- Email: [email protected]
The Challenge of Continuity of Care: Evolution of a Nursing Care Model in NICU
Newborn & Infant Nursing Reviews 15 (2015) 72–76
Contents lists available at ScienceDirect
Newborn & Infant Nursing Reviews journal homepage: www.nainr.com
The Challenge of Continuity of Care: Evolution of a Nursing Care Model in NICU Carol Turnage Spruill, MSN, APRN, CNS, CPHQ, NMTNC a, Ashley Heaton, RNC-NIC, BSN b,⁎ a b
Women, Infants, and Children Services, University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX, 77555 Neonatal Intensive Care Unit, Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX, 77030
a r t i c l e
i n f o
Keywords: Continuity of care index Continuity of care Nurse-patient ratio Parent satisfaction NICU
a b s t r a c t The aim of the study is to improve the continuity of nursing care for NICU patients and families by development and implementation of a nursing care delivery model that demonstrates a decrease in the Continuity of Care Index (CCI*) by 25% within 6 months. Twenty-four nurse volunteers joined the “Continuity of Care Taskforce” and committed to working in a designated pilot area for 6 months or more to test the evolving model of care. Improvement in continuity of care was measured by number of nurses per infant then calculating the Consistency of Care Index (CCI) per infant during defined lengths of stay. The mean for non-pilot pods of randomly selected patients was significantly greater than the mean number of nurses per patient in the pilot pod (P = .015). The percent change in CCI mean of pre-data to post-pilot data revealed a linear decrease in nurses to patients with LOS of 45 days or less. © 2015 Elsevier Inc. All rights reserved.
Continuity of care (COC) has been defined as fewer nurses per patient care experience. Little is known about the use of COC in neonatal and pediatric care. COC is significantly associated with decreased nurse-sensitive pediatric adverse events. Parents' perceptions of overall nursing COC are correlated to the number of nurses caring for an infant. Some authors have suggested this model of care delivery improves patient outcomes through relationship-based caregiving. Staff has increased their knowledge of patient/family needs by means of more frequent care opportunities. Background There is little research that addresses continuity in nursing care (CINC) and its impact on patient outcomes especially in pediatric and neonatal patients. Most of the research has been in adults and may bear no correlation with outcomes or family and staff satisfaction in neonatal or pediatric settings. Parents have said they value their relationship with the bedside nurse as the most significant aspect contributing to a positive experience and satisfaction with their infants' care. Furthermore, parents have described nursing behaviors that promote relationship building through different nursing roles that provide the framework of the model of negotiated partnership 1 (see Fig. 1). Nursing actions from this model include: 1) cautious guidance, 2) perceptive engagement and 3) subtle presence (see Table 1). These actions are brought about by specific nursing roles of teacher, guardian, and facilitator. Nurse/ ⁎ Corresponding author. Tel.: +1 832 236 7805. E-mail addresses: [email protected] (C.T. Spruill), [email protected] (A. Heaton). http://dx.doi.org/10.1053/j.nainr.2015.04.005 1527-3369/© 2015 Elsevier Inc. All rights reserved.
