was the first hospital in the area to develop the clinic and will continue the service after the grant because of the need and satisfaction expressed by the participants.

period. Prenatal breastfeeding education is currently provided, and breastfeeding inpatients receive support from five international board certified lactation consultants 7 days/week. The addition of an outpatient clinic allows an additional layer of patient support. The participants were breastfeeding women who resided in the metro area and gave birth in any of the metro area hospitals. The program was implemented on the following time line:

Proposed Change To enhance infant nutrition goals by increasing breastfeeding support and continuation to 6 months.

Midway through the grant, 258 women had received lactation support in the clinic. The majority were self-referred and reported high patient satisfaction for the service received. Outcomes data at the end of the grant period will be used to determine the effect of the clinic on supporting breastfeeding. A sustainability plan has been developed to continue the service after grant funding because of its value-added benefit to the patients.

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Implementation, Outcomes, and Evaluation The setting was the Baptist Hospital East, a 511bed community hospital, which had 3,026 deliveries and was responsible for 22.9% of all deliveries in the Louisville area between January 2010 and December 2010. Our goal is to promote, support, and protect the breastfeeding relationship across the continuum of pregnancy and the postpartum

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Karen Lamberton, MSN, FNP, APRN, Baptist Hospital East, Louisville, KY Wendy Carlin, MS, RDA, Louisville Metro Department of Public Health and Wellness, Louisville, KY Joan Wempe, RN, BSN, Baptist Hospital East, Louisville, KY

Barbara Ruedel, RN, IBCLC, July to October 2010: Explored space needs, Louisville Metro Department of Public Health and Wellness, full-time equivalent to meet staffing, and in- Louisville, KY

kind donations. October 2010: Location set; office retrofitted; charge structure to bill grant developed; and assessment/documentation forms created. November 2010: Opened for business on November 26, 2010; marketing to obstetric and pediatric offices. December 2010 to January 2011: Created promotional materials; publicized to service area residents. January 2011 to March 2012: Developed sustainability plan.

Keywords breastfeeding obesity prevention lactation support

Professional Issues Poster Presentation

Implications for Nursing Practice Partnering between community agencies can lead to mutually beneficial outcomes.

Prenatal Core Measures: Igniting Development of an Innovative Tool Using the Electronic Medical Record Purpose for the Program n 2010, the Joint Commission developed perinatal core measures. One measure is exclusive breast milk feeding. No national benchmarking systems existed for gathering or comparing institutional data. The purpose of the project was to demonstrate how the electric medical record

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could be used for data collection, quality improve- Lisa Ann Schloemer, BSN, ment, and benchmarking this nurse-sensitive in- C-EFM, The Christ Hospital, dicator. Although other initiatives were used to Cincinnati, OH meet the core measure, the focus of this project was the electronic medical record and data collection.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

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Holden, A. C. and Wood, M. F. R.

Proceedings of the 2012 AWHONN Convention

feeding measure was proposed. Instead of using a manual process to collect data for this new core measure, we saw the benefit of using the electronic medical record to automate this process. A multidisciplinary group with information technology (IT) staff, nurse managers, and staff from all areas of the family care unit formed and met routinely to design electronic medical record documentation and reports that supports data extraction needed for monitoring perinatal core measures.

fied gaps. Staff was educated on the core measure and the need for precise documentation in the electronic medical record for accurate data collection. Reports were created and validated in the test environment of the electronic medical record. Gaps in collection were noted and corrected. Validation steps were completed to ensure the quality of the tools. Reports were run monthly and the results were evaluated to improve adherence to the evidence-based Joint Commission core measure. Over the course of 6 months, we were able to complete this project. Now confident in our reports, we can focus on interventions to increase our exclusive breast milk feeding rate to reach our initiation rate of 83%.

Implementation, Outcomes, and Evaluation All electronic medical record documentation was reviewed for labor and delivery, postanesthesia care unit, and postpartum care to determine existing data points in the mother’s and the infant’s record. Data points needed for the reports were identified, such as needing a “time stamp” within the maternal chart for feeding initiation. Document flow sheet rows were created in the labor and delivery postanesthesia care unit record to fill identi-

Implications for Nursing Practice Nurses collaborating with information technology staff can develop innovative tools to easily extract data for determining outcomes. This can ignite the movement for benchmarking within an institution and perhaps regionally. Currently, perinatal core measures are not reported through the National Database of Nursing Quality Indicators. Perhaps this could be the first step toward national benchmarks for the perinatal community.

Proposed Change Angela Renee’ Campbell, BSN, This 550-bed tertiary care teaching hospital with RNC-MN, The Christ Hospital, 3,100 births per year had adopted the electronic Cincinnati, OH medical record when the exclusive breast milk Keywords electronic medical record data collection

Professional Issues Poster Presentation

Nursing, Medicine, and Law: Working Together with Renewed Commitment to Improve the Quality of Perinatal Care Purpose for the Program ince the 1990s there have been increasing numbers of lawsuits involving perinatal Margaret Frances Rhone Wood, nurses. As members of the perinatal care team, RNC, BScN, MScN, PhD, nurses need to know the legal basis of the care Margaret Wood and Associates, they provide within this team. The purpose of this Inc., Mississauga, ON session is to provide nurses with an understanding of the strengths and vulnerabilities of professional Keywords nursing duty practice and issues in providing quality care. This care standards information should be shared with nurses so that malpractice they can be more aware of the way nursing pracjudicial system tice is viewed and reviewed in courts. Ann C. Holden, RN, BScN, MSc, PNC, St. Joseph’s Health Centre, Toronto, ON

Professional Issues Poster Presentation

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Proposed Change Medical malpractice trial outcomes are increasingly influencing nurses and nursing practice. We will provide information about the integral roles of nursing, medicine, and law, and how these professions work together on issues of quality care. We will rely on cases that have gone through the judicial system to support the principle points. We will

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provide examples of key elements discussed and decided in the courts (e.g., duty, care, standards, proximate cause, and proof). We will demonstrate how the legal system, which is the arbiter of standards, has influenced nursing and medical care of women and infants. Implementation, Outcomes, and Evaluation Nurses will apply the information learned in this session to their practice by understanding the dual principles of autonomy and teamwork. We will create an awareness of the strengths and vulnerabilities inherent in professional perinatal practice. An awareness of duty, care, and standards, as taken from the trial decisions, will inform nursing practice. Implications for Nursing Practice Upon returning to their work settings, nurses will be knowledgeable to comment on the trial and appeals, and consider applications to their nursing practice.

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Implementing a Standard Electronic Perinatal Health Record in a Multihospital System: A Challenge As Great As Turning the Titanic Purpose for the Program t the first Perinatal Work-Group meeting in 2002, physicians of a large, multihospital system established a perinatal electronic health record as a top priority. Soon after, the electronic health record became not only a company priority but also a national priority. The federal government established electronic health record standards and began incentivizing electronic health record development. Concurrently, quality measure groups and payers began demanding accurate, timely data that could be produced only with an electronic health record. This environment provided the opportunity for perinatal leaders of the system’s 111 perinatal services around the country to begin the journey to an enterprise electronic health record.

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Proposed Change Perinatal nursing representatives began collaboration to establish documentation templates with standard data elements and reports. Expectations for documentation templates included the utilization of evidence when evidence was available; compliance with national regulatory standards and professional organization guidelines; and support for enterprise initiatives. Implementation of the documentation database at the first site highlighted the need for consistent education for end users, standard policies and procedures, and an established leadership structure to maintain the standard approach with future deployments. The second implementation demonstrated to information system and clinical leaders that a standard network and interfaces were imperative to reach the goal of an enterprise perinatal electronic health record. Contracts for volume purchases, utiliza-

tion of wide area networks, and consistent network architecture and interfaces decreased financial investment while enhancing efficiency of design and implementation of the standard perinatal electronic health record.

Donna R. Frye, RN, MN, HCA, Nashville, TN

Implementation, Outcomes, and Evaluation Currently, 25 perinatal services have implemented the standard electronic health record. Eighty-eight perinatal services have committed to the installation of the perinatal electronic health record by December, 2012. Preimplementation assessments were completed for designated sites and postimplementation surveys will occur 90 days after implementation. Standard reports are generated by the facilities. Facilities report improved documentation and clinician satisfaction approximately 90 days after implementation. Documentation screens, technology, and resources will continue to be refined as obstetric provider documentation templates are created and additional interfaces are built.

Keywords electronic health record perinatal data perinatal documentation change process perinatal quality perinatal technology

Gina Shay-Zapien, MSN, ARNP, RNC, CNS-BC, Menorah Medical Center, Overland Park, KS

Professional Issues Poster Presentation

Implications for Nursing Practice The successful deployment of a perinatal electronic health record includes administrative support, clinical leadership, intradepartmental collaboration, and clinician engagement. Well-designed tools, such as project management and transition plans, network architecture, policies and procedures, and educational resources are also critical to success. Perinatal electronic health record standardization will promote quality care, provide data on 220,000 births annually, and provide lessons learned for other enterprise hospitals as well as other hospitals and systems on their electronic health record journey.

Born Identity Purpose for the Program o improve the patient-identification process for neonates and to eliminate patientidentification errors, resulting in safe passage for the patient. The lack of a bar code on the infant armband makes it impossible to scan the patient prior to procedures. As a result, staff often will scan the chart, which may lead to patient-identification errors.

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Shelley Faber, BSN, RNC-NIC, Proposed Change To securely and safely place a bar code identifi- Baylor Healthcare System, Fort cation band on each infant so that it can be easily Worth, TX seen, scanned without disturbing the infant, and be consistently used to identify the infant. Considering skin integrity, infant size, access, environment, and ease of application we decided to place an adult band adjusted to fit our bar code on the monitor leads. Leads remain on the infant for the duration of the hospital stay.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

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Faber, S. and Wilkerson, K.

Proceedings of the 2012 AWHONN Convention

Kristi Wilkerson, BSN, RNC-NIC, Baylor Healthcare System, Fort Worth, TX Keywords identification NICU errors safety

Professional Issues Poster Presentation

Implementation, Outcomes, and Evaluation A trimmed identification band with the bar code is attached to the lead wires before the leads are placed on the infant. The band will stay between the infant and the cable juncture, which lies outside the infant nesting area. This allows the label to be scanned and the patient identification can be made without disturbing the infant. Prior to implementation, identification errors were erratic and often exceeded those of the hospital as a whole. Since implementing the new identification system in the neonatal intensive care unit, patientidentification errors for neonatal intensive care unit admissions were reduced to zero for a 4-month

period. During the following month, one error was discovered as a result of failure to follow the new identification procedure. Retraining and reinforcement continues. Implications for Nursing Practice Nurses were given additional educational information regarding the importance of scanning the infant rather than the chart. Nurses and respiratory therapists also were educated regarding the importance of labeling all specimens at the bedside, and respiratory therapists were instructed to refuse specimens, specifically blood gases, that were not properly labeled.

Transformational Journey of a Care Delivery Model: Implementation of Evidence-Based Practice to Increase Breastfeeding Exclusivity Purpose for the Program ransforming the care delivery model for mothers and infants began in 2010 with an invitation to participate in the New York State’s Stephanie Hisgen, MPH, RN, New York State Department of Breastfeeding Quality Improvement in Hospitals Health, Albany, NY Learning Collaborative. Twelve hospitals were selected to participate with the following objectives: Amy McGuire, MS, RN, Winthrop University Hospital, increase exclusive breastfeeding; improve hospiMineola, NY tal breastfeeding policies, practices, and systems that are consistent with New York State’s hosMary Lynn Brassil, MS, RN, pital regulations, laws, and recommended best CES, Winthrop University practices; increase staff skills and knowledge of Hospital, Mineola, NY breastfeeding and lactation support through eduCathyjo Catalano, MS, RN, RNC-OB, Winthrop University cation; empower, educate, and support new mothers to successfully breastfeed; and change the Hospital, Mineola, NY culture and social norm relative to breastfeeding. Eileen Magri, MSN, RN, NE-BC, Winthrop University Hospital, Mineola, NY

Mary Cleary, BSN, RN, NE-BC, Winthrop University Hospital, Mineola, NY

Karen Hylton-McGuire, RNC, NIC, MS, IBCLC, RLC, Winthrop University Hospital, Mineola, NY Keywords exclusive breastfeeding transforming care process improvement

Professional Issues Poster Presentation

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Proposed Change To fully transform maternity practices within a New York State’s regional perinatal center by changing the care delivery model to adhere to and support the recommendations for exclusive breastfeeding outlined by the World Health Organization. Implementation, Outcomes, and Evaluation The process of transforming the care delivery model to one that supports exclusive breastfeeding began in June 2010. The hospital formed a comprehensive team to evaluate current processes and potential barriers that inhibit exclusive breastfeeding. Team members were selected based on knowledge of the hospital systems and commitment to change. Priority was given to changes that could be accomplished quickly

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and sustained. The initial change focused on placing all newborns skin-to-skin in the delivery room and successfully latching and breastfeeding within 1 hour for vaginal and 2 hours for cesarean births. To increase rooming-in on the postpartum unit, newborns were brought back to the nursery only upon request by the mother. Physician order sets were revised to distinguish orders for formula fed and breastfed infants to discourage supplementation of breastfed infants. The most dramatic change in practice after implementing the care delivery model involved closing the transitional nursery and providing transitional care in the labor and delivery unit by the nursery registered nurses. This change eliminated the separation of mother and infant. The model for improvement utilized the Plan-Do-Study-Act cycles to test each change in the work environment and revise accordingly. The active participation of the direct care nursing staff, who evaluated their practice with each change, and their feedback were critical to the success of this program. Since inception, exclusive breastfeeding increased from 6% to 34%, rooming-in increased from 0% to 50%, and skin-to-skin increased from 50% to 80%. Transition care is relocated to the delivery room and the newborn nursery is utilized for respite care. Implications for Nursing Practice Change the care delivery model for mothers and infants to support exclusive breastfeeding as recommended by the World Health Organization through education, training, and process improvement.

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Conception to Birth: Implementation of an Interprofessional Obstetric/Neonatal Intensive Care Unit Team Simulation Program Purpose for the Program he integration of simulation into health care education has been shown to enhance clinical performance and promote teamwork. This program was designed to bring together obstetric and neonatal staff to provide an opportunity to practice the management of high-risk, lowoccurrence events in a low-stress environment without risk of patient harm.

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Proposed Change In emergency, clinical situations staff members from diverse backgrounds are expected to function as a cohesive team but are rarely provided the opportunity to learn and practice together outside the clinical area. A primary goal of this program was to transition this silo education to an interprofessional approach. The planning team envisioned individual experts from different professions and departments practicing clinical skills, teamwork roles, and behaviors as a team. Implementation, Outcomes, and Evaluation An interprofessional, interdepartmental planning team assembled to review the simulation literature, identify target participants, establish program goals and educational methodology, develop clinical scenarios, identify and obtain supplies and equipment, and test the process before program implementation. Cognitive, technical, and behavioral objectives were included. Simulations were videotaped to facilitate team debriefing, identified as a critical component of the learning process. To maximize participant comfort and learning, the

planning team started each simulation recognizing the expertise of all participants, reinforcing the nonevaluative aspect of the sessions and emphasizing the opportunity to learn together in a safe environment. Initially, medical and nursing administrative support for the simulation program ensured interprofessional staff attendance. Participation in a simulation cemented staff’s ongoing enthusiasm and desire to participate. Participants completed evaluations and this evaluative feedback was reviewed with recommendations being incorporated into subsequent sessions. As the simulation planning team worked to increase the complexity and realism of clinical scenarios, staff voiced increased satisfaction in their evaluations. Scenarios included precipitous birth, postpartum hemorrhage, maternal arrest, perimortem cesarean section, and term and preterm resuscitation. Implications for Nursing Practice Interprofessional simulation provides an opportunity for nursing to take a leadership role in facilitating collegial relationships with the planning team as well as the teams participating in the simulations. Lessons learned in simulation regarding clinical management and team communication are used by participants in subsequent patient care situations. Simulation also provides an excellent forum for research as one explores creative, effective approaches to learning in a simulated environment and most importantly the translation of this learning to the patient care environment and its impact on decreasing patient harm.

Susan E. Brown Will, MS, RNC, The Johns Hopkins Hospital, Baltimore, MD Christopher Ennen, MD, LCDR, MC, USN, Naval Medical Center Portsmouth, Portsmouth, VA Janine Bullard, MD, The Johns Hopkins Hospital, Baltimore, MD Janis Ferrell, CNA, The Johns Hopkins Hospital, Baltimore, MD Melissa Eichelberger, MS, RNC, The Johns Hopkins Bayview Medical Center, Baltimore, MD Barbara Lamartina, RNC, BSN, The Johns Hopkins Hospital, Baltimore, MD Karen Frank, MS, RNC, The Johns Hopkins Hospital, Baltimore, MD Keywords simulation interprofessional neonatal obstetrics

Professional Issues Poster Presentation

STORK Day Delivers: Creation of an Educational Experience Purpose for the Program ttending a national conference is a stimulating growth experience, and mentorship thrives, but attendance is not feasible for all nurses. Sharing knowledge and expertise with local hospital staff is needed once the national conference has ended. A vision was inspired by two labor and delivery nurses after attending the Association of Women’s Health, Obstetric and Neonatal Nurses’ convention in Las Vegas, where numerous coworkers presented case

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studies and posters. The idea to allow these same Cheryl Swift, BS, RNC, MSN, coworkers to disseminate their information in a re- Christiana Care Health System, laxed, informal, and social environment evolved Newark, DE into the first annual Sharing Topic of Research and Knowledge (STORK) day. This was an educational day centered on sharing topics of research and knowledge through oral presentations and a poster fair with an opportunity to receive continuing education credit. The development of this day was multifaceted. Initially, the basis was to honor accomplished coworkers by

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

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I N N O VAT I V E P R O G R A M S

Swift, C. and Swisher, J.

Proceedings of the 2012 AWHONN Convention

Joyce Swisher, RN, Christiana Care Health Services, West Grove, PA Keywords growth mentorship professional development vision accomplishment

Professional Issues Poster Presentation

providing a venue to repeat their presentations locally and for others to showcase their posters. This was also an opportunity for those with family, financial, or travel restrictions to attend an affordable, quality educational program. The day was designed to feature speakers from a variety of our maternal–child departments, demonstrating the interdependence and communication relationships necessary to provide optimal patient care. Moderators for each speaker were solicited from the list of registrants, which created an additional opportunity to engage nursing peers. Proposed Change To create dynamic alliances through mentoring relationships, STORK day offered an avenue for mentoring interaction between nurses through invitations sent to institutions in a tri-state area. Nursing students from local colleges and universities also were invited, potentially introducing them to their first professional conferences. This day was a commitment to the development and empowerment of others, young and old, as well as the promotion of the future of our profession.

Implementation, Outcomes, and Evaluation Professional development includes increasing knowledge regarding medical equipment and supplies or advancing an education. Vendors from maternal–child health-related products and universities with hospital-affiliated programs were invited to participate. The vendor room successfully provided information, demonstration, and sample products to all attendees. Community participation was the final component of the educational day. Door prize donations were requested from numerous local and national businesses. The winning numbers were announced between each presentation, which added excitement and pleasure to a day of intense topics. Implications for Nursing Practice STORK day proved to be an effective opportunity for professional development and distribution of nursing practice innovation. Participation created a sense of accomplishment and pride and ignited a passion and renewed commitment to professional excellence in nursing.

The Role of the Perinatal-Neonatal Nurse Navigator in a Tertiary Care Center Debbie L. Rice, RN, BSN, Purpose for the Program University of Oklahoma Health oordination of care for high-risk obstetric paSciences Center, Oklahoma tients and their infants is vital to promoting City, OK

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Keywords coordination or care promoting optimal outcomes nurse navigator

Professional Issues Poster Presentation

optimal neonatal outcomes. Under the direction of perinatologists and neonatologists, the position of the perinatal–neonatal nurse navigator was created. The purpose of this position is to provide coordination of care to high-risk obstetric patients whose infants have been diagnosed with a fetal anomaly or lethal diagnosis.