parent relationships built through negotiated partnerships support parent involvement in the care of their infant(s). Random assignments of nurses may inhibit parents' development of trust with individual nurses and delay or block partnerships that support parent participation through negotiated partnership. An examination of the relationship between CINC and patient outcomes in a pediatric surgical intensive care unit (PSICU) is one of the few studies found in pediatrics. 2 Continuity of care in this context was obtained by assigning fewer different nurses to each patient with the idea that repetitive assignment to the same patient will provide nurses more opportunities to build their knowledge of the patient and thereby achieve better outcomes through more appropriate and timely care. The measurement of CINC in this study was modified from an earlier version and in this research a lower CCI numerical value indicated less CINC (low continuity). 3 The calculation of CCI was determined as a ratio of the total number of different nurses assigned to a patient to the total number of nursing shifts for 7 days prior to the day data were collected. Of 332 patients, the average CCI was 0.36 (less continuity) where the range is from 0 (low CINC) to 1 (high CINC). Patients with a high CINC experienced fewer nurse-sensitive adverse events (P = .05) and PSICU-acquired infections. A high CINC was also associated with more ventilator days (P = .01) and longer LOS (P b .001), unexpected outcomes with these investigators. There were limitations to this study in that secondary, historical data not collected specifically for this study's purpose was used and charge nurses determined assignments. If charge nurses felt that complex patients who were expected to have worse outcomes needed better continuity then the patient acuity could be a factor in how assignments were made. The charge nurses may have assigned fewer nursing staff to the sickest patients. More research is needed however; reducing error and infections alone may not be indicative of
C.T. Spruill, A. Heaton / Newborn & Infant Nursing Reviews 15 (2015) 72–76
73
• Providing educational information • Offering positive encouragement • Facilitating independence
Cautious
• Granting permission • Encouraging parent participation • Creating an environment where there is room to learn
Perceptive Engagement
Facilitator
Guidance
Subtle Presence
• Positive affirmation • Constructive
correction • Availability and
access
Fig. 1. The model of negotiated partnership.1 Reprinted with permission: Reis, M. D., Rempel, G. R., Scott, S. D., Brady-Fryer, B. A., and Van Aerde, J., JOGNN, Wiley-Blackwell Publisher, 2010.
other important outcomes. Other potential outcomes related to the nurse–patient relationship, patient satisfaction and perceptions, or nurse retention, satisfaction, and knowledge sharing were not examined. In a meta-synthesis of qualitative studies on continuity of care (COC), it was identified that patients perceive consistency of personnel on a regular basis as a requirement of COC.4 Patients expressed that personal involvement of caregivers fostered COC. Other important elements of COC include fewer caregivers, communication between personnel and across care settings, accessibility, individualized-care, and a smooth, efficient discharge. Knowing the patient is associated with having time with a patient and being present and mindful during the experience.5 Practice settings may not support the nurse/patient or family relationship especially the available time commitment for sustained presence, continuity and consistency of care providers. Staffing difficulties may interfere with the dedicated time required by nurses to fulfill the expectations for COC. The knowledge, skill, and attitude of nurses as well as repeated opportunities to care for the same patients are essential elements for developing a relationship with patients and families (Fig. 2). When leadership supports staff in building family relationships, they can use their knowledge, nursing skills, and caring attitudes to provide safe, effective and efficient care within the context of a therapeutic relationship.
How can CINC be achieved in a large mega-NICU in an urban setting? Is it possible to staff in such a way that familiarity and trust can emerge in that type of environment? One staff nurse thought it could be done and went about gaining the approvals and volunteers to make it happen on a trial basis using quality methods and a team of nurses to do it. Aim The aim of the study is to improve the continuity of care for NICU patients and families by the development and implementation of a nursing care delivery model that addresses the complex NICU environment. Our
Taking Time with Patient: • • • •
Skill:
Table 1 Nursing actions and roles in negotiating nurse/parent partnerships.1 Negotiated partnership: a relationship between two or more people that requires skillful actions or dealings to attain a common goal. Nursing actions: Perceptive engagement: Responding to stimuli through understanding or insight to establish emotional involvement or commitment. Cautious guidance: Leading or directing another's way, while being conscientious and using forethought. Subtle presence: Being “present” in a highly skillful, artful manner Nurse roles: Facilitator: Someone who helps bring about Teacher: Someone who instructs by precept, knowledge, example, or experience Guardian: Someone who protects or oversees Reprinted with permission: Reis, M. D., Rempel, G. R., Scott, S. D., Brady-Fryer, B. A., and Van Aerde, J., JOGNN, Wiley-Blackwell Publisher, 2010.
• • • •
Care coordination Clinical judgment Expert practice Quality & Safety
Physical presence Ongoing contact Mindfulness Consistency
Nurse/Patient Relationship
Knowledge: • • • •
Familiarity Meaning Informed thinking Early Identification
Caring Attitude: • Congruence with patient needs & wishes • Intentional • Individualized
Fig. 2. Elements of a nurse/patient relationship. Author's rendition.