Proposed Change A perinatal–neonatal nurse navigator is a consistent contact person for the patient. By meeting the patient in clinic during scheduled appointments, the patient has a support resource at the facility. Coordination of care with the physicians involved in the care of the mother and the infant after birth is also a priority for the nurse navigator. A perinatal case list is utilized to maintain a record of the patient’s plan of care. Implementation, Outcomes, and Evaluation Names of the high-risk obstetric patients are gathered after their ultrasounds indicate a fetal

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anomaly. The initial meeting to introduce the patient to the nurse navigator and explain the nurse’s role occurs during the next scheduled appointment. Working under the direction of the perinatologists, prenatal pediatric specialty consults are arranged. Tours of the facility, including the neonatal intensive care unit, also are included. Referrals to community resources are provided as identified. The care provided by the nurse navigator is tailored to each patient. A monthly multiprofessional interdisciplinary team meeting has been developed to provide a forum for health professionals to come together to review complex cases and to coordinate plan of care. The evaluation of the nurse navigator role is ongoing and ever changing to meet the needs of the patients. Implications for Nursing Practice Nursing leadership participates in the monthly interdisciplinary team meeting. This exchange of information is vital to promote communication among team members and coordination of patient care.

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Breastfeeding and the Baby Friendly Initiative: An Evidence-Based Physician Education Program Purpose for the Program reastfeeding is well established in the literature as the best method of infant feeding. Although physicians agree breastfeeding is best for the infant, inadequate training or fear of inducing guilt among mothers makes some physicians hesitant to promote it. Research indicates that if breastfeeding women are supported by their health care professionals, breastfeeding rates increase. Physician support is believed to be strengthened by increasing breastfeeding knowledge of physicians who are involved with women who intend to breastfeed or are breastfeeding. The purpose of this project is to design an evidence-based physician education program that supports the BabyFriendly Hospital Initiative and promotion of the benefits of breastfeeding to obstetricians and pediatricians.

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Proposed Change The synthesized evidence was used to develop a comprehensive, evidence-based, physicianfocused, breastfeeding education program. The education program was comprised of two parts: a 30-minute lunch and learn presentation and an interactive online learning module. During the lunch and learn session, an overview of the BabyFriendly Hospital Initiative, breastfeeding benefits and management, and physician’s role in supporting the breastfeeding woman were reviewed.

The interactive online learning module provided case scenarios physicians may encounter when working with breastfeeding women. An education resource manual was developed to supplement breastfeeding knowledge and identify and promote community resources to support pregnant and breastfeeding women. Implementation, Outcomes, and Evaluation This program was offered to 60 physicians who work with expectant and breastfeeding women over a 4-month period at a hospital in south Orange County, California. The hospitals/maternity centers who partner with these physicians can anticipate improved health outcomes for mothers and infants, increased patient satisfaction, and meet Joint Commission maternity care standards for exclusive breast milk feeding. After completion of this education program, physicians should utilize their enhanced knowledge, skills, and resources and become a Baby-Friendly office. Further research is needed to determine which physician education techniques directly correlate with increased breastfeeding rates.

Anne M. Faust, RN, MSN-L, IBCLC, LCCE, Mission Hospital, Mission Viejo, CA Keywords breastfeeding physician knowledge Baby-Friendly

Professional Issues Poster Presentation

Implications for Nursing Practice Physicians will have the opportunity to provide competent, hands-on family-centered care through utilization of their increased knowledge and attitudes regarding breastfeeding.

LIFTS: Lowering Injuries for Transfer Safety Purpose for the Program ore than 10% of nurses have had injuries that have allowed them to file workmen’s compensation claims nationally. Ceiling mounted lifts are proven to reduce staff injuries and improve patient safety. Our hospital supports the use of ceiling mounted lifts to prevent injury in inpatient and outpatient settings. To renew our commitment to both patient and staff safety, our labor and delivery unit installed ceiling mounted lifts in every labor room and obstetric operating room. Laboring patients are immobilized with regional anesthesia requiring nurses to assist with all activities. These activities include turning and repositioning, assisting with elimination, and holding extremities during the second stage of labor or in medical emergencies. The increasing population of patients with a prepregnancy body mass index greater than 30 adds to the nurse’s physical stress. Standards of

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care requires that one staff member be present for each 35 pounds lifted. Staffing limitations make it challenging to follow this practice and increases the risk for patient and/or nursing injuries. These physical demands were recognized and ceiling mounted lifts were installed to assist the nurse with patient care as well as reduce lost time injury.

Gina M. Scott, BSN, RNC-OB, Christiana Care, Hockessin, DE Donna Norris-Grant, BSN, RNC, Christiana Care Health System, Bear, DE

Keywords CML safety Proposed Change To provide in-service education by our patient en- lost time injury

vironment equipment posture safety department in collaboration with the staff development specialists on ceiling mounted lifts function and usage. Implementation, Outcomes, and Evaluation This presentation is an educational learning tool and will include pictures on how to demonstrate the various slings utilized to assist with position changes and for transfers to the operating room

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

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Barrett, L. W. and Smoak, J. F.

Proceedings of the 2012 AWHONN Convention

during emergencies. Our plan to maximize the use of these slings in each area is to place one on every bed when the room is set up for admission. Full body slings used with a ceiling lift have a capacity of 1,200 lbs. Chair slings are utilized during the second stage of labor to provide an alternate pushing position. Limb slings are used to hold lower extremities while patients are pushing, or to hold the pannus back for fetal monitoring on

bariatric patients. Statistics will support the use of ceiling mounted lifts to decrease lost time injury and assist the nurse in safely caring for patients. Implications for Nursing Practice With use of these lifts patient comfort is addressed, nurses are given a sense of security knowing they are in a safer environment, and patients are provided with the best possible care.

Postpartum Hemorrhage: A Multifaceted Approach for Interdisciplinary Training Laura W. Barrett, BSN, MN, Greenville Hospital System, Taylors, SC Jennifer Foster Smoak, BSN, RN, Greenville Hospital System, Anderson, SC Keywords postpartum hemorrhage multifaceted approach interdisciplinary education and training patient safety high-fidelity simulation

Professional Issues Poster Presentation

Purpose for the Program Postpartum hemorrhage is an infrequent but potentially life-threatening event that may not be recognized until the mother’s condition is critical. Early recognition, prompt treatment, and effective teamwork are the critical skills necessary to minimize maternal mortality and morbidity. The Joint Commission recommends the use of interdisciplinary simulation drills to train staff, improve teamwork, refine protocols, and identify systems problems.

mated blood loss exercise, a cognitive quiz, and a postactivity survey. The online self-study module combined core knowledge and current evidence-based practice with standardized system processes. The program utilized the following mnemonic device for ABCD postpartum hemorrhage management: A: assess, alert, and assemble; B: breathing; C: circulation, control bleeding, and administer uterotonics; and D: determine the cause of bleeding and document effectively.

Proposed Change This project developed and implemented an interdisciplinary postpartum hemorrhage response initiative and a multifaceted training program to improve patient safety and outcome.

Simulation training focused on the demonstration of appropriate clinical management as well as the utilization of effective teamwork and communication skills. Video debriefing allowed staff to recognize areas of success and areas of deficiency. Key successes among team members were improved recognition and early treatment of postpartum hemorrhage, enhanced coordination of care, and more timely administration of uterotonics. Over time, these successes are expected to lead to an improvement in overall patient outcome.

Implementation, Outcomes, and Evaluation An interdisciplinary team of nurses, physicians, educators, pharmacists, and information technologists collaborated to design strategies that improve the coordination of postpartum hemorrhage response within our institution. The postpartum hemorrhage response initiative project standardized staff training, management protocols, order sets, and emergency response algorithms. In addition, the team developed a standardized Postpartum Hemorrhage Supply Bag and Omnicell Drug kit. Interdisciplinary development of the project created both nurse and physician buy-in. All obstetric nurses and physicians participated in the training, which included an online self-study module, an in situ simulation drill with video debriefing, an esti-

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Implications for Nursing Practice The multifaceted approach for interdisciplinary training increased staff knowledge and confidence related to the recognition and response to postpartum hemorrhage. Simulation training provided a forum for staff to integrate multiprofessional knowledge, refine skills, and perfect team member roles in responding to this low-volume, high-risk obstetric emergency.

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The Impact of Breastfeeding Rates While Implementing an All Registered Nurse Certified Lactation Counselor Staff Purpose for the Program o demonstrate how a small rural hospital implemented the goal to obtain an all registered nurse certified lactation counselor staff to improve breastfeeding success rates.

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Proposed Change To require all maternal and child health registered nurses to receive certified lactation counselor training within 1 year of hire. After the implementation, the breastfeeding rate and customer satisfaction rate will improve and be maintained and the best practice standards will be embraced by all health care personnel. Implementation, Outcomes, and Evaluation The outcomes are the following: 2008 baseline = 18 full-time staff with three registered nurse certified lactation counselors. Hired one registered nurse who was an international board certified lactation consultant (22%). 2008 to 2009: The unit goal was to send at least 1 to 2 registered nurses to certified lactation counselor training every year until 100% are certified. New hires would obtain certified lactation counselor training within one year of hire.

In 2010, the following events occurred:

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MaryAnne Goodwin, RN, Franklin Memorial Hospital, Thirteen (13) staff registered nurses out of 18 Farmington, ME

certified lactation counselors (72%). Formed a professional breastfeeding coun- Keywords breastfeeding cil team and developed an evidenced-based certified lactation counselor standard breastfeeding policy. The policy (CLC) was accepted by the Maternal Child Service Committee in 2009. Reached the 2010 Healthy America Goal of Professional Issues a 75% breastfeeding initiation rate. Franklin Memorial Hospital was rated sixth in the State Poster Presentation of Maine out of 33 hospitals that deliver infants with a 75% breastfeeding initiation rate. The 2010 Centers for Disease Control and Prevention National Survey Maternity Practices and Infant Nutrition and Care Quality Practice Score was 94% as compared with 91% for the United States, 72% for Maine, and 94% for facilities of similar size.

In 2011, we achieved our unit goal by having 100% of staff registered nurses obtain certified lactation counselor status. Implications for Nursing Practice Advanced knowledge and practice in breastfeeding education will increase breastfeeding rates and improve customer satisfaction.

CETT: Critical Event Team Training, the Journey to Increase Teamwork and Culture of Safety Purpose for the Program ritical event team training is significant to an obstetric unit. Research indicates that teamwork and perinatal safety during critical events is enhanced when multidisciplinary team training programs are implemented. The Joint Commission recommends that perinatal units implement team training and mock drills for critical obstetric events. The process for implementing a critical event team training program is presented.

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Proposed Change The goal was to improve perinatal safety and teamwork during critical events through implementing a critical event team training program.

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Implementation, Outcomes, and Evaluation The need to improve teamwork and perinatal safety during critical events was identified. A core team of perinatal nurses was formed along with the unit educator and director to discuss this issue. The team was introduced to simulation training. A plan to implement critical event team training was eventually developed. This core team of nurses served as the key to staff buy-in. The critical event team training program divides multidisciplinary staff from the perinatal unit into four teams. These teams participate in in situ, team training simulation scenarios. These simulations are videotaped and then played back during a formal debriefing session. Education is provided on skills,

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Candice Cottrell, RNC-OB, Adventist Health Central Valley Network, Hanford, CA Keywords multidisciplinary team critical events team training perinatal safety performance improvement

Professional Issues Poster Presentation

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Newhouse, L., Yeager, R. and Englehart, M.

I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

equipment, and processes. A critique and action plan with recommendations is developed after the training. Outcomes have been positive. Challenges encountered involved staff participation and a need for a more formalized communication teaching format. The culture of safety survey was compared over a 2-year period, during which critical event team training was implemented, and scores dramatically increased from the baseline. Response times from incision to decision improved. The use of quantitative measuring tools and postpartum hemorrhage kits has now become the standard in postpartum hemorrhage events. Praise by the staff participants has greatly increased participation since initial implementation of the program.

The staff also has demonstrated taking on a more serious attitude and acceptance to simulation participation since it began. Staff surveys are favorable and reflect a sense of increased teamwork and skill competency. Multidisciplinary participation during critical event team training also has increased. Implications for Nursing Practice The program has received the attention of administrators, educators, and the safety department in the network. A grant has been received to enhance and continue the program. Approval to incorporate TeamSTEPPS, an evidence-based framework to optimize teamwork competency, has been received and will be added to the critical event team training program.

Obstetric Emergency In Situ Simulation: Practice Leads to Change Linda Newhouse, MSN, RNC, WHNP, Riverside Methodist Hospital, Columbus, OH Robin Yeager, BSN, RNC, Riverside Methodist Hospital, Columbus, OH Mary Englehart, RNC, Riverside Methodist Hospital, Columbus, OH Keywords emergency drills in situ simulation standardized patient practice change

Professional Issues Poster Presentation

Purpose for the Program The Joint Commission and the American College of Obstetricians and Gynecologists recommend using emergency drills/simulation to improve teamwork and communication. Proposed Change High-fidelity simulation can be expensive. Because most obstetric emergencies involve moving the patient, our multidisciplinary team determined the best method of implementing emergency drills was to use in situ simulation using a standardized patient. Implementation, Outcomes, and Evaluation Participation in the monthly drills is mandatory for all labor and delivery staff and obstetric residents. Attendance is optional for private physicians. Before the drill begins everyone is given a role card and there is a short presentation on safety, teamwork, and communication. The drill is videotaped followed by a debriefing session. As a result of doing in situ drills, many opportunities to implement change were discovered. The primary nurse wears a red hat, which identifies her

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as the person to give the Situation-BackgroundAssessment-Recommendation. The role of the charge nurse and physician in emergency situations were delineated. Nurses have heightened awareness of how they can assist anesthesiologists. Nurses learned the importance of being able to work the operating room table. Oxygen masks are removed from the patient while she is being transported to the operating room. A nurse is designated to be a support person to the patient. Problems with our wireless communication system were identified and fixed and equipment was purchased. With more effective communication the noise level has decreased. Communication between disciplines has improved and physicians and nurses state they work more effectively as a team. Implications for Nursing Practice In situ simulation using a standardized patient can create learning opportunities that result in more effective communication, improved teamwork, and the ability to identify issues related to the physical environment.

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Eating Our Young Should Not Be Acceptable: Are You Laterally Violent? Purpose for the Program ateral violence has a long history among nurses, and the phrase, “Nurses eat their young” is a true statement and should no longer be taken lightly or as an excuse for demeaning behavior. Lateral violence affects job satisfaction and productivity, patient satisfaction and safety, turnover rate, and reimbursement. Lateral violence should be the antithesis of nursing.

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Proposed Change We are striving to create an environment that promotes each other and that holds everyone accountable for unacceptable behavior. The formation and implementation of an employee contract and a lateral violence policy are in the near future. Implementation, Outcomes, and Evaluation The process began by sending a short survey via e-mail to all staff members to test the base knowledge and perception concerning lateral violence. The results of the survey indicated a need for education and intervention. Following the education pieces, posters placed in our units, and a slide presentation, we resurveyed staff to check

the effectiveness of our interventions. The results were very positive and our project continues to grow. We are now in the process of implementing suggestions made by the staff concerning accountability, managerial support, and peer involvement. Shared governance is an integral part of the success of this project. We are sharing our presentation, implementation, and evaluation with other units and hospitals in the Baylor system to increase the number of nurses who can benefit. Implications for Nursing Practice Nursing is a career built on compassion, and the annihilation of lateral violence would affect nursing profoundly. Nursing is a profession built on mutual respect and teamwork with a common goal of the healing and safety of patients. Another significant advantage is financial benefit, such as the one realized by decreasing the turnover rate. Happier nurses equal happier patients and a safer environment for our patients and their families. We continue to think of new ideas that translate into a win-win situation for our patients, staff, and hospital.

Nora K. Robinson, RNC, BSN, Baylor Allsaints Medical Center, Andrews Women’s Hospital, Fort Worth, TX Glenda J. Patrick, RNC, BSN, Baylor Allsaints Medical Center, Andrews Women’s Hospital, Fort Worth, TX Keywords lateral violence horizontal violence bullying

Professional Issues Poster Presentation

Improving Care during a Postpartum Hemorrhage: A Patient Safety Initiative Purpose for the Program ccording to the American College of Obstetricians and Gynecologists (the College), 140,000 maternal deaths occur each year and approximately 25% of those deaths are due to postpartum hemorrhage. One of the Healthy People 2020 goals is to decrease maternal deaths from 13.3 deaths per 100,000 live births to 11.4 per 100,000 live births. The purpose of our project was to develop a method of obtaining necessary supplies for prompt treatment of a postpartum hemorrhage.

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Proposed Change Our plan was to develop a multidisciplinary team to discuss the best approach and supplies needed to promptly manage a postpartum hemorrhage. Our multidisciplinary team consisted of staff nurses, nurse educators, a nurse practitioner, ancillary staff, management, and resident physicians. Current literature and available products

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were reviewed by the team. The product chosen Ruth M. Labardee, MSN, RNC, to best meet our needs was a medical supply cart. CNL, The Ohio State University Medical Center, Columbus, OH

Implementation, Outcomes, and Evaluation Once a consensus of the team was reached regarding cart style and specific features required, the cart was purchased and assembled with the supplies as identified by the team. The cart was displayed on the postpartum unit for 2 weeks, allowing staff the opportunity to become familiar with the contents. Feedback from staff was encouraged. The team evaluated the feedback and changes to the cart were made. Data regarding the frequency of use of the hemorrhage cart, along with staff feedback are being collected and shared with the multidisciplinary team. Anecdotally, staff state response time to postpartum hemorrhage has decreased significantly. Instead of spending time gathering needed supplies, staff members are able to respond and assist in prompt patient treatment. Ongoing education needs regarding

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Roberta Mitch, MS, RN, WHNP-BC, The Ohio State University Medical Center, Columbus, OH Keywords postpartum hemorrhage process improvement initiative patient safety

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Smith, B. and Smart, C. J.

Proceedings of the 2012 AWHONN Convention

cart contents, layout, and restocking procedures have been identified, and therefore, continual education occurs through one-on-one discussion and weekly newsletters. Implications for Nursing Practice Future emergency simulations on our unit will incorporate the use of the postpartum hemorrhage

cart. These simulations will not only allow staff to practice their skills in caring for a patient with a postpartum hemorrhage, but also will encourage staff to refamiliarize themselves with the cart contents. Our hope is that future sharing of our experiences with other maternity centers will foster collegiality and improve patient outcomes across the country.

More Than a Band-Aid: A Transdisciplinary Team Approach to Perinatal Loss Brenda Smith, BSN, RN, Mission Hospital System, Asheville, NC C. J. Smart, MSN, RNC, CPN, Mission Hospital System, Asheville, NC Keywords perinatal loss trans-disciplinary team nursing confidence grief

Professional Issues Poster Presentation

Purpose for the Program urses face many challenges in cases of pregnancy loss and must address the patient’s physical problems and her emotional and mental needs. Approximately 15% to 20% of all clinically identified pregnancies in the United States result in miscarriage. The physical and mental health concerns of families experiencing pregnancy loss include grieving, potential for depression, and the risk of experiencing feelings of loss with subsequent pregnancies. The purpose of this project was to establish a process for providing consistent, high-quality, hospital-wide care for patients and families experiencing a pregnancy loss.

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Proposed Change The first area of change was the formation of a multidisciplinary team consisting of social workers, physicians, nurses, office staff, chaplains, laboratory managers, and leaders from service areas that included the laboratory, operating room, emergency department, risk management, and women’s service line to institute process improvements. Through questionnaires and interviews, the team identified a need for education and support for the nurses who care for these patients. Implementation, Outcomes, and Evaluation The Resolve Through Sharing program was made available to assist staff to ensure their competence in providing the desired level of care. The program was offered to nurses throughout the hos-

pital system who encounter patients and families with pregnancy loss. A pretest and posttest were given to volunteer participants (N = 152) in the program to measure confidence levels using a developed Likert scale. Statistical analysis using a t-test paired sample correlation demonstrated significant differences in all items on the pretest and posttest nursing confidence measure (p < .0001). The Resolve Through Sharing educational session was shown to improve self-reported nursing confidence when caring for families who have experienced pregnancy loss. Implications for Nursing Practice The formation of a trans-disciplinary, system-wide team facilitates intervention strategies that address the complex issues surrounding perinatal loss and focuses on family outcomes. The implementation of educational offerings to support nursing staff when caring for families experiencing perinatal loss increases self-reported nursing confidence. Nursing care for patients and families experiencing pregnancy loss may have an effect on the future health of the family. This study supports the use of trans-disciplinary teams and evidence-based interventions, including educational programs, to develop nursing confidence in caring for families experiencing perinatal loss. Further intervention studies are needed on specific nursing interventions and behaviors that assist families from multiple cultures with physical and mental recovery after a perinatal loss.

Merging Opportunity and Creativity to Create a Novel Approach to Assigning Care of Postpartum Dyads Kimberly M. Price, RN, IBCLC, Grant Medical Center, Columbus, OH

Purpose for the Program ust as the former staffing guidelines of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) had been in exis-

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tence for several decades, our staffing methods of assigning postpartum staff were dated. Rising acuity and complexity of mother–infant dyads highlighted the necessity to better define the level

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of nursing care required. Our stagnant methods of assigning care providers based on room proximity, mode of infant birth, and length of stay had long since outlived their usefulness. Though commercial patient classification software exists, most programs are based on medical–surgical models that fail to adequately address sudden changes in census and acuity common to our maternity population. In addition, literature is scant on establishing infant acuity in a normal newborn setting. Assigning care for infants based on gestational age, neonatal abstinence, and feeding issues presents a formidable challenge. Proposed Change To address the difficulty of appropriate patient care assignments, separate acuity classification tools for mothers and infants were developed. Used in conjunction, these tools serve as guidelines in determining appropriate levels of care for both patients. Maternal acuity is based on method of birth, existing physical complications, and psychosocial barriers and concerns. Newborn acuity is based on congenital and birth complications, transitional instability, and feeding readiness and effectiveness. Both tools assist in aligning staffing patterns with the 2010 AWHONN guidelines of 1:3

ratio of nurse to mother–infant dyads. Appropriate levels of care as determined by the tools, provide a framework for assuring optimal staffing that meets the needs of staff and patients. Implementation, Outcomes, and Evaluation The tools were implemented in June 2011. Initial feedback has been very positive and staff indicated that the classification system has made assignments more manageable. Following the pilot period, the tools will be tweaked based on suggestions from nurses. With more than half of our staff certified as lactation counselors, our goal is to ensure that breastfeeding couplets receive this additional skilled support. Implementing use of the tools has not been without challenge. As staff adjust to appropriately assigning classification levels to mother and infant, patient acuity remains fluid, resulting in changes in level of care. Data collection is ongoing, with patient and staff satisfaction, breastfeeding support, and breastfeeding exclusivity at discharge, 3 months, and 6 months all being measured.

Mary Walters, MS, RN, Grant Medical Center, Columbus, OH Keywords patient classification acuity nursing workload

Professional Issues Poster Presentation

Implications for Nursing Practice Appropriate acuity-based assignments benefit both patients and nurses by promoting safe, effective care within the 2010 AWHONN guidelines.

Our Journey toward Exclusive Breast Milk Feeding: A System-Wide Approach for Lactation Services Purpose for the Program hen the Joint Commission identified “exclusive breast milk for all term infants” as a 2010 core measure, we were challenged to increase exclusive breast milk feeding rates in a multihospital system using the limited resources of four international board certified lactation consultants. A vast amount of evidence demonstrates that exclusive breastfeeding in the hospital setting leads to increased breastfeeding success rates in the later postpartum period. Research indicates that the knowledge and training of the bedside nurse is essential in supporting the breastfeeding dyad.

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Proposed Change The four international board certified lactation consultants collaborated to develop educational tools and training to assist the bedside nurses with providing evidenced-based breastfeeding assistance. Implementation, Outcomes, and Evaluation A baseline competency assessment was completed using an online training module for all bedside nurses in this large health care system.

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Twenty-five frontline nurses were then given the opportunity to attend an on-site certified lactation counselor course. Each certified lactation counselor was assigned a mentor international board certified lactation consultant for guidance and support. Once the certified lactation counselor demonstrated competency with the international board certified lactation consultant, the certified lactation counselor continued providing staff education and completed competency evaluations for each bedside nurse. Criteria were developed outlining the roles of the bedside nurse, the certified lactation counselor, and the international board certified lactation consultant. A triage tool also was developed to identify the breastfeeding dyads at risk and requiring further international board certified lactation consultant consultation. An extensive breastfeeding charting tool was created using an electronic documentation system to assist the bedside nurse with documenting breastfeeding intervention and requesting a formal lactation consult. This documentation system allowed for tracking of exclusive breastfeeding rates and nursing interventions to increase breastfeeding rates. A lactation chalkboard was developed that centralized this documentation to allow the inter-

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Chasta M. Hite, BSN, RNC, IBCLC, Mountain States Health Alliance, Johnson City, TN Lydia Ann Perry, BSN, RN, IBCLC, Mountain States Health Alliance, Johnson City, TN Mary Katherine Rice, BSN, RNC, Mountain States Health Alliance, Johnson City, TN Lisa K. Dolinger, RN, IBCLC, Mountain States Health Alliance, Abingdon, VA Cynthia R. Bradburn, RNC, IBCLC, Mountain States Health Alliance, Johnson City, TN Keywords exclusive breastfeeding breast milk hospital bedside nurse

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Proceedings of the 2012 AWHONN Convention

national board certified lactation consultants to identify patients requiring consults. Also, a central lactation phone line was created for nursing staff and physician office staff to request lactation consults from the international board certified lactation consultant team. One international board certified lactation consultant was selected for the role of clinical coordinator of lactation services, and this person coordinates phone requests and online requests from the electronic documentation system. Although, this project is still in the introduc-

tory phase, breast milk exclusivity rates for the six-hospital system have increased from 30.1% to 33.7% in 1 year. Implications for Nursing Practice This program identifies a multidisciplinary collaborative approach to increasing exclusive breast milk feeding rates. The end result is increasing patient and nurse satisfaction by allowing consistent evidenced-based information to be readily available to all frontline nursing staff and, thus, promoting exclusive breastfeeding.

Newborn Screening: A Lifetime of Impact from a Simple Heel Stick Lauren C. Flogel, BSN, RNC, Forsyth Medical Center, Winston Salem, NC Meagan P. Widener, BSN, RNC, Forsyth Medical Center, Winston Salem, NC Keywords newborn screening NBS PKU

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Purpose for the Program ewborn screening is a state-required test in which blood is collected and analyzed for specific genetic, metabolic, hormonal, and other disorders. If a disorder exists, life-saving treatments and interventions can be initiated to facilitate the most healthy growth and development possible for the affected infant. Because early treatment is vital, state guidelines mandate that hospitals send blood samples for analysis within 24 hours of collection, and results be reported to hospitals and health care providers within 7 days of the infant’s birth. Even though the nurses in our mother–baby unit were knowledgeable about guidelines regarding newborn screening and how to prepare specimens, errors in specimen preparation, collection, and submission still existed. These errors contributed to health care costs for parents and pediatricians and delayed the detection of potentially debilitating or fatal diseases. Earlier in 2011, our specimen rejection rate was 2.5%.

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Proposed Change To improve our ability to follow evidence-based guidelines regarding newborn screening, our nurses were required to complete the North Carolina State Laboratory of Public Health online training. Once the training was complete, nurses observed specimen collection under the supervision of a preceptor before they collected specimens independently. We selected a team of nurses to be-

come experts in newborn screening. These nurses were provided with additional education on common mistakes when performing collections. In addition, several new processes were implemented within the unit. A new practice was implemented for collecting blood by warming the infant’s heel to facilitate blood flow. A new method for collecting guardian demographic information was implemented to ensure notification in the event of a serious diagnosis. Finally, properly drying the filter paper was emphasized. Implementation, Outcomes, and Evaluation After implementing new measures, we conducted a 3-month trial of our new processes. Of the 1,297 samples sent to the North Carolina State Laboratory, only 3 were rejected (0.23%), a 10% improvement from our previous rate. In addition, no complaints have been filed from local pediatricians or our hospital’s risk management team. Implications for Nursing Practice Our new processes for collection and submission of newborn screening specimens have shown positive results. We continue to emphasize education and strict adherence to collection methods. Although our rejection rate is low, we realize that even one missed result may change a life. The results of a properly collected newborn screening can save an affected newborn from suffering lifelong disability, mental retardation, and sometimes death.

Postpartum Hemorrhage: Are You Prepared? Catherine M. Retskin, MSN, Purpose for the Program RNC-EFM, Mission Hospitals -

ostpartum hemorrhage has been identified as one of the leading risks of maternal mortality worldwide, with the rate in the United States increasing from 7.9% in 1996 to 13.3% in 2006.

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The purpose of the postpartum nurse response team project is to prevent poor outcomes resulting from this obstetric emergency. The project includes a postpartum hemorrhage response team with identified roles, a postpartum hemorrhage

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emergency bag, and continued education using simulation to update nurses on the current evidence-based practice for responding to postpartum hemorrhage. Proposed Change Nurses working in birthing and postpartum units need to have strong assessment skills and a thorough understanding of the life-saving interventions needed for postpartum hemorrhage. Excessive blood loss after birth should set into motion evidence-based predetermined measures that provide the interventions necessary to restore the women’s homeostasis. By creating a postpartum hemorrhage response team with identified roles, an emergency bag with necessary equipment to respond to the emergency, and continuing education that updates nurses on current evidence-based practice, nurses gain an understanding of the skills necessary to respond to postpartum hemorrhage. Implementation, Outcomes, and Evaluation A pretest was given to evaluate the current knowledge level of the nursing staff on the mother–baby unit in a large regional medical center. An education module was created that followed evidencebased practice, hospital policy, and protocol for managing a postpartum hemorrhage. A posttest was required at the end of the educational mod-

ule. The total mean scores were significantly different between the pretest and posttest. In addition to the test, a team of nurses created the postpartum hemorrhage emergency bag, which was used in a required simulation drill for all nursing staff on the mother–baby unit. A postpartum hemorrhage response team was formed with defined roles. Implications for Nursing Practice With the implementation of an educational program, an emergency postpartum hemorrhage bag, and a postpartum hemorrhage response team, nurses demonstrated increased knowledge of postpartum hemorrhage response. Being prepared for the third leading cause of maternal mortality will enhance patient safety and improve quality of care. Longitudinal analysis of knowledge retention on response to postpartum hemorrhage is being completed in the next 6 months and will result in further reporting of outcome data related to retention of education. Recommendations from this program include incorporating response to postpartum hemorrhage into orientation to maternal services, incorporating an annual competency assessment on postpartum hemorrhage, and updating education to reflect evidence-based recommendations to postpartum hemorrhage response.

Memorial Campus, Asheville, NC Keywords postpartum hemorrhage obstetric emergency quality improvement patient safety

Professional Issues Poster Presentation

A Passion for Partnership: Development of a Neonatal Surgical Education Program Purpose for the Program o develop an educational program for care of the surgical neonate.

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Proposed Change A community hospital developed a new neonatal surgical education program utilizing an existing partnership with a tertiary center. This program provided valuable clinical experience and enhanced the didactic education learners received. Implementation, Outcomes, and Evaluation The existing partnership through the perinatal center allowed the leadership team, including managers and educators, to meet and explore the feasibility of this clinical program. The educators continued to collaborate to identify goals and objectives. Expectations, goals checklists, and evaluations were developed, and potential challenges were identified. The didactic program held at the community hospital was a foundation for the clinical experience, which was

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scheduled at the tertiary center. Experienced staff nurses from the community hospital were identified and paired with expert clinicians from the tertiary hospital who were eager to provide this clinical opportunity. A core team of staff received training in the most common types of neonatal operative cases anticipated. Participants were able to follow patients through preoperative, intraoperative, and postoperative care. Staff nurses, advanced practice nurses, and physicians all contributed to the learner’s experience. Participant evaluations provided strong positive feedback in the areas of value of clinical experience, teaching methods, effectiveness of preceptors, and clinical key points. Enthusiasm for the experience also helped in the recruitment of additional participants. The evaluations provided feedback for educators and preceptors to adapt the training as needed. Additional outcomes of the education will continue to be assessed as the surgical cases present. The community hospital has not had a surgical case yet.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Susan M. Sinopoli, BSN, RNC-MNN, Northwest Community Hospital, Arlington Heights, IL Carol Rosenbusch, RN, Children’s Memorial Hospital, Northwestern Perinatal Center, Chicago, IL Keywords surgical care neonates neonatal intensive care unit community hospital

Professional Issues Poster Presentation

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Westveer, C.

Proceedings of the 2012 AWHONN Convention

Implications for Nursing Practice This program prepared participants with the didactic and clinical experience necessary to care

for surgical neonate, however, this process could be adapted by other institutions for other aspects of care.

Ignite the Passion in Your Patient Satisfaction Christina Westveer, RNC, BSN, Purpose for the Program CCE, Jeff Gordon Children’s y being present at the beginning of the forHospital -Carolinas Medical mation of a family, our perinatal units are afCenter-NorthEast, Concord, forded a unique experience in the lives of our paNC

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Keywords family-centered care quality patient satisfaction

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tients. As providers, we strive to ensure a positive experience.

Proposed Change Our perinatal care model was previously traditional with separate labor and delivery, postpartum, and nursery units. Each family had one postpartum nurse and one nursery nurse caring for them. We transitioned to mother–baby couplet care to improve our process of care for our patients. We continued to assign a nurse to remain in the nursery. Even after we had fully implemented mother–baby care, infants continued to spend long periods of time in the nursery for care and procedures. We found that we were not meeting our full potential in caring for our families as evidenced by our patient satisfaction scores. Implementation, Outcomes, and Evaluation Our leadership team led an effort to keep mothers and infants together, stressing the importance of positive outcomes for our patients, such as early breastfeeding and promotion of bonding. We started this project by developing our mission, vision, and values; brainstorming issues identified

on the units and reviewing our processes; and outlining the ideal seamless, high-quality experience for our patients. Staff members from labor and delivery, mother–baby, high-risk obstetric, and neonatal intensive care unit participated in workgroups to develop our new processes and staff training. We conducted train-the-trainer sessions using staff members, not leaders, as the trainers. After these sessions, we held a familycentered care skills fair where all staff in the perinatal units attended training sessions. In these sessions, they learned about the evidence behind the change and how to implement the change in their everyday practice. Implications for Nursing Practice After our new family-centered care model was implemented, we very quickly identified positive outcomes related to our changes. During the first few weeks, the leadership team conducted faceto-face interviews with 100 patients and received overwhelmingly positive responses. Patient satisfaction scores went from the 61st percentile to the 100th percentile, and quality measures improved related to skin-to-skin after delivery and breastfeeding within the first hour. We also achieved multiple awards related to our patient and employee satisfaction, which provided the confirmation that we had achieved our mission of higher patient quality and satisfaction.

No More Silos: Implementing an Integrated Obstetric Computerized Documentation System Candace L. Rouse, RNC, MSN, Purpose for the Program CNS-BC, Sinai Hospital of n integrated perinatal computerized docuBaltimore, Baltimore, MD Keywords perinatal computerized documentation OB documentation systems change theory

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mentation system.

Proposed Change The proposed change was moving from a stand-alone labor and delivery computerized documentation system (including fetal monitoring) to an integrated perinatal computerized system. This system is accessible throughout the institution and remotely. It is integrated with the institution’s mainframe computerized documentation.

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Implementation, Outcomes, and Evaluation Implementation of the computerized documentation was completed in several phases, starting with the postpartum unit, the normal newborn nursery, and the neonatal intensive care nursery. Labor and delivery went live with the antepartum and intrapartum piece, whereas the computerized fetal monitoring was the last to be implemented. Outcomes include the benefit of the entire perinatal system being able to view the maternal and newborn delivery data in one system, as opposed to the hybrid system that existed prior. The fetal monitoring surveillance is now available in several

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areas across the institution: the emergency department, intensive care unit, and main operating room. An anticipated outcome is the ability to pull reports from the data documentation. This has so far included types of birth, use of provider order sets, audits of nursing documentation, and capturing delivery elements.

Implications for Nursing Practice Implications for nursing practice include ease of reviewing data and capturing data for reports and the potential for earlier recognition of patient abnormal values, thus increasing quality patient care.

Using the Strength of a System to Reduce Deliveries Prior to 39 Weeks Gestation Purpose for the Program he purpose of the program was to dramatically reduce elective deliveries prior to 39 weeks gestation across a health care system of nine hospitals in the Midwest.

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Proposed Change The proposed change was a systematic, evidence-based, reliable approach to assess and adhere to rationale for elective deliveries consistent with medical necessity. The proposed change would unfreeze the status quo, which would prepare physicians and nurses to reliably provide safe, evidence-based maternal care.

Implementation, Outcomes, and Evaluation The change process was led by the system-wide Obstetric Practice Committee, including facilitybased nurses, physicians, and system level nursing representation. Adoption potential for the change process was systematically evaluated at each facility. Strategies were designed to respect the voice of each facility while being mindful about fail-proofing the process. The existing shared governance structure was effectively used as the horizontal and vertical communication vehicle ensuring representation from the bedside to the boardroom. Early adopters shared barriers and successes to facilitate universal adoption. Inclusion of outpatient clinics and providers was essential in garnering support for this initiative.

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The Obstetric Practice Committee began policy development with a draft presented in January 2010. After conferencing, audit, and feedback at the individual unit-based level, the policy was finalized in March 2010. Implementation at each hospital was championed by a core group but varied in timing because of unit-based readiness. Evidence-based practice guidelines were not negotiated, but specific implementation processes were facility-specific based on the cultural characteristics of the health care team. All hospitals achieved policy implementation, which utilized purposeful diffusion by May 2010. Initial outcomes of this system-wide practice change included dramatic drops in the number of elective deliveries prior to 39 weeks of gestation, but assessment of the extent of adoption and barriers continue. A system scorecard with sensitive, timely indicators identified through gap assessment provides ongoing opportunities to evaluate the use of the evidence-based practice policies.

Julie K. Kathman, MSN, RN, CNS-BC, Indiana University Health, Bloomington Hospital, Bloomington, IN Kerista Hansell, MSN, RN, CNS-BC, C-EFM, IBCLC, Indiana University Health at Indiana University Hospital, Indianapolis, IN Margie Pyron, MS, RNC-OB, LCCE, Indiana University Health, Ball Memorial Hospital, Muncie, IN Keywords elective deliveries prior to 39 weeks collaborative network evidence-based practice

Professional Issues Poster Presentation

Implications for Nursing Practice Utilizing evidence-based practice guidelines decreases point of care disagreements regarding the appropriate timing of any individual delivery. This initiative prevents avoidable morbidity and mortality of mothers and infants. Purposeful development and integration techniques, communication, feedback, and policy development of the committee provide a framework for sustaining this change. This shared governance model has created a loop of accountability from bedside provider to system level leaders.

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Proceedings of the 2012 AWHONN Convention

Managing the Obstetric Emergency: A Collaborative Team Training Approach in the Labor and Delivery Setting Using Simulation Ryan M. Olivere, MSN, RNC-OB, The Hospital of the University of Pennsylvania, Philadelphia, PA Karen L. King, MSN, RNC, The Children’s Hospital of Philadelphia, Philadelphia, PA Keywords shoulder dystocia team training interdisciplinary

Professional Issues Poster Presentation

Purpose for the Program Many organizations, such as the Joint Commission, the National Quality Forum, and the Accreditation Council for Graduate Medical Education have cited the importance of teamwork in patient safety. At the University of Pennsylvania Health System, the incidence of shoulder dystocia was underacknowledged and underreported. This emergent, often unforeseen, complication can only be diagnosed during the birth process as the fetal body negotiates the maternal pelvis. And as with many clinical emergencies, heightened levels of anxiety, role confusion, and miscommunication among caregivers often result. Proposed Change As a risk reduction strategy, an interdisciplinary team recognized the need to create an evidencedbased, seamless, team approach to manage shoulder dystocia. This team approach, called Managing the Obstetrical Emergency: Team Training in Labor and Delivery through Simulation, included multidisciplinary teams from two of the health system’s hospitals. Implementing such a program using specific birth maneuvers and role clarity may decrease the incidence of associated shoulder dystocia injuries, improve communication, and increase the reporting and proper documentation of shoulder dystocia. Implementation, Outcomes, and Evaluation The program includes interdisciplinary classes devoted to didactic presentations, case studies, and simulation sessions using a high-fidelity simu-

lator, team training, communication, and role identification. A self-assessment tool is administered at the beginning of the didactic session and readministered immediately following the session. The results of the self-assessment tool have demonstrated the improved knowledge and communications skills to effectively function as a team. To evaluate the participant’s competency and application of knowledge, direct observational simulation sessions are conducted using case scenarios. These sessions are videotaped and immediately debriefed following the drill. In addition to the didactic and simulation sessions, practice drills also are conducted on the labor and delivery units. These drills provide the team with the opportunity to practice the interventions for a shoulder dystocia emergency in a nonemergent setting. In addition to the improved self-assessment, team training has also possibly helped to increase nursing staff satisfaction as demonstrated by yearly National Database of Nursing Quality Indicators Nursing Satisfaction Survey scores. Furthermore, an additional outcome of the team training initiative has been the reduction of brachial plexus injuries from 2008 to 2010. Implications for Nursing Practice As a result of the program, nurses are able to identify indicators that may preclude a shoulder dystocia, assist the provider in facilitating appropriate maneuvers to deliver the shoulder, and accurately document the event.