74
C.T. Spruill, A. Heaton / Newborn & Infant Nursing Reviews 15 (2015) 72–76
• Committed to working in the pilot area for each PDSA cycle to test the evolving model of care to reduce caregivers/patient.
Continuity of Care Index (CCI): CCI = # of Different Nurses (LOS x 2 shifts)
Fig. 3. Continuity of Care Index (CCI).3
goal is to demonstrate a 25% improvement in the Continuity of Care Index (CCI) within 6 months. The CCI is defined as the total number of nurses caring for an individual patient divided by length of stay in days times 2 shifts per day (Fig. 3). Setting The setting was a 118 bed NICU IV in a large metropolitan medical center where six-bed rooms serve as the patient care areas.
The Safety Attitudes Questionnaire (SAQ) was used to assess nursing and medical staff attitudes toward interdisciplinary communication, teamwork, collaboration and satisfaction with the pilot nursing care model. In addition, as baseline data, we measured the CCI on a group of 55 patients in our NICU. Using data from the staff SAQ survey, our Continuity of Care Improvement Team developed a nursing model based on geographic pods as microsystems so that teams of nurses would be responsible for staffing each pod, and nursing assignments made within this team. The plan was to implement this staffing model as a 6-week pilot in one patient pod area. The team model emphasizes: consistency in patient assignments for nurses, nursing assignments made by nursing team versus charge nurse to improve nursing shared governance, nursing team huddles to enhance communication and a daily goal sheet that will enhance nurse participation in interdisciplinary team rounds. Following the pilot period, data were analyzed to assess the effectiveness in reducing the CCI and NICU medical and nursing administration as well as the Clinical Quality and Safety team approved the project. Measures
Mechanisms Highly functioning, interdisciplinary teams that provide continuity and effective care transitions for patients and families greatly decrease the incidence of adverse events and increase staff and family satisfaction. Effective continuity is complicated in larger NICUs with a high number of nursing staff. Several different nursing care delivery models have been described which result in improved continuity of nursing care Methods Utilizing the model for improvement, a project plan was developed and implemented and twenty-four nurse volunteers: • • • •
Joined “Continuity of Care Taskforce” Reviewed relevant literature Performed pre- and post-data collection Participated in care model development
Improvement in continuity of care, specifically consistency in nursing caregivers, was measured by collecting the CCI of patients in the NICU pre and post implementation of the pilot model. The CCI divides the total number of different nurses caring for a patient by the number of nursing shifts during that hospitalization (see Fig. 3). A high number for a CCI indicates less consistency in caregiving, the opposite being true for a low CCI which means higher consistency in nurse caregivers. Nursing, medical team, and family satisfaction survey data and feedback were also analyzed. Data were analyzed using Excel and Minitab©16. Results Pre implementation CCI of 55 patients prior to pilot showed that wide variation in CCI exists among the 55 patients (see Fig. 4). The CCI allows analysis of consistency in nurse caregivers. The boxplot shows the percent change in CCI mean of pre-data and concurrent audit to pilot data indicates a linear downward trend in nurses to patients
Fig. 4. Wide variability in number of nurses per infant and subsequent CCI. Assignment process is not in control.
C.T. Spruill, A. Heaton / Newborn & Infant Nursing Reviews 15 (2015) 72–76
75
Fig. 5. PDSA #1 pre- and post data comparison. A linear decrease in CCI was observed in the pilot pod compared to pre-data and random audit.