Implementing a Nurse Navigation Program for High Risk Obstetric Patients: An Evidence-Based Practice Approach Sandy G. Langheld, BSN, RN, RNC-OB, Caromont Healthcare, Gaston Memorial Hospital, Gastonia, NC

Purpose for the Program urse navigation has become an important part of many oncology centers and is an emerging trend that has been used to increase patient satisfaction, improve outcomes, and decrease barriers to care. Navigation programs can be implemented and operationalized differently depending on the practice setting.

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Proposed Change The obstetric high-risk nurse navigation program provides complex obstetric patients with special-

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ized education, patient advocacy, follow-up, support, and coordination of care in today’s complex health care setting. Time constraints, increasing documentation, and the rising complexity of patients mean less time with the maternal–child nurse and her providers. Because of this identified need, a multidisciplinary council visualized applying the navigation concept to maternity care. The purpose and primary goals for creation of the program were to develop standardized high-risk patient education forms with recommendations and to provide an accurate follow-up summary for patients

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experiencing a high-risk pregnancy. The summary becomes part of the medical record to ensure accurate information and timely retrieval of obstetric history with return to care in subsequent pregnancies. Implementation, Outcomes, and Evaluation The program was implemented after the development and standardization of patient information with the guidance from maternal–fetal medicine with two tiers of 15 high-risk conditions. An emphasis of the program design was educating patients about disease processes that affect health and complicate future pregnancies. A computerized system for referral, tracking, and documentation was developed. After a referral is received, education and recommendations are given to the patient postpartum. Follow-up care is provided and a comprehensive summary form is completed. The

patient benefits from a cultivated relationship with the navigator who serves as a contact person and as a liaison between providers. The program design complements the continuum of care and identifies high-risk conditions that affect postpartum care, the interconception interval, and subsequent pregnancies. Navigator use in obstetrics can ensure that the high-risk patient has dedicated follow-up care after discharge through preconception.

Keywords nurse navigation high-risk obstetrics patient navigation implementing

Professional Issues Poster Presentation

Implications for Nursing Practice By examining the role of the nurse navigator depicted in literature and its successful application to oncology units, we can benefit from its use in maternal–child nursing. Patient navigation is an emerging trend that can be applied to obstetrics to play a significant role in increasing patient, nurse, and provider satisfaction.

A Felony Has Been Committed in the Operating Room: An Interactive Approach to Annual Competency Purpose for the Program e will describe an innovative technique for staff completion of annual competencies that will result in enhanced knowledge retention, increased staff engagement, and consolidation of many competencies into one event.

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Proposed Change Learning principles indicate that adults learn more when they perceive the knowledge will benefit them in real-life situations. In addition, use of several senses during learning may result in better recall. The more ways an adult learns a particular fact, the more likely they will recall it when needed. In the past, staff have reviewed journal articles, completed written tests, and participated in skills labs for completion of annual competencies. These learning strategies did not support maximum knowledge retention and recall, nor did they engage staff. With this knowledge, our goal was to create an interactive crime scene investigation to provide performance practice, experiential learning, and validate operating room competencies for labor and delivery staff in an efficient and cost-effective manner without compromising patient safety or educational quality.

Implementation, Outcomes, and Evaluation The main operating room and our simulation team partnered, realistic supplies were obtained, and a simulated operating room environment was created. Staff were challenged to identify aseptic

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technique and surgical safety violations, along with safety concerns surrounding infant resuscitative equipment. Additionally, staff were asked to prioritize the felonies identified and include the rationale for their top three safety concerns. Staff appreciated the new and innovative approach to assessing their knowledge. They were fully engaged in this educational offering and began competing with each other to identify as many violations, or felonies, as possible. Following the crime scene investigation simulation, staff were sent a summary listing of all the violations that were evident in the simulated operating room. Interestingly, staff found additional safety concerns that were not originally intended to be incorrect. We successfully engaged both novice and experienced nursing and ancillary support staff. This operating room crime scene investigation learning model presented an entertaining and effective method to complete annual competency assessment.

Kristin Scheffer, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Kathryn J. Corso, BSN, RNC-OB, Baylor University Medical Center, Dallas, TX Keywords annual competency labor and delivery crime scene investigations (CSI) adult learning principles simulation

Professional Issues Poster Presentation

Implications for Nursing Practice Through real-world settings, we can facilitate learning and evaluate staff’s ability to recognize minor safety issues that often get overlooked and could possibly cause major incidents. Incorporating everyday practice into a simulated learning environment creates a safe place to verbalize safety concerns without the threat of harm to patients. Using adult learning principles, this interactive and innovative learning strategy can be used to focus on patient safety, best practices, and quality improvement.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

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Poe, M.

Proceedings of the 2012 AWHONN Convention

Leading a Culture Change to Nursing and Patient Excellence Mary Poe, RNC, MSN, Women’s Memorial Hermann Memorial City, Houston, TX Keywords transformational leadership shared governance nurse autonomy professional practice councils improved patient and nurse satisfaction

Professional Issues Poster Presentation

Purpose for the Program To improve patient and nurse satisfaction on the postpartum and gynecology nursing unit through an improved positive practice environment.

Proposed Change Transformational leadership creates a culture of nurse autonomy, shared governance, and professional competence. The goal was to improve and sustain nurse and patient satisfaction on the postpartum and gynecology unit. The results were possible through extraordinary courage, skill, and spirit, which was the energy that created a significant difference in achieving extraordinary results. Transformational leadership ties a nurse’s emotion and passion to her skill level. This leadership style raises human conduct and improves personal aspirations to enhance the professional nurse practice environment. The postpartum and gynecology unit developed four professional practice councils to create a culture of autonomy and shared governance. The council created an avenue of individual accountability and professional contribution to move the practice environment from mediocre to positive. The essence of the process was to get the right people engaged and to create revolutionary results through an evolutionary process. Each council provides an opportunity for every staff member to participate and improve clinical knowledge and nursing excellence.

The four councils included professional practice, development, research, and quality. The councils’ objectives included but were not limited to improve professional relationships, shared governance, evidenced-based practice implementation, commitment to nursing excellence, autonomy and professional accountability, staff nurse leadership, judgment and action, motivation and recognition, nursing competence, professional growth and development, teaching and mentoring, coaching and learning, improved patient satisfaction, and improved employee satisfaction. Implementation, Outcomes, and Evaluation The results were extraordinary. The employee satisfaction rate went from 4.10 with low employee participation to 4.77 with high employee participation. The council work helped improve patient satisfaction by increasing all eight Hospital Consumer Assessment of Healthcare Providers domains to the 90th percentile with a composite score of 90. Implications for Nursing Practice Transformational leadership allows nurses to connect to their inner drive, be autonomous, selfdetermined, and self-driven. It creates a safe positive practice environment for nurses and patients. The postpartum and gynecology unit created a culture of disciplined professionals that used disciplined thinking and disciplined action to meet the rigorous clear set expectations and standards related to patient and employee satisfaction.

“Many Hands Make Light Work”: Using a Kaizen Approach to Ignite Innovation While Increasing Patient Safety and Productivity on an Obstetric Triage Unit Suzanne Flohr-Rincon, BSN, RNC-OB, Sharp Healthcare, Chula Vista, CA Lora Tucker, RN, Sharp Chula Vista Medical Center, Chula Vista, CA Keywords Kaizen lean six sigma OB triage

Professional Issues Poster Presentation

Purpose for the Program n response to increasing pressures, the health care industry is rapidly adopting methods and tools that have been successfully used in other industries. These tools develop health care associates to drive process changes and, thus, improve the performance of the organization. Methods that are being used in health care are the following: Six Sigma, Kaizen, and performance management.

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Proposed Change Provide care in a high-risk obstetric triage unit and provide data to support sustained improvement toward a decrease in patient wait time that is within community and service line standards.

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Implementation, Outcomes, and Evaluation High-risk obstetric (class I/emergent) patients at Sharp Chula Vista Medical Center are required by policy to be placed on an electronic fetal monitor for immediate evaluation upon arrival. There has been an increase in the volume and acuity of patients at the Sharp Chula Vista Medical Center Obstetric Triage, however, space is limited and the workflow has not been adjusted. This resulted in baseline data of obstetric triage patient wait times that were outside Sharp HealthCare policy and community standards, and caused an increased potential for adverse outcomes. Therefore, in December 2010, an interdisciplinary, intradepartmental team used a Kaizon event to address the issues with the obstetric triage area.

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This event consisted of several weeks of planning, followed by an intense (3 to 5 day) burst of activity to try-storm and implement improvements. The targeted time frame for reduction is the time from when the patient arrives at the admission front desk until when the electronic fetal monitor is applied. The Kaizen team approach focused on workflows for patient assignment and assessment, resource allocations, and physical surroundings to achieve this objective. The outcomes were a change in how we provide care in a high-risk obstetric triage unit and data to support a decrease

in patient wait time that is within community and service line standards. Implications for Nursing Practice Lean Six applications, such as lean education, waste walk, brainstorm improvements, current and future state process mapping, try-storming ideas, and document standard work were implemented. Service excellence was demonstrated and the team was empowered to facilitate immediate, action-orientated solutions to improve the triage admission process.

From Policy to Practice Change: Nursing Partnerships in Practice to Change Low-Income African American and Hispanic Initiation of Breastfeeding Rates Purpose for the Program t has been well documented in previous research that a low-income African American pregnant women are less likely to initiate and continue breastfeeding for the recommended first year of the infant’s life. According to National Health and Nutritional data, breastfeeding rates include the following: non-Hispanic White (61%), Spanish-speaking Mexican American (63%), and African American (26%). Mothers with higher levels of education and income have greater breastfeeding initiation and continuation rates than mothers with low-income and low levels of education. Contributing factors are cultural, economic, educational, and social. Low-income African American mothers who have lower levels of education need additional support during and after pregnancy with follow-up continued for the first year of their infants’ lives. Previous, evidence-based, educational interventions have demonstrated success in breastfeeding initiation and duration in lowincome African American and Hispanic pregnant populations.

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The purpose of this presentation is to demonstrate an innovative breastfeeding educational program in a large medical center in an urban setting providing maternal–child health services to primarily low-income African American and Hispanic women, where breastfeeding initiation rates stand at 45% compared with the Healthy People 2020 initiation rate of 89%. Using a practice partnership

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model, the aligned nursing program of the medical institution developed and implemented a program in conjunction with the maternal–child health services. This educational program begins in the antenatal clinic using the support of nursing faculty and students and continues through the intrapartum and postpartum units with post-licensure nurses. Proposed Change In collaboration with the multidisciplinary breastfeeding task force, which guides practice initiatives based on evidence-based practice guidelines, a comprehensive breastfeeding program will begin in the prenatal office and continue through discharge.

Patricia DiGiacomo, MSN, RNC, Temple University, Lafayette Hill, PA Amy McKeever, PhD, CRNP, Temple University, Lafayette Hill, PA Keywords breastfeeding women’s health Baby-Friendly

Professional Issues Poster Presentation

Implementation, Outcomes, and Evaluation With the support of a grant from the Pennsylvania Department of Health 2011, $5,000 was awarded to facilitate staff breastfeeding education through in-services and reading materials. Also, patient education materials will be purchased to utilize through the continuum of perinatal services. Our goal is to increase our breastfeeding initiation rates and to emphasize the duration time for breastfeeding to ensure our newborns become healthy children and adults. Implications for Nursing Practice Implications for nursing practice will be discussed.

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Lingafelter, M., Brockmeyer, J. and Foley, P.

I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Bridging the Gap: Building a Collaborative Relationship between Labor and Delivery and Emergency Medical System Response Units Purpose for the Program review of our process was conducted and demonstrated the need to design an incoming obstetric patient report to be utilized between Jennifer Brockmeyer, BSN, RNC, Mount Carmel St. Ann’s, labor and delivery and emergency medical serWesterville, OH vices. It is imperative that a collaborative relationship be established in the community between the Pamela Foley, BSN, RNC, departments due to the increasing acuity of materMount Carmel East Hospital, Columbus, OH nal patients. There is a direct link in poor maternal and fetal outcomes as a result in delay of care Keywords due to inadequate preparation of incoming obcommunication stetric patients received from emergency medical education obstetric patient services. Mia Lingafelter, RNC, Mount Carmel East Hospital, Columbus, OH

quick tips labor and delivery EMS

Professional Issues Poster Presentation

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Proposed Change The Incoming Obstetric Patient Report was implemented to improve patient safety and maternal and neonatal outcomes. The emergency medical services Quick Tips for Obstetric Patients also was developed to be utilized as a reference when caring for obstetric patients. The implementation of these two processes addresses the Joint Commission Sentinel Event Alert #44 to decrease maternal morbidity and mortality. Implementation, Outcomes, and Evaluation The Incoming Obstetric Patient Report and the emergency medical services Quick Tips for Obstetric Patients were developed and implemented by visiting local emergency medical services de-

partments to provide consistent education. The emergency department also was provided with the same education to ensure that all three departments had a common understanding and appreciation for obstetric patients. By establishing an interdisciplinary approach between the departments, patient outcomes have improved. The emergency medical services response units have used these tools to perform a quick assessment of obstetric patients and relay the appropriate information to the dispatcher. With the use of both of these tools, patients have been successfully transferred to the appropriate departments and optimal patient outcomes have been achieved. Using a survey to evaluate the effectiveness before and after the education shows a vast increase in the level of comfort when caring for obstetric patients. Implications for Nursing Practice Implementation of the Incoming Obstetric Patient Report and emergency medical services Quick Tips for Obstetric Patients provides a consistent process for communication and assessing obstetric patients outside a hospital setting. It has been noted through evidence-based practice that up to 80% of adverse patient outcomes are related to poor communication. By providing education and communication tools, maternal and neonatal outcomes have improved.

Breast Feeding Care Management Team: The Crew E. Christina Conner, BSN, RN, Purpose for the Program IBCLC, Baylor University ospitals are encouraged to improve Medical Center at Dallas, evidence-based practices based on varDallas, TX

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Keywords breastfeeding team quality initiatives collaborative education nurses lactation consultant

Professional Issues Poster Presentation

ious initiatives, such as the Joint Commission Perinatal Core Measures and the Baby-Friendly Hospital Initiative, both of which recognize the value of breast milk. The breastfeeding care management team is a strategy used by lactation consultants to partner with the nursing staff when implementing best breastfeeding care practices in our large health care system. Within the women and children’s units, each shift faces different breastfeeding support challenges. What better way to identify these needs than to have nurse champions from each shift, representing each unit serving to educate, advocate, and celebrate on behalf of families and staff?

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Proposed Change The breastfeeding care management team, The Crew, uses quality initiatives throughout the women and children’s service line to initiate and support breastfeeding related issues. This core group works together with the lactation department in the following ways:

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Gears our facility toward becoming a BabyFriendly hospital; Supports the goals in the Texas 10-Step program; Leads the women and children’s departments in World Breastfeeding Awareness week; Starts mothers pumping for expressed breast milk within 6 hours of infant’s birth as indicated;

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Assists mothers in breastfeeding their infants; and Identifies solutions related to concerns from parents and/or staff.

Implementation, Outcomes, and Evaluation The boot camp training of The Crew team consisted of the learners completing five modules geared toward assisting the mother and infant with breastfeeding support. At the beginning of class, a pre-evaluation and prequestionnaire were completed by attendees. This was repeated a month

later to reflect the improvement of skills and knowledge in this core group of nurses. Implications for Nursing Practice The breastfeeding care management team is an innovative tactic used to partner the lactation team with the nursing team in supporting breastfeeding within a large hospital. Breast milk and breastfeeding are known to provide many benefits to both the mother and infant. Hospitals can use this plan by implementing a breastfeeding care management team to support families and staff.

Meeting the Emergency Preparedness and Disaster Response Core Competency Set One Step at a Time Purpose for the Program n the last 11 years, we have seen more disasters that have affected our health care system in numerous ways. Some of these disasters have had an indirect effect with an influx of patients into the system, whereas others have directly affected the ability to deliver health care. The lessons learned led to the very comprehensive “Emergency Preparedness and Disaster Response: Competency Based Educational Objectives for Perinatal and Neonatal Nurses.”

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Proposed Change In this age of continually evolving health care, our staff nurses have an overwhelming amount of information to process on an ongoing basis while working in a busy women’s hospital that performs approximately 7,000 births per year. Our approach to meeting these competencies is to provide handson training addressing one area of need at a time. Implementation, Outcomes, and Evaluation We started by having all clinical mother–baby team members actually wear our baby evacuation vests carrying four 1-gallon water jugs to simu-

late what it would feel like to physically evacuate four infants. We reviewed our fire evacuation plan and location of emergency evacuation routes. Six months later, we added adult evacuation using the ParaSlyde and had teams of two to four staff members evacuate a real person from a bed to the floor and down a flight of stairs. This was paired with additional training on initial fire response, our hospital emergency response team, and recognizing fire compartments and when to evacuate a fire compartment. The feedback from team members was overwhelmingly favorable and indicated that they enjoyed being able to actually do hands-on practice with the vests and ParaSlyde.

Patricia Parker, MS, CNM, RN, BayCare Health System, Tampa, FL Keywords disaster preparedness evacuation training

Professional Issues Poster Presentation

Implications for Nursing Practice We plan to address the following topics with hands-on training in the next 1 to 2 years: active shooter scenario requiring lockdown of the facility; recognition of chemical, biological, radiological, nuclear, and explosive agents and how to respond; use of disaster supply carts with obstetric specific supplies; lecture and practice of triage system; and practice and review of caring for patients in low-tech environments.

Hospital Associate Breastfeeding Supporters Initiative Purpose for the Program o increase breastfeeding initiation, exclusivity, and duration rates.

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Proposed Change To implement a breastfeeding peer support practice using hospital employee volunteers. Implementation, Outcomes, and Evaluation Our hospital-based Parent Services Lactation Resource Center nurses reviewed breastfeeding rates from performance improvement data and re-

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search evidence on breastfeeding support. Peer counseling was a practice shown to improve breastfeeding rates, however, there were many pros and cons to the various types of peer counseling interventions in various types of care settings. Our team considered the research along with our setting’s clinical and financial resources and chose an innovative approach: recruiting volunteer peer counselors from hospital-wide employees (associates) called associate breastfeeding supporters. The implementation includes the

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Mudiwah A. Kadeshe, RNC-OB, MSN, IBCLC, CCE, Washington Hospital Center, Lanham, MD

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Driver, R. L. and Sturges, K.

Proceedings of the 2012 AWHONN Convention

Keywords breastfeeding peer counseling peer group counseling social support

recruitment and training of the associate breastfeeding supporters before and after outcomes of breastfeeding initiation, exclusivity, and duration.

Implications for Nursing Practice This innovative practice change can be implemented in other hospital childbirth settings.

Professional Issues Poster Presentation

Do You See What I See? A Collaborative Nurse/Physician Approach to Fetal Monitoring Robin Lynn Driver, RNC, BS, Mount Carmel East Hospital, Columbus, OH Kathleen Sturges, RN, BSN, MSA, Mount Carmel East Hospital, Columbus, OH Keywords fetal monitoring NCC EFM certification

Professional Issues Poster Presentation

Purpose for the Program lectronic fetal monitoring has recently been the subject of many perinatal patient safety initiatives. The American College of Obstetricians and Gynecologists (ACOG) released a Practice Bulletin in 2009 addressing electronic fetal monitoring terminology updates, interpretation, and management. Evidence indicates that fetal monitoring is often a factor in obstetric lawsuits. A review of the literature also shows that poor communication is a primary factor in sentinel events. Therefore, our facility initiated a protocol to ensure appropriate interpretation and management of fetal monitor tracings.

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Proposed Change The facility instituted a new protocol requiring that all nurses and physicians caring for fetal monitoring patients pass the National Certification Corporation (NCC) electronic fetal monitoring exam. Implementation, Outcomes, and Evaluation The obstetric collaborative team, a group of obstetrician champions, perinatal educators, nurse managers, and quality specialists met to create an implementation plan. A fetal monitoring expert taught a review course at our facility with physicians and nurses in the same class. The course was repeated 2 days in a row to allow as many nurses and physicians as possible to attend. The review course also was videotaped and offered as

a Web-based conferencing on the facility’s library Web site. This option was available for those who were unable to attend the live version and/or for review purposes. The NCC electronic fetal monitoring exam was offered immediately after the review course and at various times over the following 2week period. Approximately, 165 nurses and 103 physicians took the exam and 92% have passed to date. Both nurses and physicians have reported improved collaboration in caring for electronic fetal monitoring patients. In addition, the medical record has shown improved adherence to interpretation and management of the results of fetal tracings in the 2 months after education and completion of the exam. Indeterminate/abnormal electronic fetal monitoring tracings were identified 97% of the time, and the outcomes were managed appropriately 92% of the time. Implications for Nursing Practice Nurses and physicians have an increased responsibility for professional accountability. Facility requirements include team training drills, collaborative electronic fetal monitoring strip reviews, and case studies. In addition, continuing electronic fetal monitoring education is required. Because of this collaborative approach to fetal monitoring, both nurses and physicians have reported improved confidence in caring for electronic fetal monitoring patients, thereby, improving patient safety and maternal/neonatal outcomes.

Igniting Change in the Women’s Service Line through the Healthy Workplace Intervention Mickey Parsons, PhD, MHA, Purpose for the Program RN, FAAN, University of Texas o describe University Health System, Health Science Center at San Women’s Service Line, interdisciplinary planAntonio, San Antonio, TX

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ning process and outcomes to improve the inpatient and outpatient care of women. The healthy workplace intervention served as the

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planning method to empower clinicians, executives/managers, and quality and business professionals to design a future vision: health for women. The innovative method reignites passion and commitment for excellence in patient care.

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Proposed Change The healthy workplace intervention is a capacitybuilding process that promotes shared leadership, participatory change, and empowerment. Through future search conferencing, participants bridge differences in status, position power, work experience, gender, and hierarchy by working as peers to achieve shared goals and fast action. This generative process incorporates the tenets of appreciative inquiry by amplifying positive anticipatory images of the future and the team defines the actions to actualize their future, measure the outcomes, and ensure sustainability. Implementation, Outcomes, and Evaluation The participants identified a shared history of patient care and the current operational status of inpatient women and newborn care and the 12 Greater San Antonio clinic outpatient sites. Goals were to design seamless, coordinated care for women and to promote healthy families. Interdisciplinary communication, care coordination, and partnering with physicians were key strategies.

Outcomes included the following: (a) 10.5% increase in births through changing the process to identify women with positive pregnancy test results earlier and schedule a clinic visit; (b) 100% of patients are now facilitated throughout pregnancy and postpartum care by a redesigned patient navigator role to provide coaching and follow-up for appointments and education; (c) 56% decrease in newborn postdischarge visits to the nursery by collaborating with physicians and scheduling appropriate clinic visits; (d) reduced patient clinic waiting times through the implementation of a preregistration process prior to the clinic visit; (e) enhanced team communication through the initiation of monthly service line meetings; (f) standardization of breastfeeding education; and (g) the implementation of mother–baby couplet care is in process. Implications for Nursing Practice The healthy workplace intervention builds relationships across the complex landscape of health care and empowers staff to lead and sustain positive change.

Teri Grubbs, RN, BSN, University of Texas Health Science Center at San Antonio, San Antonio, TX Angela A. Casias, MSN, BSN, RN, University Health System, San Antonio, TX Patricia A. Cornett, EdD, MS, RN, Sol´ucion Associates, Canyon Lake, TX Keywords healthy workplace intervention interdisciplinary service line team empowerment organizational capacity-building

Professional Issues Poster Presentation

Two Peas in the Same Pod: Transitioning to Couplet Care Purpose for the Program he birth of an infant is a major life event for mother and family. Current literature suggests that outcomes are best when mothers and infants stay together. The existing care model in the Family Birth Center was contrary to the current recommendations and promoted the separation of mothers and infants. Care was often more nurse centered than patient or family centered and this culture can be difficult to change.

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Proposed Change The goal was to transition from traditional postpartum and newborn care to mother–infant couplet care. This change process had been attempted in the past but had failed. This failure was thought to be due to the lack of front line involvement and the presence of an authoritative leadership style that attempted to dictate rather than collaborate with staff. To be successful, front line team members had to be involved, champion, and ignite the change process. Leadership served as facilitators and allowed the process to be driven by front line team members. Throughout the transition, feedback on process changes was encouraged, welcomed, and accepted from front line team members. Implementation, Outcomes, and Evaluation Transition occurred in less than 3 months when front line team members were driving the change.

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The staff embraced the change, promoted it to co-workers, and encouraged involvement and input. Patient satisfaction scores have shown improvement consistently above the target mean. Team member satisfaction has been noted as well. Breast milk feeding rates have improved. An outcome that was not anticipated was improved thermoregulation of the newborn. Continued challenges exist related to getting full buyin from pediatricians who still insist on making rounds in the newborn nursery rather than the mother’s room. As a result of the success of the change, the process is now being implemented system-wide and the team members are being used as resources for other hospitals to aid in their transition.

Marsha Rodgers, RNC-OB, BSN, Johnson City Medical Center, Johnson City, TN Keywords change process couplet care front line team members mother–baby care patient satisfaction

Professional Issues Poster Presentation

Implications for Nursing Practice This was an excellent example of how change occurs smoothly when stakeholders and front line team members participate, are given the rationale and evidence for making change, and are allowed to own the project. Leaders must instill the need to support change and promote evidence-based care in front line team members. The change demonstrates the effectiveness of involving front line staff to take on the challenge for making change and improving quality of care to benefit the health care of patients.

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Heft, T., Price, L. and Harper, T.

Proceedings of the 2012 AWHONN Convention

Addressing Healthcare Concerns during Construction and Renovation Purpose for the Program he purpose of this presentation is to address the challenges of providing safe, efficient patient care during construction and reLisa Price, RNC-OB, The Medical Center of Plano, Plano, modeling of a maternal–child unit. Frequently TX identified challenges include lack of communication of day-to-day construction plans from faciliTracy Harper, RN, BS, The Medical Center of Plano, Plano, ties management and construction crews to the TX bedside nurse; lack of timely notification of inaccessible patient care areas and alternate routes; Keywords patient dissatisfaction associated with construcconstruction tion noise; and potential displacement of paremodeling safety tients because of limited bed space outside construction areas. Additional factors that must be considered include accommodations in tempoProfessional Issues rary patient care areas, including emergency response equipment, access to appropriate docuPoster Presentation mentation processes, infection control, and safety Terri Heft, BSN, RNC-NIC, The Medical Center of Plano, Plano, TX

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and security of the mother, infant, visitors, and staff. Proposed Change To improve the process of patient care delivery during construction, we share lessons learned in one facility that went through major construction in the maternal–child care area. Implementation, Outcomes, and Evaluation Improved nursing efficiency and safe patient handling during construction projects. Implications for Nursing Practice By preparing nurses to consider these challenges, we hope that many facilities will be prepared and able to provide safe, efficient quality patient care with minimal disruption during the construction process.

Advocacy for Mothers & Babies on a Statewide Level: Regional Consortiums Make a Difference Gail F. Walker, RN, MS, Lawrence General Hospital, Lawrence, MA Keywords nursing collaboration advocacy consortium

Professional Issues Poster Presentation

Purpose for the Program he Northeast Perinatal Team in northeastern Massachusetts is an active consortium of level I and II perinatal facilities throughout Massachusetts consisting of perinatal department leadership and educators. It fosters collaboration in care between its members and with the Commonwealth of Massachusetts Health Department, along with the Massachusetts section of the Association of Women’s Health, Obstetric and Neonatal Nurses to attain and maintain high standards of care for the perinatal population of the state.

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Proposed Change Members of the Northeast Perinatal Team committed to working with the Department of Public Health in revising and updating the perinatal regulations in 2006 with members attending every subcommittee and full committee meeting on all regulatory revisions to ensure that the regulations were evidence-based and used outcome measures for future regulatory changes. A member of the Northeast Perinatal Team now sits on the Department of Health Perinatal Advisory Committee, the Newborn Screening Advisory Committee, and the Newborn Hearing Screening Advisory Committee. We continue to seek statewide solutions

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and approaches for improved perinatal care that meet the individual, collective, and cultural needs of our diverse perinatal populations.

Implementation, Outcomes, and Evaluation Educational programs are provided regionally to ensure consistent and cost-effective ongoing education for perinatal staff. In particular, we offer regularly scheduled Sugar and Safe Care, Temperature, Airway, Blood Pressure, Lab Work, and Emotional Support (STABLE) programs, STABLE cardiac programs and annual mother–baby conferences aimed at evidence-based practice. We developed a statewide guideline for management of infants under the Safe Haven law to reduce the number of abandoned infants in Massachusetts, which each hospital individualized as its own. In 2010, we worked with the Department of Public Health to construct guidelines statewide for the management of placentas; we participated in and are currently working on state guidelines for drug testing of pregnant mothers and substance exposed newborns as well as the reporting guidelines with the Massachusetts Department of Children & Families.

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Implications for Nursing Practice The team remains committed to improving practice through nursing education and collaboration and advocating for our patients at local and state

levels. Nurse members of the Northeast Perinatal Team also participate in other statewide collaboratives in perinatal care that advocate for the highest quality of perinatal care.

Chain of Resolution: A Bold New Way to Go Purpose for the Program o enhance the utilization of chain of command principles in resolving everyday issues.

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Proposed Change At Baylor All Saints Medical Center, we reinvented the terminology for chain of command to be more appropriate and updated. Our new term, “chain of resolution,” more effectively describes what staff members and leaders are doing when activating a process to quickly resolve issues and concerns regarding patient care and safety, environmental needs, equipment issues, as well as a myriad of other possibilities.

Implementation, Outcomes, and Evaluation Leaders and frontline staff came together to rewrite policy, develop clinical vignettes for scenario-based teaching, and roll out education to all employees of Baylor All Saints. Managers, directors, and vice presidents were trained on the vignette teaching vehicle.

Rebecca Hardie, RN, C-OB, MS, HCAD, NEA-BC, Baylor All Saints, Andrews Women’s Hospital, Fort Worth, TX

Implications for Nursing Practice Staff and leaders have a better understanding of and willingness to use the chain of resolution process. The chain of resolution process is easily utilized by varying sizes of hospitals and other health care settings, such as surgery centers, and is an excellent fit for any geographic location.

Professional Issues Poster Presentation

Keywords chain of resolution

Beyond Firefighting: How a Resource Nurse Contributes to a Culture of Safety Purpose for the Program reating a culture of safety on obstetric units is paramount to preventing adverse events and improving staff satisfaction. In a high census, level III labor and delivery unit, it was recognized that the charge nurse was spending an increasing amount of time on administrative tasks required to run the unit and there was a perception among the charge nurses that they were forced to focus on “putting out clinical fires.”

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Proposed Change Charge nurses needed assistance from staff resource nurses to address the clinical areas of need during their shifts, such as determining plans of care for patients with concerning fetal tracings, assuring that new graduate nurses were practicing safely, and assuring staffing ratios were appropriate for patient conditions. Implementation, Outcomes, and Evaluation A formal resource nurse position was created in the labor and delivery unit, with clinical leads selecting the nurses that had the knowledge, communication, and clinical skills to perform this role. Feedback from staff alerted the leadership team that consistency in the expectations and qualifica-

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tions was essential to the success of this role and perceptions of patient safety. A job description with required nurse qualifications was developed and a plan for formalized training of staff selected to function in this role was instituted. After implementation of the formalized resource nurse role, charge nurses, staff, and physicians were queried regarding their perceptions of the culture of safety in the labor and delivery unit. Evaluation of the formalized approach to the resource nurse role indicates a positive effect on staff perceptions toward both the value of a resource nurse and the culture of safety on the unit, as indicated by increases in survey scores for all topics queried. The most significant increase (56%) was in staff perception that there is consistently another qualified nurse ensuring accuracy of fetal monitor strip interpretation. Additionally, our results mirrored information found in the literature that indicates job satisfaction increases with staff’s perceived improvement in the culture of safety.

Samantha Ament Longsworth, BSN, RNC-OB, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA Susan Faron, MN, RNC-OB, CNS, Sharp Mary Birch Hospital for Women, San Diego, CA Keywords obstetrics resource nurse culture of safety

Professional Issues Poster Presentation

Implications for Nursing Practice Application of this process could have positive implications for all areas of nursing, especially those where potential for adverse events is high or expertise is widely varied among staff. The

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Teague, M. L., Saxton, M. J. and Day, S. A.

I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

resource nurse role is designed to achieve an environment of professional excellence by removing the “fire-fighting” approach to managing a nurs-

ing unit and creating a role where clinical issues are dealt with proactively, thus improving patient safety.

Unlocking the Subconscious to Improve the Patient Experience Marcia L. Teague, MS, RNC, Exempla Lutheran Medical Center, Wheat Ridge, CO Mary Jane Saxton, RN, Exempla Lutheran Medical Center, Wheat Ridge, CO Scott A. Day, M.A, Human, Resource, Administration, Exempla Lutheran Medical Center, Wheat Ridge, CO Keywords patient satisfaction nurse satisfaction patient and family-centered care subconscious patient expectations

Professional Issues Poster Presentation

Purpose for the Program his presentation will describe our intervention model in women’s services, which resulted in our dramatic improvement in the “would recommend” category of the Hospital Consumer Assessment of Healthcare Providers and Systems survey from an overall score of the 74th percentile in 2009 to the 92nd percentile in 2011 as reported by NRC Picker.

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Proposed Change Frustration mounts when nurses provide exceptional care, going above and beyond to meet their patients every need, yet those patients do not perceive the care they received as exceeding their expectations. We struggled to discover why we were not achieving the scores to reflect the care we believed we were providing. We discovered the disconnect between mothers’ cultural expectations of how to be cared for and the culture of caring that exists in hospitals. By understanding and aligning the subconscious drivers of both cultures, we developed an interventional model based on the archetype of Mother’s Guidance that considerably changed our approach to expectant mothers as they enter the unit (welcome), during their stay (care), and their transition and discharge to home (goodbye).

Implementation, Outcomes, and Evaluation Staff were educated on the subconscious beliefs our patients have that affect their expectations of care. Our approach to how we care for patients was changed to align with these expectations and to activate their emotional triggers to influence their perception of a positive experience. An intervention and coaching-to-sustainability model was designed to improve patient satisfaction. Continued patient feedback was provided to sustain new care model, improve patient satisfaction scores, and ignite nursing passion for providing excellent care. Patient satisfaction scores steadily increased, initially in the nursing Hospital Consumer Assessment of Healthcare Providers and Systems scores, and accordingly in the “would recommend” category and the overall rating of their stay. Not only have we sustained these scores, they have continued to increase throughout 2011. Staff and management continue to analyze patient comments and scores for continued improvement. Implications for Nursing Practice We changed the way we deliver care, adding new processes and modifying others. These changes have led to increased patient satisfaction, as well as increased nurse satisfaction and renewed professional commitment.

Creating A Nursing Research Fellowship Shereen L. Young, RN, MSN, Saint Elizabeth Regional Medical Center, Lincoln, NE Keywords nursing research fellowship

Professional Issues Poster Presentation

Purpose for the Program his bedside nurse will share her journey of conducting research as a member of a nursing research fellowship. The fellowship was developed at this nurse’s nonteaching private hospital to promote knowledge of the research process for the bedside nurse.

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Proposed Change Creating a research fellowship program gives the bedside nurse the education and support to pursue primary research and the skill to mentor others in future research endeavors. The goal is to make

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research familiar and second nature for bedside clinicians within the culture of the hospital setting.

Implementation, Outcomes, and Evaluation The 18-month fellowship allows time to infuse didactic training as the cohort works through the research process and methods. A doctorally prepared nurse leads the cohort through the process from design to reporting of outcomes. The cohort is guided through literature review, writing the research question, obtaining Institutional Review Board approval, conducting research, collecting data, and analyzing and reporting of results.

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Implications for Nursing Practice This presenter will illustrate the joys, disappointments, and lessons learned for those interested

in starting a similar program based on her experience in the first cohort of her hospital’s research fellowship program.

Implementing Enterprise-Wide Electronic Fetal Monitoring Certification for All Perinatal Clinicians Purpose for the Program he Trinity Health Perinatal Patient Safety Initiative was launched in March 2009 to improve safety for mothers and infants. Trinity Health is a large Catholic health system with 25 hospitals that provides obstetric services, with annual births ranging from 50 to 8,500. The total number of deliveries for Trinity Health in 2010 was 38,656, which is approximately 1% of the nation’s deliveries. Nationally, one of the most frequent allegations in perinatal malpractice claims is delayed diagnosis of an indeterminate/abnormal fetal heart rate tracing. An analysis of Trinity’s claims data revealed similar findings. A primary focus for the Perinatal Patient Safety Initiative is electronic fetal monitoring competency.

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Proposed Change In response to claims data and findings from onsite assessments by national experts at each hospital, the Perinatal Patient Safety Initiative steering team adopted the National Institute of Child Health and Human Development (NICHD) terminology for electronic fetal monitoring and a plan calling for over 1,500 clinicians who interpret fetal monitoring tracings to obtain electronic fetal monitoring certification by the National Certification Corporation. Implementation, Outcomes, and Evaluation To prepare clinicians for the certification examination, Trinity Health was awarded a grant in the amount of $1,170,500 to fund electronic fetal monitoring education and the cost associated with each clinician taking the National Certification

Corporation certification examination. Thirteen 6hour electronic fetal monitoring review courses presented by a national expert were scheduled at seven different locations. The same course also was presented as three 2-hour Web-based seminars and recorded for clinician access on the Trinity intranet. Additionally, an online course in advanced fetal monitoring, an electronic fetal monitoring review book, and selected readings and books related to electronic fetal monitoring were made available to clinicians. Adherence to the electronic fetal monitoring policy requiring electronic fetal monitoring certification is tied to a 15% hospital professional liability discount. A plan for requiring electronic fetal monitoring certification for privileges was developed and communicated. As of July 2011, more than 580 clinicians have taken the electronic fetal monitoring certification examination with an 87% pass rate. Medical record audits are conducted to determine appropriate use of NICHD terminology and recognition of tachysystole and indeterminate/abnormal fetal heart rate patterns with appropriate interventions. Additionally, data are being collected on the number of newly reported obstetric incidents/claims per month, which will be compared to past performance.

Barbara R. Stillings, RNC, MSN, MEd, Trinity Health, Farmington Hills, MI Lydia Glusko, MHA, CPHRM, Trinity Health, Farmington Hills, MI Keywords electronic fetal monitoring (EFM) certification

Professional Issues Poster Presentation

Implications for Nursing Practice Adoption of a standardized language in electronic fetal monitoring improves communication among clinicians and, therefore, increases patient safety. Validation of electronic fetal monitoring knowledge and competency has been shown to improve outcomes.

Lights, Camera, Action: Implementation of In-Situ Drills in the Perinatal Setting Purpose for the Program he multidisciplinary simulation team at Baylor University Medical Center sought to expand training beyond the simulation lab and into the clinical setting to achieve a multidisciplinary, multiunit team approach. This would allow them to identify gaps in communication and process issues and,

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therefore, implement change before any harm was Christine Renfro, BSN, RNC-OB, C-EFM, Baylor done to a patient. Proposed Change To evaluate clinical skills, communication, and processes on the units, the simulation team chose to implement in situ simulation drills in an effort to capture real-world experiences and evaluate the multidisciplinary team’s performance.

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University Medical Center, Dallas, TX

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Rovell, K. M. and Messer, L.

Proceedings of the 2012 AWHONN Convention

Laura Zambrana, RNC-OB, C-EFM, Baylor University Medical Center, Dallas, TX Keywords simulation in situ drills perinatal sim

Professional Issues Poster Presentation

Implementation, Outcomes, and Evaluation To effectively plan and operationalize the in situ simulation drills, the team devised high-risk, lowvolume scenarios based on the input from the unit educators, risk management, and patient safety. The staff on the units were unaware of the upcoming drill to fully capture their knowledge, skills, and communication patterns in these high-stress scenarios. Video recording captured the scenario as it unfolded and appropriate high- and low-fidelity simulators were used to mimic the most realistic scenario possible. Immediately following the scenario, the staff debriefed the video recorded event. In the facilitated debriefing, the participants were able to recognize gaps in communication, identify errors in clinical skills, acknowledge teamwork deficiencies, ascertain the need for a leader, as well as identify process issues that required immediate

change. One of the common themes discussed in the debriefing was the need to implement more effective communication as well as the need to establish a common language to help bridge the gap in understanding spoken terminology to ultimately optimize patient safety. Implications for Nursing Practice In situ drills allow for a more accurate evaluation of knowledge, clinical skills, and behavioral skills among the health care team, especially in relation to gaps in communication that can lead to the increased risk for errors or near misses. Facilitated video recorded debriefing allows participants to recognize gaps in performance. Utilizing simulation for in situ drills creates a safer environment for the patient especially in these high-risk, lowvolume situations.