Fig. 6. The pilot pod (elephant) had the lowest CCI compared to all other NICU patient pods in 2nd PDSA cycle.
with LOS of 45 days or less. No clear reason has been determined that clarifies the decrease in CCI from early preliminary data to final pilot CCI (see Fig. 5). Results from PDSA cycles after the 6 month pilot period:PDSA #1: First pilot of 6 months • 13% decrease in total number of RNs per infant during hospital stay • 24% decrease in CCI in pilot pod from pre-pilot data collection
• 32% decrease in CCI from preliminary data to pilot data • 10% decrease in CCI in non-pilot NICU pods (non-pilot nurses began to take more interest in primary care of patients during the pilot) After the 6-month pilot was completed, a focus group discussed lessons learned from the experience. They agreed to trial some changes to the project with another PDSA cycle where nurses worked on schedules and made assignments. All of the nurses from the first pilot volunteered
Table 2 Staff pre-survey compared to pilot team post-safety surveys showed that perceptions regarding teamwork, communication, and conflict resolution were improved in the pilot team nurses. Safety survey
NICU pre-survey (agree)
Pilot team post-survey (agree)
% Change
During rounds, my input is important to the plan of care. Communication between the team during care transitions in NICU is effective Nurse input is well-received in this area In this area, it is difficult to speak up if I perceive a problem in patient care. Disagreements are resolve appropriately (not who is right, but what is best for patient) Physicians and nurses here work together as a well-coordinated team.
85% 80 82 66 61 77
90% 100 90 90 90 100
6% 25% 10% 36% 47% 30%
76
C.T. Spruill, A. Heaton / Newborn & Infant Nursing Reviews 15 (2015) 72–76 Table 3 Fewer nurses per patient and family during the hospital stay of patients with lower CINC.
Fig. 7. Parents expressed their feelings regarding CINC. “I feel much more comfortable going home when I know my baby is in the care of a familiar nurse” (NICU parent).
to continue in the second pilot. The data show the pilot pod (elephant) with the lowest CINC out of the groups (n = 39 each pod) and the range was tighter than most of the groups (Fig. 6). PDSA #2: Pilot nurses developed schedules and made assignments • 36% decrease in pilot pod compared to pre-data values • 15% change from 1st pilot CCI Not only was the CCI lower in the pilot area, but also the staff in that pod had better scores on the SAQ survey (Table 2). Volunteer staff in the pilot began to feel strongly that continuity was essential to the care of infants and families. In the focus group and in the comments section added to the survey, volunteer pilot nurses were able to express their opinions about continuity of caregiving. One pilot team volunteer RN commented, “…it is not about us; it is about the babies and their families and providing them with the very best care possible, of which continuity of care is a very big part.” Discussion The NICU care model project combines a validated culture survey to inform our improvement team to help us transform our culture and
LOS days
Total no. of nurses
CCI
25 14 69 6 382
33 18 42 9 89
0.66 0.64 ↓0.30 0.75 ↓0.23
develop a patient-centric microsystem approach to care delivery. By creating a model of care that improves caregiver and family relationships and maximizes team collaboration, we expect that our pilot will result in improved parent and staff satisfaction, and ultimately, patient outcomes (Fig. 7). It is possible to decrease the number of staff caring for infants in a small area of a large NICU so the next step is dividing the NICU in half and conducting more PDSA cycles to test the model with more patients and families. Once the model has evolved and refined, actual research needs to be done to determine the effects of COC compared to traditional nursing care delivery. The positive experience of physicians, neonatal nurse practitioners, families and nurses staffing the pilot pod suggests that this model may be an effective means to providing a small community atmosphere within the overwhelming environment of an extremely large, complex NICU. Families articulate the burden of the constant change in their infant's nurse and have been heard to say that is difficult to leave their infant with strangers in the NICU (Table 3). The nurse volunteers received many accolades as physicians, nurse practitioners, and family members all gave positive comments in the surveys and interviews. Future research on this topic needs to address both the quantitative and qualitative aspects of COC to understand its impact on patients, families, teamwork, handoffs and clinical outcomes. References 1. Reis MD, Rempel GR, Scott SD, Brady-Fryer BA, Van Aerde J. Developing nurse/parent relationships in the NICU through negotiated partnership. JOGNN. 2010;39:675-83. 2. Siow E, Wypij D, Berry P, Hickey P, Curley MAQ. The effect of continuity in nursing care on patient outcomes in the pediatric intensive care unit. JONA. 2013;43:394-402. 3. Curley MAQ, Hickey PA. The Nightingale Metrics. Am J Nurs. 2006;106:66-70. 4. Waibel S, Henao D, Aller MB, Vargas I, Vazquez ML. What do we know about patients perceptions of continuity of care? A meta-synthesis of qualitative studies. Int J Qual Health Care. 2011;24:39-48. 5. Zolinierek CD. An integrative review of knowing the patient. J Nurs Scholarsh. 2013;46: 3-10.