Implementing a Late Preterm Infant Protocol across a Multi-level Nursery Hospital System Purpose for the Program trong evidence supports specialized care for vulnerable late preterm infants. Care of these Lori Messer, MSN, RNC, NNP, infants at four maternity facilities within a five hosK. Hovnanian Children’s pital system was not protocol based and varied Hospital at Jersey Shore depending on physician preference and nursery University Medical Center, level designation. A multidisciplinary team from Neptune, NJ the affected hospitals formed to develop a systemKeywords wide late preterm infant protocol with the goal of late preterm infant standardizing care. Kristine M. Rovell, MSN, RN, C, Riverview Medical Center, Red Bank, NJ

protocol nursery designation

Professional Issues Poster Presentation

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Proposed Change Development and implementation of a late preterm infant protocol ensures care is evidencebased and provides a framework for measuring patient outcomes. The team agreed to develop a protocol for implementation within the current configuration of nursery designations and environments and with minimal effect on staffing and budgetary constraints. The protocol required approval by the respective departments of pediatrics at each member hospital. The team proposed a timeline of 6 to 9 months for full implementation. Implementation, Outcomes, and Evaluation Consisting of nurse managers, educators, neonatologists, and staff nurses from the affected facilities, the team met monthly with work done individually between meetings. After a review of current practices and literature, areas of care were assigned to members for protocol development. Drafts were reviewed electronically and revised, as indicated. Administrative representa-

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tives from system and site finance and nursing pledged support for the practice change. The director of neonatology presented proposed protocol and documents supporting practice change to the departments of pediatrics, and obstetrics and gynecology. Upon approval, nurse managers and educators developed individualized and sitespecific education plans for team members, including evidence supporting the practice change. Implementation occurred concurrently at all sites with posting of the new protocol on the system’s internal policy and procedure database. Development and implementation of the protocol posed significant challenges. The protocol required consideration of varying environmental and staffing configurations. Providing the patient with the care in the protocol became paramount to how and where that care was provided. Full implementation did not occur until 1 year after process initiation. Chart reviews demonstrate consistent implementation of the protocol at all sites. Implications for Nursing Practice Nursing involvement in developing and implementing evidenced-based protocols validates practice decisions and affects patient outcomes. The development of this particular protocol standardized care and created avenues for measuring outcomes for the late preterm infant. Comparisons of readmission rates, weight loss during hospitalization, and days to discharge before and after protocol implementation are currently in progress.

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Collaborative Conferencing: AWHONN and ACOG Joint Venture to Improve Patient Safety Purpose for the Program he purpose of this poster is to describe how to implement a collaborative conference to enhance patient safety. Recently, a number of publications have touted the benefits of team training to improve obstetric outcomes during emergent situations. However, very little has been published regarding multidisciplinary education and improved patient safety in other venues. In 2010, the Association of Women’s Health, Obstetric and Neonatal Nurses’ Ohio Section and the American College of Obstetricians and Gynecologists’ (ACOG) Ohio district planned a joint venture conference to be held in August 2011 with a focus on collaborative education to promote patient safety.

Implementation, Outcomes, and Evaluation The conference planning was approved by the leadership of both organizations. A preliminary budget was developed and agreed upon by both parties. The agenda and flyer was developed and distributed across the state and to neighboring states. Additionally, a callout for poster abstracts was done and leaders from both AWHONN and ACOG sought out exhibitor support. On Saturday, August 20, 2011, the conference was held in central Ohio. This joint venture drew 120 attendees, 12 exhibitors, and 17 poster presenters. Evaluations were positive and attendees cited planned practice changes for themselves and for their respective institutions.

Proposed Change Collaboration and a common purpose can drive change. Multidisciplinary topics were offered to a joint audience at the AWHONN/ACOG conference. Such topics included oxytocin administration, outpatient quality, late preterm deliveries, safety culture, and obstetric simulations. These topics were chosen because they are applicable to physicians, advance practice nurses, and nursing staff. The presenters were nursing professionals as well as physicians, which enhanced the atmosphere of collegiality.

Implications for Nursing Practice The implications for nursing practice are clear. Nurses need to collaborate with physician colleagues to improve patient safety. Likewise, physicians need to collaborate with nurses to improve patient safety. By offering a collaborative conference, enhanced awareness of the roles of others can occur and best practices shared with all involved in patient care to improve safety and outcomes.

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Jennifer L. Doyle, MSN, WHNP, Summa Health System, Wadsworth, OH Amy Burkett, MD, Summa Health System, Akron City Campus, Akron, OH Robert Flora, MD, MBA, MPH, Summa Health System, Wadsworth, OH Linda Newhouse, MSN, RNC, WHNP, Riverside Methodist Hospital, Columbus, OH Keywords collaboration multidisciplinary education team training patient safety

Professional Issues Poster Presentation

Putting the Pieces Together: A Collaborative Approach to Scenario-Based Training Purpose for the Program o provide a safe learning environment for staff to build on their prior knowledge, improve understanding of roles during high-risk and highstress scenarios, and increase communication between members of the women’s care staff and the staff from other units at Saint Joseph East.

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Proposed Change The staff-based education committee sought new and innovative methods to perform competency validation for annual training that included a realistic clinical setting in which staff could build on their own knowledge, relate the scenario to real life, and develop their skills in a safe learning environment that did not compromise patient safety. Improvement in communication and teamwork both from intradepartmental and interdepart-

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mental perspectives was also part of the proposed Elaine G. Smith, BSN, RNC, Women’s Hospital at Saint change. Joseph East, Lexington, KY Keywords scenario-based training

Implementation, Outcomes, and Evaluation teamwork Key staff members and leaders were identified communication and asked to participate in the collaborative mul- competencies tidisciplinary scenario team. A standardized scoring rubric was developed to assess learning and success outcomes. Quarterly scenario-based Professional Issues drills with scores of 90 or greater on the standardized rubric were one part of the desired outcome. Poster Presentation Program effectiveness also was determined from the staff’s reports that they felt decreased anxiety, improved critical thinking skills, and improved communication and teamwork among staff during scenario-based training and in real-life situations. This program is ongoing and the outcomes and evaluation are still being monitored.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

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Bowling, C. Z.

Proceedings of the 2012 AWHONN Convention

Implications for Nursing Practice Perhaps the first lesson from this program that has affected nursing practice at the Women’s Care Hospital is that practice really does make perfect; the once per year checklist is not always enough to prepare a staff member for real-life high-risk scenarios. Nurses also now feel like they

have a voice and have the opportunity for open dialogue with staff and physicians from their areas and other departments. This program’s most valuable implication is that staff members have discovered that communication is key, that each person and department is critical in a high-risk scenario, and that it takes teamwork to promote good patient outcomes.

Challenges to Implementing the AWHONN Staffing Guidelines Carmen Z. Bowling, RN, MSN, Purpose for the Program Wilson Memorial Hospital, o improve the current nursing staffing plan Sidney, OH Keywords AWHONN staffing guidelines patient safety challenges

Professional Issues Poster Presentation

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and, thereby, improve patient safety.

Proposed Change To implement the recommended Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) staffing guidelines in a level l family birth center. Implementation, Outcomes, and Evaluation Implementation began with education of the charge nurses, which included mandatory participation in the AWHONN Web-based seminar on the staffing guidelines. Monthly charge nurse committee meetings were dedicated to education and practicing different scenarios of the staffing plan based on the staffing guidelines. Second, a charge nurse sheet was created to include an audit tool to assist the charge nurse in identifying when there was a staffing variance in comparison with the staffing guidelines. The charge nurse sheet provided a more accurate assessment of current staffing levels in 4-hour increments and an opportunity to determine if staffing levels were appropriate for the next 4-hour increment. Each charge nurse sheet was carefully reviewed by the charge nurse committee for learning opportunities. Lastly, initiation of the new staffing plan based on the AWHONN guidelines began in November 2010 using a three-phase approach. Phase one implemented the intrapartum aspect of staffing, which was adjusted to accommodate la-

boring patients, cesarean births, and postpartum recovery for vaginal and cesarean births. Phase two introduced the postpartum/newborn care aspect of staffing, which was adjusted to accommodate postpartum couplets and newborn care. Phase three was the implementation of the antepartum/charge nurse role change, which was adjusted to accommodate triage patients and charge nurse availability. Transition to the recommended AWHONN staffing guidelines occurred with the following challenges having the greatest effect on staff: failure to rescue as it relates to the perinatal team’s ability to gather resources required to decrease risk of adverse events in situations of obstetric complications and emergencies; and staff turnover as it affects staff morale because of the inability to spend time with patients, increased workload, and inability to meet the guidelines as recommended. Implementation of the phases should have progressed over a longer period of time to ensure the educational component for the staff and the completion of one phase before concurrently moving on to the next. Labor, delivery, recovery, and postpartum (LDRP) room staffing is unique for a level l facility as all areas and all implemented phases affect one another. Careful analysis of data will provide justification for additional staff if needed as well as improvement of patient safety outcomes. Implications for Nursing Practice Appropriate staffing plans and careful monitoring of outcomes are needed to ensure patient safety.

Intimate Partner Violence: Igniting Awareness and Increasing Referrals to a Hospital Based Program Cindy Hartwig, MS, RN, Purpose for the Program Northwest Community ur intimate partner violence prevention proHospital, Arlington Heights, IL

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gram, WINGS at Northwest Community Hos-

pital, utilized a nurse champion model to deliver staff education and implement screening for all adult patients and subsequent referral. A similar model was used for physician

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offices and included on-site education for office staff to achieve the same outcomes. Proposed Change Since the start of the program in 2007, although several methods were used to educate and increase awareness for the key stakeholder groups, referrals for counseling remained flat. In 2008, a plan was created to develop a nurse champion model for peer-to-peer education as well as a “pharmacy detailing” model with a physician champion for physicians’ offices. In addition, several initiatives were developed with the input of these two groups to provide enhanced just-in-time education for our community. Implementation, Outcomes, and Evaluation In June 2008, a workshop was held for 25 nurses who were identified by their unit leadership as nurse champions for intimate partner violence education and awareness. This training included the dynamics of intimate partner violence as well as a presentation from a survivor of intimate partner violence who emphasized the importance of screening. Training included methods of questioning using standardized questions, barriers to screening, our hospital policy, documentation, and the referral process for patients and staff. Nurse champions were challenged to create unit-based goals for education and awareness. Champion follow-

up included monthly meetings with unit reports on progress. Outcomes from this group included increased compliance with education, changes to the standardized questions, and creation of a resource card for patients and visitors, which can be found in all public bathrooms and put discretely in a shoe or pocket. The group has a yearly workshop to re-energize and plan activities. Awareness activities planned for 2011 include a purple ribbon campaign on campus trees, toiletry drive for WINGS residents, and a quarterly nurse champion newsletter, which contains ongoing evidence-based information about intimate partner violence and the WINGS at Northwest Community Hospital program.

Keywords nurse champion peer-to-peer education intimate partner violence

Professional Issues Poster Presentation

Education for physicians and office staff was presented in collaboration with a Northwest Community Hospital physician champion and the WINGS hospital liaison and held in the physician offices. Outcomes included standardized screening to identify and refer patients. Referrals to the WINGS at Northwest Community Hospital counseling services are tracked by provider type and have demonstrated growth since both programs were implemented. Implications for Nursing Practice The nurse champion method of peer-to-peer education provides a strong foundation to achieve change.

Code 77, 1 Page, 1 Team: Maternal-Fetal Emergencies Requiring a Cesarean Birth. One Hospital’s Multidisciplinary Journey Purpose for the Program mergency cesarean births occur everyday in the United States. These high-risk surgical procedures require a unified multidisciplinary response to optimize maternal–fetal outcomes. Nationally, the recommended guideline for an emergency cesarean birth is 30 minutes from decision to incision. Oftentimes, 30 minutes is too long. Our high-risk tertiary center determined that there needed to be a marked improvement in moving obstetric patients from labor and delivery to the operating room. In turn, this would improve time lines in expediting an emergency delivery leading to a successful maternal–fetal outcome.

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Proposed Change Effective response to an emergency cesarean birth requires a multidisciplinary approach. We created a multidisciplinary committee that in-

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cluded perinatal nurses as well as physicians from the departments of obstetrics and gynecology and anesthesia. Standardization of our ability to respond to emergency cesarean delivery was the central theme of our process improvement.

Implementation, Outcomes, and Evaluation A multidisciplinary policy was developed that reflected the roles and responsibilities of those personnel involved with a “Code 77.” The staff was educated through e-mails, staff meetings, and bulletin boards. After a Code 77 has occurred, a debriefing form is completed by the charge nurse and the attending obstetrician. Problems and areas for improvement are identified. The turn around time for improvements is 24 to 48 hours. A key component of our success was the development of a group page that enabled us to page our entire team with one phone call. The team includes three obstetricians, two anesthesiologists,

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Sue Ellen Abney-Roberts, RNC, MSN, C-EFM, Georgia Health Sciences Medical Center, Augusta, GA Keywords emergency cesarean multidisciplinary team quality improvement

Professional Issues Poster Presentation

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Miller, K. L., Leimberger, A. E. and Brickey, J.

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a neonatal resuscitation team, labor and delivery staff, and key nursing leadership. Periodically, Code 77 drills are conducted to ensure that all steps of the policy are followed and system errors are identified. The time an emergency is identified until the patient leaves the labor room averages less than 60 seconds. The average time from decision to incision has decreased from 12 minutes to 7 minutes specifically in those cases where fetal bradycardia occurred and the patient required general anesthesia.

Implications for Nursing Practice Standardization of emergency cesarean birth processes can save valuable time in an emergency. The establishment of a process improvement program will help in the identification of processes that need to be revised or updated. By having a multidisciplinary team, the ideas and tasks that need to be accomplished are at the forefront of providing quality care to ensure an optimal maternal–fetal outcome.

Perinatal Nurse Wars: “Getting Beyond Us versus Them” Purpose for the Program fter a shared drill that was negatively affected by obvious fractures in the personal relationships between our antepartum, labor and delivery, Alyssa Elaine Leimberger, and mother–infant units, we were brought back RNC-OB, BSN, Bon Secours to our hospital-wide model of relationship-based St. Mary’s Hospital, Richmond, care. One of the three pronged focuses of this care VA model is our relationship with our colleagues. This Jennifer Brickey, RN, Bon was the beginning of the formation of our divisional Secours St. Mary’s Hospital, relationship-based care team. Kasondra Lynn Miller, RNC-OB, C-EFM, Bon Secours St. Mary’s Hospital, Richmond, VA

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Richmond, VA

Keywords relationships communication quality safety job satisfaction

Professional Issues Poster Presentation

Proposed Change Each unit identified three nurses that expressed specific concerns and invited them to serve on the committee. These were nurses that were not highly involved in other areas of our units but were interested in improving relationships. They were felt to be team players and solution seekers who displayed constructive behaviors in the past. We asked them to seek feedback from their peers. Prior to beginning, we enlisted a facilitator from outside our division and we each read the book, Crucial Conversations. Implementation, Outcomes, and Evaluation Our first meeting began with a symbolic devotion: each nurse gave a hand massage to another nurse from a different unit. The message was that each of our hands affects the birth experience of all of our patients. Representatives brought the most pertinent issues they had identi-

fied. Our defined objectives were to focus on improvements in relationships, communication, care delivery, and workflow processes. The committee identified five areas of focus: (a) issues surrounding family-centered care; (b) hand-offs between all three units; (c) role definition when floating among units; (d) contingency plans during crucial times of diversion or threatened diversion; and (e) the antepartum unit’s “step child” perception. We developed an action plan and follow-up person(s). Progress of the committee includes the creation of a “baby communication” notepad to facilitate safe transfer; the revision of the couplet report tool; the diversion watch stork system was created and implemented; the antepartum/labor and delivery patient report was revised; meetings were facilitated between the antepartum unit and physicians to find ways to meet each other’s needs; and the antepartum nurses felt validated by sharing their “step child” perceptions. Implications for Nursing Practice Our initial plan had been for this committee to meet for a finite, focused period of time, but the benefits of this committee had become clear. This committee is an excellent example of bedside nurses coming together in a professional way to improve relationships and communication between units, thereby increasing job satisfaction, efficiency, and patient safety.

Use of Neonatal High-Fidelity Simulation in Rural Nursing Schools Alissa R. Parrish, RN, MSN, The University of Tennessee at Martin, Martin, TN

Purpose for the Program s the nursing shortage increases nursing school admission also increases. Accredited nursing programs strive to provide nursing students with quality, up-to-date, innovative ed-

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ucation. Rural nursing schools struggle to provide these students with adequate hands-on neonatal care. Decreasing obstetric care in rural hospitals and the competitive pool of clinical sites contribute to an increasing struggle. The

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purpose of this presentation is to disseminate the use of simulation education in our rural university setting.

Shirley A. Fry, RN, MSN, The University of Tennessee at Martin, Martin, TN

Proposed Change Incorporation of at least six high-fidelity simulated clinical hours per student dedicated to the care of both the high- and low-risk neonate into a maternal–child nursing care course.

ical hours with hands-on experience to students who would otherwise receive minimal observation clinical time. The simulation lab does not take the place of current in-hospital clinical time but augments the students’ comfort and knowledge with additional hands-on clinical hours. Students and faculty verbalize an increased satisfaction and preparedness with the use of the simulated neonates.

Implementation, Outcomes, and Evaluation Initiation of the high-fidelity simulation program began with the purchase of two high-fidelity simulations capable of giving students experience with neonates in a safe, controlled environment. Faculty members attended an in-depth simulation training course to prepare for the program. A simulation lab area dedicated to these highfidelity simulators in the most realistic environment available has been constructed. Simulation scenarios are incorporated into both the theoretical and clinical aspects of the course. Return demonstration from the students is utilized in reproduced real-life settings using realistic newborn scenarios. Students have the ability to ask questions and the instructor provides appropriate, immediate feedback. Using the high-fidelity simulation permits nursing faculty to provide high-quality clin-

Implications for Nursing Practice Technology is progressing in health care and nursing schools by leaps and bounds. Nurse educators can utilize this technology to better prepare nursing students for practice. Use of high-fidelity simulation can provide hands-on experience to licensed personnel within rural hospital settings. Tough economic times may not lead the rural hospitals to purchase such equipment, but in collaboration with local nursing schools the hospitals can provide continuing education to their staff who may not receive frequent hands-on experience with high-acuity newborn circumstances. Collaboration between rural community hospitals and rural nursing schools may strengthen the clinical relationship and provide high-quality education to both organizations.

Professional Issues Poster Presentation

Keywords newborn simulation high-fidelity simulation clinical hours clinical technology

Electronic Medical Records: The Wave of the Future Purpose for the Program o provide direction on the selection and implementation of an electronic medical record. The 2014 mandate within the Affordable Care Act states that medical records must be in an electronic format by this year. The purpose of our initiative was to standardize language and documentation in an electronic format, thereby complying with the 2014 mandate. Administrative, clinical, and technical leadership partnered to achieve this goal. OB TraceVue, our choice of electronic medical record after much research, was found to be the best suited for our growing needs. Quality standardized documentation is vital in providing good communication among members of the health care team.

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Proposed Change To provide nurses with a common language for documentation. Implementation, Outcomes, and Evaluation Due to the significant effect that the electronic medical record would have on nursing practice, a team was developed, including management, a nurse educator, and a clinical nurse. Once it was determined which electronic med-

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ical record to use, we developed a time line for training and customization of the product. The key to successful implementation was dependent upon adequate training. Using the adult learning model, training involved super user sessions, team teaching for end users, and handson time in a test environment. Physicians were trained on how to access real-time nursing assessments by using a hands-on interactive training approach. This practice team also determined that going live all at once with documentation and forms would be too overwhelming and so the “go live” phases were separated into three phases that followed the continuum of the patient’s stay.

Carol Ann O’Connell, BSN, RNC-OB, Saint Joseph East Hospital - Saint Joseph Health System, Lexington, KY

Implementation of OB TraceVue has been an ongoing, interactive, and evolving process. An ongoing improvement process through the use of employee training sessions, a corrective action counseling system, and system administrator training is a critical factor in the success of our electronic medical record. Continued nursing and system audits, as well as a collaborative effort with the vendor for upgrades, are essential for success. Feedback from not only the nursing staff but also the physicians has been an essential part in making this transition from paper to an electronic

Professional Issues Poster Presentation

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Trisha Goode, ADN, RN, Saint Joseph Healthcare System, Lexington, KY Elaine G. Smith, BSN, RNC, Women’s Hospital at Saint Joseph East, Lexington, KY Keywords documentation EMR implementation

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Abney-Roberts, S. E. and Norman, C.

I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

medical record. Our goal is to continue to provide the highest quality of health care we can to our patients while using a standard language to document this care.

Implications for Nursing Practice The implementation of an electronic medical record improves and secures a common language for documentation.

Patient Family Centered Care: It’s More than Open Visitation Purpose for the Program atient family centered care (PFCC) is a concept familiar to most health care professionals. The Institute of Medicine deChristy Norman, PharmD, MS, fines PFCC as care that is respectful and Georgia Health Sciences responsive to patient preferences, needs and valMedical Center, Augusta, GA ues, and ensures that patient values guide all clinical decisions. But when questioned, many health Keywords PFCC care professionals think PFCC means open visipatient-/family-centered care tation only. Patient family centered care was first patient advisors implemented at Georgia Health Sciences Health System in 1993 during the planning and design of the Children’s Medical Center. Patients and their Professional Issues families were intimately involved in every decision meals to sleeping arrangements. These conPoster Presentation from cepts of PFCC have become an integral component of our mission and vision, and PFCC is a vehicle to improve patient satisfaction, quality, and safety. Sue Ellen Abney-Roberts, RNC, MSN, C-EFM, Georgia Health Sciences Medical Center, Augusta, GA

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Proposed Change Perinatal services identified several opportunities for improvement, including establishment of a patient advisory council, targeted education of medical and nursing staff, renovations of the women’s health unit into a state-of-the-art environment approved by current and former patients, and a work redesign implementing mother–infant couplet care with patient input.

Implementation, Outcomes, and Evaluation In 2007, the Children’s Medical Center Perinatal Patient Advisory Council was established. By 2009, renovations were underway based on input from patient advisors and key hospital employees. A significant work redesign was implemented with elimination of an admission/transition nursery and implementation of true mother–infant couplet care. Mothers and their newborns were no longer separated at birth. Patient advisors gave significant input on our infant security system. Patient education handouts and discharge instructions were redesigned to be user friendly and approved for use by our patient advisors. Specific comments on our Press Ganey surveys were examined. Patients and their families were routinely asked during bedside report and leadership rounds what could be done to “wow” them during their inpatient stay. Follow-up phone calls and patient satisfaction surveys have demonstrated that PFCC does make a difference. Implications for Nursing Practice Adoption of a patient-/family-centered care philosophy is pivotal to improving patient satisfaction and potentially affecting health care outcomes. In an academic institution, ensuring the involvement of patients and families in student and resident education can have a lasting effect on one’s health care career.

Growing Our Own: The Development of an Internship/Residency Program for a Hospital Division Lynn Campanaro Gross, RN, The Medical Center of Plano, Plano, TX

Purpose for the Program he North Texas Division of Hospital Corporation of America wanted to develop a compreLisa Price, RNC-OB, The hensive intern/residency program for labor and Medical Center of Plano, Plano, delivery nurses. The purpose of the residency is TX multifaceted: to ensure that new labor and delivRenee’ Jones, MSN, RNC-OB, ery nurses are educated using the newest inforWHNP-BC, Medical Center mation from evidenced-based practice; to ensure Plano, Wylie, TX that all of the labor and delivery interns/residents in the North Texas Division are taught the same material; to build a rapport among the residents/staff by providing monthly reflective learning opportunities to the residents to ease their

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transition into practice; and to establish a cohesive curriculum that will decrease the amount of time each educator spends developing individual internships. Proposed Change The proposed change involves moving from a facility-specific orientation/internship to developing a division-wide residency that addresses the complex needs of the new graduate. Instead of simply focusing on the didactic and skills that a new labor and delivery registered nurse will need, our residency will address the socialization needs

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of new hires, and ease their transition into practice. In addition, the change to a division-wide residency allows the labor and delivery educators from each facility to collaborate and develop an education plan that will be used by many hospitals. Implementation, Outcomes, and Evaluation The chief nursing officers from the North Texas Division were responsible for presenting the idea of a residency to the North Texas Division. Once the internship/residency was approved, the human resources departments at each facility were responsible for posting the positions and screening the applicants. The nurse managers at each facility hired the interns/residents. The response to the residency was met with approval and great enthusiasm. Hundreds of applications were received,

allowing each facility to choose exceptional candidates. In the future, we will measure overall sat- Keywords isfaction of the residents as well as retention rates. residency internship socialization

Implications for Nursing Practice By developing a comprehensive, cohesive internship/residency, we will enable the labor and delivery nurses in our division to be exposed to the highest quality education possible. Implementing the reflective learning and socialization process will demonstrate to our residents the hospital system’s commitment to their personal and professional development. In developing a uniform residency across all of our division’s hospitals, we will ensure that all nurses will be exposed to the same level of education, which will facilitate sharing of competent employees.

Professional Issues Poster Presentation

Community Partnership for Level III Neonatal Intensive Care Unit Skills Purpose for the Program o describe an innovative new orientation program that was begun in 2011 with registered nurses from St. Elizabeth Healthcare and Cincinnati Children’s Hospital Newborn Intensive Care Unit.

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Proposed Change To increase knowledge, confidence, and skills for registered nurses at St. Elizabeth Healthcare who are preparing to transition from a Level II to Level III neonatal intensive care unit (NICU). The proposed unit would provide ventilation and other services to infants born between 28 and 32 weeks gestation. Implementation, Outcomes, and Evaluation The program was developed by nursing leadership from St. Elizabeth Healthcare and Cincinnati Children’s Hospital Newborn Intensive Care Unit. The training program is a combination of learning experiences, online and classroom education and clinical time in the Level III NICU. During the 160 hours of hands-on training in the NICU, the registered nurses are under the direct supervision of a preceptor who is a clinically advanced registered nurse. Weekly meetings took place with

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the Cincinnati Children’s Hospital Newborn Intensive Care Unit Level III NICU educator to discuss and individualize learning experiences for each registered nurse, including observations with respiratory therapy, unit charge nurse, speech pathology, and the peripherally inserted central catheters team. Newborn Individualized Developmental Care and Assessment Program’s theory, principles, and techniques introduced at Cincinnati Children’s Hospital Newborn Intensive Care Unit were reinforced with programs at St. Elizabeth Healthcare. A final evaluation of the program will occur with a simulation day that is planned for November 2011 to safely practice interaction and clinical skills without compromising the safety of real neonatal intensive care unit infants.

Christina L. Rust, MSN, RNC-OB, C-EFM, St. Elizabeth Healthcare, Edgewood, KY Keywords orientation Level III NICU nursing education transition simulation

Professional Issues Poster Presentation

Implications for Nursing Practice This program is an exemplary demonstration of two health care facilities working together to implement best practice via a cooperative educational agreement. St. Elizabeth Healthcare and Cincinnati Children’s Hospital Newborn Intensive Care Unit are both Magnet hospitals that continually focus on the importance of collaboration, innovation, and the enhancement of professional growth and development of nurses.

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Schultz, L.

Proceedings of the 2012 AWHONN Convention

Applying a Multidisciplinary Approach Using the TeamSTEPPS Communication and Teamwork Methodology While Debriefing a Critical Event Simulation Laurel Schultz, MS, RN, Purpose for the Program C-EFM, Highland Hospital and his innovative safety program incorporates a MCIC Vermont, Inc., multidisciplinary approach to team debriefRochester, NY, NY

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Keywords adverse events perinatal safety nurse simulation team training communication safety attitude questionnaire

Professional Issues Poster Presentation

ing and high-fidelity simulation-based training during a simulated critical event (shoulder dystocia). This simulation program includes all providers (physicians, midwives, nurses, and residents) associated with our obstetric unit and reinforces the concept of patient safety through practiced communication and teamwork.

Proposed Change Simulation participants will be given the chance to apply their previously learned TeamSTEPPS knowledge and skills to a critical patient scenario on an annual basis. In turn, this simulation program will be successful in establishing an effective approach for all disciplines with each patient encounter. Implementation, Outcomes, and Evaluation Several years ago, MCIC Vermont, Inc., our hospital’s risk retention group, developed the position of a patient safety nurse. The patient safety nurse not only works as a patient safety advocate, but also as a team training clinical nurse specialist through several MCIC driven initiatives. Among these initiatives are TeamSTEPPS team training and simulation. Each member of our health team must attend one initial 4-hour TeamSTEPPS class shortly after starting clinical work within our obstetric unit.

This course highlights the Agency for Healthcare Research and Quality’s TeamSTEPPS approach to teamwork and communication. Our simulation program was introduced not only for skills-based training, but to reinforce and practice/apply interdisciplinary teamwork and communication taught within this TeamSTEPPS course. Each attending physician, midwife, registered nurse, and resident must attend at least one simulation annually to sustain their skills. It is expected that our unit’s safety culture will continue to show growth, which has resulted in a significant reduction in adverse outcomes. Also, an evaluation tool is anonymously completed by all participants after completing each high-fidelity simulation. So far, all responses have been very positive. In addition, every 18 months we measure our culture of safety by administering Sexton’s Safety Attitudes Questionnaire. All disciplines practicing within our obstetric unit participate with this research tool. So far the teamwork and safety scores have steadily risen reflecting a positive attitude toward our simulation program as well as other initiatives. Implications for Nursing Practice Effective communication, collaboration, and teamwork are central to professional nursing. All are crucial within the clinical settings and bring research-based quality care to the bedside for those patients who depend on us.

Utilization of Simulation Based Training for Annual Competency Day for Labor and Delivery RNs Susan Crafts, MS, RN, Beth Israel Deaconess Medical Center, Boston, MA

Purpose for the Program o provide opportunities to safely practice specialized care and behaviors for infrequent but Tracey Pollard, RNC, BSN, potentially catastrophic obstetric problems requirBeth Israel Deaconess Medical ing emergency attention. By using simulated sceCenter, Boston, MA narios as part of our annual competencies our goal was to provoke each learner to demonstrate Barbara B. Stabile, RN, MS, Beth Israel Deaconess Medical nursing assessment, medical knowledge, techniCenter, Boston, MA cal skill, and teamwork behavior.

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Proposed Change To challenge our nursing staff and allow them to make mistakes in an environment that is safe and supportive with no real harm to patients. Discover

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performance and knowledge gaps, focus education, and increase confidence in managing emergent situations. Implementation, Outcomes, and Evaluation The first two groups of nurses completed the competency day and simulations in September of 2011. The nurses were actively engaged in their learning and were willing participants in the scenarios. Staff were asked to complete an evaluation after the program and these will be reviewed after each competency date as well as after all staff have completed the simulations. The leaders will meet after each date to review and debrief

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regarding what went well and what can be improved. The multidisciplinary participation was invaluable. The goal is to further explore ways in which we can have these simulations be truly multidisciplinary, with each discipline meeting their learning objectives. Implications for Nursing Practice This is a safer way for staff to practice their assessment and technical skills and teamwork behaviors.

We hope that by practicing in this safe environment, our care will be safer for the patient, and the staff will feel more competent and confident in their skills. We also identified gaps in knowledge regarding some systems that the leadership team will address in the coming months (e.g., how to get certain infrequently used items from the main operating room).

Keywords simulation psychological safety obstetric emergencies competencies teamwork

Professional Issues Poster Presentation

Playing with Dolls: Effective Utilization of Simulation for Staff Training and Quality Improvement Outcomes Purpose for the Program iscuss the effective use of simulation in the clinical setting for the obstetric population.

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Proposed Change Utilization of multidisciplinary simulation in the clinical setting. Implementation, Outcomes, and Evaluation We will briefly discuss barriers to simulating in the acute setting and focus on eliminating those barriers. Barriers include scheduling simulation, getting staff buy-in, and ensuring multidisciplinary involvement. Every effective education implementation should be accompanied by a tracking sys-

tem, and we will review the use of an online learning management system to track staff participation. Additionally, we will examine how simulation can be used to provide measurement for quality improvement and to evaluate effectiveness of hospital specific protocols with a case study review of a massive hemorrhage protocol implementation that was supplemented by data collected during simulation. Implications for Nursing Practice Improved practice of the bedside clinician, improved teamwork, and improved quality outcomes.

Bridget Lai, RNC, Kapiolani Medical Center for Women and Children, Honolulu, HI Keywords simulation electronic team multidisciplinary education training

Professional Issues Poster Presentation

“Share the Wealth”: Shared Governance in the Neonatal Intensive Care Unit Purpose for the Program n 2007, our organization embarked on a journey to establish shared governance throughout the nursing division of our hospital. Shared governance is a nursing model that revolves around moving power and decision making to the level of action. This movement gives health care professionals autonomy over their practice and extends their voices into decisions previously made by managers.

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Proposed Change All nurses in our organization are encouraged to participate in shared governance at the unit level through the unit coordinating council. The unit coordinating council manages unit decision making through six councils: practice, service/satisfaction, research, quality/safety, professional development, and leadership. The chair of each unit council serves on their respective council at the organization level, facilitating the dissem-

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ination of ideas. These councils meet monthly on Wednesdays. The chair of each council serves on the Nursing Coordinating Council, which functions as a clearinghouse and disseminator of information and decisions to the appropriate council for action.

Implementation, Outcomes, and Evaluation Our success is attributed to best practice and the desire to see goals accomplished. Leaders are committed to empowering staff nurses to be involved in decision making by arranging for nurses to have scheduled time to attend meetings and work on projects in the midst of tighter budgets. Finally, our success is demonstrated by our excellent outcomes, which motivate staff to continue to be involved and commit to the next initiative to improving our practice. Our outcomes are the following:

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Shelly Rhoney, RNC, Carolinas Medical Center-Northeast, Jeff Gordon Children’s Hospital, Concord, NC Keywords shared governance power decision making Nursing Coordinating Council Unit Coordinating Council empower

Professional Issues Poster Presentation

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Howell, T. and James, T.

Proceedings of the 2012 AWHONN Convention

r r r r r r

Leadership: Self-scheduling, peer interview team. Practice: Developed policies for unit practice changes: kangaroo care, cue-based feeding, and care of micropreemie. Professional development: Unit skills fair, “Policy of the Month” as continuing education. Service and Satisfaction: Neonatal intensive care unit parent support group, developed floating expectations for staff. Research: Cue-based feeding research project. Quality and safety: Because of a catheter associated blood stream infection initiative and a methicillin-resistant Staphylococcus aureus

action plan, we have more than 1,000 days with no reported cases of catheter associated blood stream infection, and we have been methicillin-resistant Staphylococcus aureusfree for almost 1 year. Implications for Nursing Practice Our unit’s mission is to patient and family first, set goals for patient care, and believe in ourselves to achieve the goals we have set. To achieve our mission, we had to change the way we think: This unit belongs to us. We have a voice. Together, with leaders, we control practice and what happens in the practice environment. Shared governance has helped us to reach our goals and go far beyond our wildest dreams.

Innovative Instructional Design to Alleviate the Shortage of Clinical Practice Sites for Education Through the Use of a Simulated OB Experience Purpose for the Program se of simulation in nursing education is a very effective pedagogy that provides students Teresa James, MSN, RN, CNE, with an opportunity to practice clinical decision Morehead State University, making in an environment that does not permit Morehead, KY harm to actual patients. Even when clinical sites are available for maternal/newborn nursing the exKeywords perience is many times an observational experiinstructional design simulation ence only. This leaves students without the skills critical thinking to critically think and perform in maternal/newborn practice. Providing simulated experiences can facilitate the learning process. Teresa Howell, MSN, RN, CNE, Morehead State University, Morehead, KY

Professional Issues Poster Presentation

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Proposed Change The Associate Degree in Nursing program at Morehead State University has doubled its enrollment and opened an extended campus. Although the student population is growing, clinical site growth has remained stagnant. Providing handson experience through clinical rotations is an essential component of a nursing student’s education. However, the availability and accessibility of obstetric clinical sites is becoming a potential barrier for providing nursing students with an optimal learning environment. The Department of Nursing at Morehead State University addressed this issue by embracing the use of clinical simulation to enhance student’s critical thinking, increase student

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retention, and provide students with high-risk situations and low-risk outcomes. Such a learning environment will promote teamwork while encouraging communication, constructive critiquing, and the reflection of client outcomes. Implementation, Outcomes, and Evaluation Low-fidelity scenarios were initially implemented. Each semester the scenarios are enhanced to meet student learning objectives for the course. Clinical simulation was used in maternity and newborn where clinical experiences were limited. Student responses to the questions and faculty observations indicated that more time was needed for the simulation, along with orientation to the lab. Overall, both students and faculty found that clinical simulation is very beneficial in helping develop clinical decision making skills and promoting critical thinking. Implications for Nursing Practice Use simulation to provide maternal/newborn experiences to nursing students to facilitate critical thinking skills that can be used in maternal/newborn practice. Simulation also is used to give students hands-on experience in high-risk situations, such as postpartum hemorrhage and shoulder dystocia.

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Let’s TWIST (Teambuilding in Women’s Health Incorporating Simulation Training): Implementing Obstetric Crisis Simulation Program Purpose for the Program n 2009, Baltimore Washington Medical Center opened the Pascal Women’s Center offering maternal–child services. As the unit was in its developmental phase, the management team and the unit’s quality team decided it would be beneficial to implement simulation training in the new obstetric unit to ensure that staff developed and maintained crisis skills.

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Proposed Change The group recognized required changes in patient outcomes and staff training. Implementation, Outcomes, and Evaluation In December of 2010, Pascal Women’s Center instituted their version of simulation training called TWIST, Teambuilding in Women’s Health Incorporating Simulation Training, which includes managing patients with shoulder dystocia, postpartum hemorrhage, prolapsed cord, and neonatal resuscitation. During this training, clinical skills, crisis management processes, and TeamSTEPPS tools were incorporated. Each scenario was videotaped followed by a debriefing period. The staff and facilitators identified areas of strength and developed a commitment to improve our processes of managing obstetric crises. The initial phase of simulation training inspired new ideas for continuing the TWIST program. The leadership team felt crisis training makes a significant improvement in outcomes and staff readiness. According to the Hospital Consumer Assessment of Healthcare Providers and Systems surveys, per-

ception of safety before institution of TWIST training was 79% and after institution safety perceptions increased to 89%. Therefore, every month TWIST facilitators conduct an unannounced simulation training in which the staff engages in realistic scenarios to improve safety, processes, and maternal–neonatal outcomes. One TWIST scenario examined a newborn resuscitation in the mother–infant unit. Our goal was not only to review clinical skills of the neonatal resuscitation program, but also to examine the processes and resources for staff within the organization. During this TWIST training, the team was able to identify telecommunications failure to reach all essential obstetric and pediatric staff. Another issue identified was a breakdown in the emergency call buttons, requiring follow-up by facilities. TWIST training enlightened the staff to clinical and operational breakdown. As a result, this scenario prepared staff clinically for preventing operational breakdowns that may have occurred in an actual emergency.

Kendra Ellison, MS, RNC, Baltimore Washington Medical Center, Glen Burnie, MD Michele Lynn Bierman, RN, Baltimore Washington Medical Center, Glen Burnie, MD Ivana Knitowski, RN, Baltimore Washington Medical Center, Glen Burnie, MD Keywords simulation training TeamSTEPPS outcomes

Professional Issues Poster Presentation

Implications for Nursing Practice Pascal Women’s Center is now involving different departments into our monthly training, which includes the emergency department, blood bank, emergency medical services, and laboratory. Through the incorporation of these units, the goal is to optimize patient care and emergency responses. TWIST is recommended to other units and organizations in order to focus on patient safety and improve outcomes.

Maternal Code: You Have 4 Minutes. Are You Ready? Purpose for the Program he Women’s Center at University Community Hospital has been participating in postpartum hemorrhage drills and shoulder dystocia drills for the last year. Maternal code drills have been discussed for many years and it was time to take action.

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Proposed Change We came up with a plan to begin maternal code drills in the labor and delivery unit.

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Implementation, Outcomes, and Evaluation To implement maternal code drills at University Community Hospital, we had to first come up with a game plan. The best way to formulate a plan was to have an interdisciplinary approach. The director, nurse manager, team leaders, clinical nurse coordinator, anesthesiologist, and obstetrician all met to do a walk through in a labor and delivery room for the drill. Role cards were created for the primary nurse, team leader, additional registered nurses, unit secretary, anesthesiologist, obstetrician, and nurse tech. The policy for cardiopulmonary resuscitation in the obstetric patient was

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

Patricia Walton, BSN, RNC, Florida Hospital Tampa, Tampa, FL Keywords maternal code drills cardiopulmonary resuscitation primary nurse

Professional Issues Poster Presentation

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Boisvert, M. E.