Contents lists available at ScienceDirect
Newborn & Infant Nursing Reviews journal homepage: www.nainr.com
The Challenge of Continuity of Care: Evolution of a Nursing Care Model in NICU Carol Turnage Spruill, MSN, APRN, CNS, CPHQ, NMTNC a, Ashley Heaton, RNC-NIC, BSN b,⁎ a b
Women, Infants, and Children Services, University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX, 77555 Neonatal Intensive Care Unit, Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX, 77030
a r t i c l e
i n f o
Keywords: Continuity of care index Continuity of care Nurse-patient ratio Parent satisfaction NICU
a b s t r a c t The aim of the study is to improve the continuity of nursing care for NICU patients and families by development and implementation of a nursing care delivery model that demonstrates a decrease in the Continuity of Care Index (CCI*) by 25% within 6 months. Twenty-four nurse volunteers joined the “Continuity of Care Taskforce” and committed to working in a designated pilot area for 6 months or more to test the evolving model of care. Improvement in continuity of care was measured by number of nurses per infant then calculating the Consistency of Care Index (CCI) per infant during defined lengths of stay. The mean for non-pilot pods of randomly selected patients was significantly greater than the mean number of nurses per patient in the pilot pod (P = .015). The percent change in CCI mean of pre-data to post-pilot data revealed a linear decrease in nurses to patients with LOS of 45 days or less. © 2015 Elsevier Inc. All rights reserved.
Continuity of care (COC) has been defined as fewer nurses per patient care experience. Little is known about the use of COC in neonatal and pediatric care. COC is significantly associated with decreased nurse-sensitive pediatric adverse events. Parents' perceptions of overall nursing COC are correlated to the number of nurses caring for an infant. Some authors have suggested this model of care delivery improves patient outcomes through relationship-based caregiving. Staff has increased their knowledge of patient/family needs by means of more frequent care opportunities. Background There is little research that addresses continuity in nursing care (CINC) and its impact on patient outcomes especially in pediatric and neonatal patients. Most of the research has been in adults and may bear no correlation with outcomes or family and staff satisfaction in neonatal or pediatric settings. Parents have said they value their relationship with the bedside nurse as the most significant aspect contributing to a positive experience and satisfaction with their infants' care. Furthermore, parents have described nursing behaviors that promote relationship building through different nursing roles that provide the framework of the model of negotiated partnership 1 (see Fig. 1). Nursing actions from this model include: 1) cautious guidance, 2) perceptive engagement and 3) subtle presence (see Table 1). These actions are brought about by specific nursing roles of teacher, guardian, and facilitator. Nurse/ ⁎ Corresponding author. Tel.: +1 832 236 7805. E-mail addresses: [email protected] (C.T. Spruill), [email protected] (A. Heaton). http://dx.doi.org/10.1053/j.nainr.2015.04.005 1527-3369/© 2015 Elsevier Inc. All rights reserved.