Proceedings of the 2012 AWHONN Convention

revised to reflect the role definitions. Once the policy was reviewed and signed off by the chief of obstetrics and one of our perinatologists, the policy went to the critical care committee for final approval. A slide presentation was created, printed, and placed in a notebook for a month. The entire staff had the opportunity to review, prepare, and ask questions about the upcoming drills. The code cart used for hospital-wide staff training was extremely outdated and we didn’t have a manikin. With the help of one of the team leaders, a pregnant belly was hand sewn that fit on the torso of a cardiopulmonary resuscitation manikin. Once a

blonde wig and hospital gown were added, we had our patient. In July 2011, the women’s center ran 10 maternal code drills. The drills were a huge success and all team members were able to acquire valuable experience to improve patient safety. Implications for Nursing Practice Being prepared for high-risk, low-volume emergencies have been the subject of many articles and research. However, actually getting started and motivated to run drills is not always easy. It’s time to stop talking about it and implement maternal code drills at your facility.

The Impact of Culture: Our Hospital’s Journey to Designation as a Baby Friendly Hospital Mary Ellen Boisvert, MSN, CLC, CCE, Southcoast Hospitals Group, Wareham, MA Keywords Baby-Friendly Hospital Initiative nursing practice culture breastfeeding

Professional Issues Poster Presentation

Purpose for the Program o demonstrate the link between hospital culture, nursing practice, and implementation of the Baby-Friendly Hospital Initiative. Best nursing practices are those that combine art and science. There is evidence for specific hospital practices that will promote breastfeeding success. However, a hospital’s culture can greatly affect and influence breastfeeding success from early pregnancy through the postpartum period. There is an intricate relationship between best practices in our maternity setting with care that is holistic and patient centered. Practices that are ingrained into our culture include all of the elements of the 10 steps to successful breastfeeding as supported by the Baby-Friendly Hospital Initiative. The ability of the nurse to integrate the science of lactation with the nuances of the human response to labor and birth is the foundation for breastfeeding success.

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Proposed Change Change practices within the maternity setting to promote successful breastfeeding. Implementation, Outcomes, and Evaluation Implementation of best practices throughout the birthing and postpartum continuum to support optimal breastfeeding for newborns. Evaluation of success is through achieving designation as a Baby-Friendly hospital. Our process toward designation in the Baby-Friendly Hospital Initiative made us realize that our culture, which supports

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an environment that trusts the birth process, provided a foundation that empowers patients to be successful. Practices that are influenced by nursing, including early initiation of breastfeeding and skin-to-skin care; promoting rooming-in; and delaying the bath, create an environment where breastfeeding is promoted. The importance of an environment where the health care team is knowledgeable about the benefits of breastfeeding has been studied. However, the translation of the knowledge into practice, while integrating the individual needs of each mother–infant dyad is key to empowering mothers and achieving best outcomes. Hospital practices affect both the art and science of breastfeeding. Our model of care supports a family’s needs during this developmentally important time. A culture where birth is seen as a normal process is essential to promote physiologic changes for lactation and bonding of the mother– infant dyad. Recognizing that each mother–infant dyad is unique with individual experiences, while using evidence to promote best practice enables mothers to achieve success with breastfeeding. Implications for Nursing Practice Nurses are the key to ensuring that hospital practices promote breastfeeding. Nurses have the knowledge to integrate the science of lactation with the nuances of each patient’s experience to achieve breastfeeding success.

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Putting Together the Puzzle for Professional Development Purpose for the Program o describe the development and utilization of the professional development model at Grant Medical Center, Columbus, Ohio. Professional development for nurses can sometimes be puzzling. Although professional practice is more clearly defined, individuals can become overwhelmed with their own continued professional development. In our organization, the nursing professional practice model was developed by staff nurse members of our hospital-wide nursing congress. These nurses collaborated to determine the key concepts essential to nursing practice. Proposed Change To provide a tool to assist managers and nursing staff with their ongoing professional development.

adopted the model into their everyday practices. Although our professional practice model serves to guide nursing practice, it recently became obvious that a supplement to represent the development of an individual professional nurse also would be valuable. Again, we turned to the nursing congress. The model they developed is a creative, complex, and organized graphic tool that describes the concepts and extraordinary options available for professional development within our organization. The key concepts of the model include self-development, membership/leadership, role choices, recognition, and academic development. Our model serves as a vibrant visual tool that provides a framework to explore resource choices. Nurse leaders work with staff to coach and mentor their custom individual development plan.

Implementation, Outcomes, and Evaluation The tool has been developed and the benefits and results of the process, which are ongoing through Spring 2012, will be shared. The result is a creative representation of a downtown cityscape with the core elements of our nursing practice. A framed copy of the artistic schematic on every unit guides staff nurses to articulate the concepts. They have

Implications for Nursing Practice A Magnet hospital rich in resources benefited from a concise, graphic tool to assist with coaching and mentoring of every staff member. Using the model as a reference, managers can guide nurses in choosing puzzle pieces from the comprehensive list to create an individual pathway, making professional development less of an enigma.

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Mary Walters, MS, RN, Grant Medical Center, Columbus, OH Lianne Dickerson, BSN, CCRN, CNML, Grant Medical Center, Columbus, OH Kim Boggs, MSN, RN-BC, Grant Medical Center, Columbus, OH Keywords professional development model nursing practice model individual development plan

Professional Issues Poster Presentation

Implementing an Obstetric Navigator Program Purpose for the Program escribe the development of the role of obstetric navigator at a community hospital.

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Proposed Change Current issues in labor and delivery were affecting the patient, staff, and physician experience. We created the role of obstetric nurse navigator to improve coordination of care for the obstetric patients before, during, and after birth. The goal was to improve physician satisfaction and improve Hospital Consumer Assessment of Healthcare Providers scores.

Implementation, Outcomes, and Evaluation Implementation includes position approval, choosing the right person as the nurse navigator, and developing tools to measure outcomes. After 1 year, the navigator has improved staff, patient, and physician satisfaction. Implications for Nursing Practice The role of nurse navigator can be developed for any size hospital in most settings. Navigators have been shown to help patients through the maze of decisions and improve satisfaction. The role of the navigator in the obstetric setting is relatively new but has numerous benefits.

Sharon McCoy, MS, RNC, Johnston-Willis Hospital, Richmond, VA Keywords navigator care coordination role development

Professional Issues Poster Presentation

Answering the Call: Evaluation of the Obstetric Telephone Triage Process Purpose for the Program regnant patients frequently call obstetric triage to speak with nurses to obtain obstetric advice in regarding their pregnancies and im-

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pending labors. Nurses were providing a variety Megan Parsons, MSN, of responses, and many were not documenting RNC-OB, Banner Thunderbird their instructions during these phone calls. It not Medical Center, Glendale, AZ only created a liability for the hospital and the

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Johnson, T. S.

Proceedings of the 2012 AWHONN Convention

Keywords obstetric telephone triage reduced liability patient safety telephone assessment telephone advice

Professional Issues Poster Presentation

triage nurses, but it also created a safety issue for the patients on the phone. It became clear that an evidence-based process needed to be put in place to guide nurses’ telephone assessments for obstetric patients. Proposed Change To develop a telephone triage process that provides nurses with algorithms and standard documentation to utilize during patient calls to obstetric triage. This process will help to ensure that advice remains consistent among the nurses and will correlate with system standardized discharge instructions. Implementation, Outcomes, and Evaluation The current obstetric telephone triage process was put into practice in June 2009. A standardized documentation form was developed for effective and efficient documentation of calls. Standardized algorithms were made available to nurses to reference for phone assessment and to provide advice based on the type of patient complaint that was provided. Since implementation, staff have

demonstrated a significant increase in documentation adherence. Banner Thunderbird Medical Center obstetric triage nurses who voluntarily took an anonymous survey reported they agreed that the ability of obstetric triage nurses to provide safe patient care to telephone triage patients has been improved since the implementation of the obstetric telephone triage process. Implications for Nursing Practice The Banner Thunderbird Medical Center obstetric telephone triage process is supported by peerreviewed literature, as well as statements by the American College of Obstetricians and Gynecologists and the Association of Women’s Health, Obstetric and Neonatal Nurses. Nursing adherence with documentation of obstetric telephone triage phone calls has improved significantly since the implementation of the process. Nurses perceive a greater reduction of risk for the hospital and themselves and agree that they are able to provide safer patient care as a result of the process implementation.

Community and Academic Partnerships to Increase Breastfeeding Initiation, Duration, and Exclusivity among African-American Women Teresa S. Johnson, RN, PhD, University of Wisconsin-Milwaukee, Milwaukee, WI Keywords breastfeeding African American

Professional Issues Poster Presentation

Purpose for the Program dentify and encourage nurses from multiple inpatient and community settings to encourage and support African American (and all other) breastfeeding women.

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Proposed Change Identify institutional and community-based interventions in concert with community partners that have been demonstrated to be successful with multiple ethnic/racial populations in a culturally sensitive manner.

Implementation, Outcomes, and Evaluation Describe the many processes and relationships engaged to implement this program. The numbers of women participating have continued to increase, and many African American women have been eager to share their stories and experiences with other pregnant women to support them in their breastfeeding intentions. Explore strategies to increase the outreach of the program. Implications for Nursing Practice There are multiple ways through inpatient and community settings that nurses can provide education and support African American women and their families.

Illinois Department of Public Health Obstetric Hemorrhage Program: Outcomes and Lessons Learned Shirley Scott, MS, RNC, APN, University of Illinois at Chicago, Evanston, IL

Purpose for the Program n the United States, two to three women die everyday due to pregnancy-related complications. The three leading causes of national maternal death are eclampsia/preeclampsia, embolism,

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and hemorrhage. Of these causes, obstetric hemorrhage is known as the most preventable cause of maternal mortality. It is important to study maternal mortality and morbidity for two reasons: First, evidence suggests that at least one-half of pregnancy-related deaths may be preventable

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through changes in patient, provider, or system factors; and second, mortality rates are disproportionately high among certain racial and ethnic groups. In addition, deaths are only the tip of the iceberg. Maternal morbidity also represents a huge burden of disease for women and their families. Proposed Change The Illinois Department of Public Health Maternal Mortality Review Committee reviewed 52 cases of maternal death between the years 2001 to 2006. Of those 52 cases, 38% (n = 20) of the maternal deaths were due to hemorrhage. The Maternal Mortality Review Committee found that most mortality cases occurred while women were hospitalized. The Obstetric Hemorrhage Education Project is a response to the Maternal Mortality Review Committee’s past and continued findings that a leading cause of maternal morbidity and mortality in Illinois is hemorrhage related and preventable. Developed by the Obstetric Hemorrhage Education Project workgroup, the goal of this educational program is to reduce maternal morbidity and mortality due to obstetric hemorrhage in all birthing hospitals within the state. The program

emphasizes a multidisciplinary approach requiring all providers (physicians, registered nurses, certified nurse–midwives, anesthesiologists, and Keywords residents) to attend education. The educational re- obstetric hemorrhage quirements of each provider included the comple- maternal mortality tion of a pre- and postprogram benchmark assessment validation, didactic presentation, skill station, and simulation drill. Professional Issues Implementation, Outcomes, and Evaluation The outcomes for this project were analyzed and confirm that this type of program is initially very beneficial. Maternal mortality in the United States remains a pressing issue for multiple reasons, the simplest and perhaps most important of which is the reality of an infant and child without a mother, and the consequences for the family as a whole.

Poster Presentation

Implications for Nursing Practice Improving maternal mortality involves a committed and long lasting effort on behalf of many individuals along with medical and social organizations to better appreciate the scope of and risk associated with maternal mortality. Discovery of nursing practices that will reduce morbidity and mortality are discussed.

Respect, Communication, and Best Practices: Empowered Nurses Making a Difference Purpose of the Program A convergence of events, including published literature on causation of adverse events in maternal newborn care, claims analysis, a Joint Commission Sentinel event alert, and a lawsuit galvanized our resolve at Hunterdon Medical Center to discover and address all issues that compromise the safety of our patients. Proposed Change The Joint Commission has published Sentinel Event Alerts for preventing infant and maternal harm. Most of the events that harm our patients are preventable. Often there is an experienced nurse who is concerned but fails to rescue her patient. Implementation, Outcomes, and Evaluation We studied the science around perinatal safety and went to work to put the principles into place on our unit. We began to ask what our chief medical officer referred to as the “wicked questions.” What keeps staff and providers up at night about the way we provide care? Where are near misses happening? Do folks feel free to speak up? Are we getting incident reports? Do staff members

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advocate when needed and activate an effective chain of command? We found the answers to these questions were not always easy to hear. We hired outside consultants to do team training with all members of our team. We formed interdisciplinary teams. The first worked on policies. We had a group for fetal monitoring, which decided to teach a course jointly with the providers and staff utilizing the new Eunice Kennedy Shriver, National Institute of Child Health & Human Development language. We had a group who worked on briefings and debriefings. We originally had resistance on debriefing, but it has ended up being a favorite tool. We brought the comments from the debriefings to the Perinatal Committee. We have seen our malpractice suits decrease in the past 5 years. This year our hospital’s liability premium was cut by more than $375,000.

Ardath Youngblood, MN, IBCLC, RNC-OB, Hunterdon Medical Center, Flemington, NJ Keywords perinatal safety debriefing

Professional Issues Poster Presentation

Implications for Nursing Practice We have been able to sustain true process changes. We have built a team that is serving our mothers and infants well and feel the pride that comes from a hard won battle that is well worth the cost.

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Sonnentag, R. A.

Proceedings of the 2012 AWHONN Convention

The Ongoing Challenges of Obstetric Staffing: Development and Implementation of a Cross-Campus Registered Nurse Staffing Model Roberta A. Sonnentag, BSN, MSOLQ, CNML, ProHealth Care, Waukesha, WI Keywords champions patient safety coordination

Professional Issues Poster Presentation

Purpose of the Program Staffing to the dynamic volumes of an obstetric department presents a challenge for staff and leadership. The introduction of the Association of Women’s Health, Obstetric and Neonatal Nurse’s Staffing Guidelines further demonstrates the need to respond to patient needs through adequate staffing. Our two community hospitals 17 miles apart became unified as a health care system in 1998. Both hospitals have obstetric services. Once joined as a system, these units were led by a single senior leader. Goals were established to standardize policy and procedures, equipment, and workflow. Despite these goals the obstetric units continue to have unique cultures and great pride in their individual units/hospitals. It was not unusual for these sister hospitals to compete for staff. One hospital might send registered nurses home because of low volume, whereas its sister unit had critical needs. Proposed Change To balance staffing across two hospital campuses within the same system through implementation of a cross-campus staffing model that responds to changing needs and volume fluctuations. Implementation, Outcomes, and Evaluation In the spring of 2010, unit managers in both obstetric units renewed their commitment to profes-

sionalism and safety through development of a cross-campus staffing model for obstetric registered nurses. Volunteers and new hires were first to orient and participate. The message to registered nurses included the following: fewer hours lost because of low volumes, enhanced skill development, greater job security, and safer patient care. In the fall of 2010, cross-campus orientation became the standard for all obstetric registered nurses. Clear and consistent messaging from both hospital leadership teams was critical. Identification of champions was necessary, and front line registered nurse leaders emerged. Implications for Nursing Practice Development of a cross-campus staffing model provides greater options for staffing obstetric units in our system, a larger pool of registered nurses to draw upon for safety in staffing. Hours are more secure for the obstetric registered nurse staff. In the first 2 months of full cross-campus staff, one hospital realized a 3.5% reduction in cancelled registered nurse hours. Further metrics for success are being established. Our higher acuity registered nurses are working with colleagues across campus, and coaching and skill building is occurring for all involved. Maintaining and expanding crosscampus staffing is having a positive effect upon patient safety, staff satisfaction, and fiscal goals for our health care system.

Obstetric Triage and Surgical Scrub Duties: Standardizing the Labor and Delivery Nurse’s Specialty Roles to Improve Outcomes Valerie Yates Huwe, RNC-OB, MS, CNS, UCSF, Benioff Children’s Hospital, San Francisco, CA Patricia Creedy, RN, BS, UCSF, San Francisco, CA

Purpose for Program Obstetric triage often occurs within the perinatal department as opposed to an emergency room. Women presenting to triage may need immediate intervention or require extensive assessment and specialty consultation. It is crucial for obstetric triage nurses to understand and comply with the regulations from the Emergency Medical Treatment and Active Labor Act (EMTALA). Delays in a timely response, improper follow-up to laboratory tests, or failure to communicate a sense of urgency to the physician can jeopardize maternal–fetal safety and increase the liability risk

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for the nurse. Also of concern, in 2005 the United States estimated cesarean birth rate was 30.2%. According to the National Health Safety Network, the rate of surgical site infection after cesarean birth ranges from 1.5% to 2.6%. Proposed Change Having readily available staff, well educated, and skilled in the standards established by the Association of periOperative Registered Nurses presents challenges to many perinatal departments. Implementing the triage/scrub role can simultaneously address two safety/quality challenges in obstet-

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ric care: timely and thorough triage of childbearing women and compliance with operating room standards. The following describes one hospital’s attempt to meet the challenges of triage and scrub duties with specialized staff education and training. Implementation, Outcomes, and Evaluation A department decision was made to improve and revise the nurse’s triage/scrub role. Duties included answering all triage phone calls, care for arriving triage patients, and surgical scrub availability for cesarean births. Two senior staff nurses agreed to create a program aimed at educating experienced labor and delivery nurses to the revised role. The educators collaborated with the operating room clinical nurse specialists, staff physicians, and equipment/material representatives. A review of triage literature revealed information on EMTALA, standard of care, and liability risks. The reviewed surgical literature included site preparation, sterile technique, and documentation. Class

curriculum was based on evidence from literature review and expert opinion. Multiple teaching methods include slide presentation, demonstrations, Keywords videos, and hands-on training of trainees. Compe- triage/scrub nurse tency is documented with written examination and obstetric triage verbal evaluation. Only nurses meeting these requirements could function as a triage/scrub nurse.

Implications for Nursing Practice The creation of triage/scrub has fostered collaborative practice among nurses, physicians, and midwives. Department guidelines and protocols were created to define roles, outline standards, and streamline triage care. Standing orders were created for common obstetric problems. Utilization of nursing staff and department workflow have improved. Surgical site wound infection rates have decreased. Nurses reported improved confidence of knowledge and skills, increased awareness of liability risks, and overall enhanced job satisfaction.

Professional Issues Poster Presentation

Increasing Nurses’ Awareness of Spiritual and Cultural Diversity in Health Care Purpose of the Program Spiritual and cultural diversity are prevalent in our society and in the clients we serve in our healthcare system. Our patients have challenging medical complexities that require careful integration of their individualized spiritual and cultural needs. The effectiveness of the care nurses provide is dependent on their awareness of and sensitivity to these needs. The purpose of this program is to determine if providing education, post education resources, and a personal self-assessment could increase nurses’ confidence, comfort, and knowledge base in the area of spiritual and cultural diversity in health care. Proposed Change This project was designed to examine the impact of an educational offering on nurses’ attitudes and beliefs about cultural and spiritual care. Implementation, Outcomes, and Evaluation Data acquired in a pre-assessment convenience sample of 29 nurses in the neonatal intensive care unit (NICU) supported the need for this project. Participants completed a self assessment tool to document personal perceptions to help increase awareness of their own values and beliefs that influenced their attitudes and behaviors. They were

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also given a self learning module to provide more intensive education. Additional resource material was also available post education. Survey data after project activities demonstrated a significant increase in nurses’ confidence to provide appropriate interventions for families in spiritual/cultural distress (72%), a significant increase in confidence of personal knowledge of spiritual and cultural care (55%), and an increase in overall comfort in discussing spiritual and cultural needs of the family (39%). Lastly, 100% of staff felt that completing a personal self-assessment increased their overall learning.

Heidi E. Johnston, RNC-NIC, MAOM, Neonatal Intensive Care Unit, Community Memorial Hospital, Ventura, CA Keywords nursing education awareness spiritual/cultural diversity

Professional Issues

Implications for Nursing Practice Nurses should focus on awareness of spiritual and cultural diversity. One of the main goals of nursing is to provide state of the art health care balanced with a holistic plan of care. Our patients present with challenging medical complexities that require careful integration of their individual spiritual and cultural needs. Basic nursing education only scratches the surface of what is truly needed for staff to be comfortable with the vast diversity in which we practice. The effectiveness of care is dependent on an understanding of the critical issues at hand and an awareness of and sensitivity to multicultural/spiritual demographics.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01361.x

http://jognn.awhonn.org