parent relationships built through negotiated partnerships support parent involvement in the care of their infant(s). Random assignments of nurses may inhibit parents' development of trust with individual nurses and delay or block partnerships that support parent participation through negotiated partnership. An examination of the relationship between CINC and patient outcomes in a pediatric surgical intensive care unit (PSICU) is one of the few studies found in pediatrics. 2 Continuity of care in this context was obtained by assigning fewer different nurses to each patient with the idea that repetitive assignment to the same patient will provide nurses more opportunities to build their knowledge of the patient and thereby achieve better outcomes through more appropriate and timely care. The measurement of CINC in this study was modified from an earlier version and in this research a lower CCI numerical value indicated less CINC (low continuity). 3 The calculation of CCI was determined as a ratio of the total number of different nurses assigned to a patient to the total number of nursing shifts for 7 days prior to the day data were collected. Of 332 patients, the average CCI was 0.36 (less continuity) where the range is from 0 (low CINC) to 1 (high CINC). Patients with a high CINC experienced fewer nurse-sensitive adverse events (P = .05) and PSICU-acquired infections. A high CINC was also associated with more ventilator days (P = .01) and longer LOS (P b .001), unexpected outcomes with these investigators. There were limitations to this study in that secondary, historical data not collected specifically for this study's purpose was used and charge nurses determined assignments. If charge nurses felt that complex patients who were expected to have worse outcomes needed better continuity then the patient acuity could be a factor in how assignments were made. The charge nurses may have assigned fewer nursing staff to the sickest patients. More research is needed however; reducing error and infections alone may not be indicative of
C.T. Spruill, A. Heaton / Newborn & Infant Nursing Reviews 15 (2015) 72–76
73
• Providing educational information • Offering positive encouragement • Facilitating independence
Cautious
• Granting permission • Encouraging parent participation • Creating an environment where there is room to learn
Perceptive Engagement
Facilitator
Guidance
Subtle Presence
• Positive affirmation • Constructive
correction • Availability and
access
Fig. 1. The model of negotiated partnership.1 Reprinted with permission: Reis, M. D., Rempel, G. R., Scott, S. D., Brady-Fryer, B. A., and Van Aerde, J., JOGNN, Wiley-Blackwell Publisher, 2010.
other important outcomes. Other potential outcomes related to the nurse–patient relationship, patient satisfaction and perceptions, or nurse retention, satisfaction, and knowledge sharing were not examined. In a meta-synthesis of qualitative studies on continuity of care (COC), it was identified that patients perceive consistency of personnel on a regular basis as a requirement of COC.4 Patients expressed that personal involvement of caregivers fostered COC. Other important elements of COC include fewer caregivers, communication between personnel and across care settings, accessibility, individualized-care, and a smooth, efficient discharge. Knowing the patient is associated with having time with a patient and being present and mindful during the experience.5 Practice settings may not support the nurse/patient or family relationship especially the available time commitment for sustained presence, continuity and consistency of care providers. Staffing difficulties may interfere with the dedicated time required by nurses to fulfill the expectations for COC. The knowledge, skill, and attitude of nurses as well as repeated opportunities to care for the same patients are essential elements for developing a relationship with patients and families (Fig. 2). When leadership supports staff in building family relationships, they can use their knowledge, nursing skills, and caring attitudes to provide safe, effective and efficient care within the context of a therapeutic relationship.
How can CINC be achieved in a large mega-NICU in an urban setting? Is it possible to staff in such a way that familiarity and trust can emerge in that type of environment? One staff nurse thought it could be done and went about gaining the approvals and volunteers to make it happen on a trial basis using quality methods and a team of nurses to do it. Aim The aim of the study is to improve the continuity of care for NICU patients and families by the development and implementation of a nursing care delivery model that addresses the complex NICU environment. Our
Taking Time with Patient: • • • •
Skill:
Table 1 Nursing actions and roles in negotiating nurse/parent partnerships.1 Negotiated partnership: a relationship between two or more people that requires skillful actions or dealings to attain a common goal. Nursing actions: Perceptive engagement: Responding to stimuli through understanding or insight to establish emotional involvement or commitment. Cautious guidance: Leading or directing another's way, while being conscientious and using forethought. Subtle presence: Being “present” in a highly skillful, artful manner Nurse roles: Facilitator: Someone who helps bring about Teacher: Someone who instructs by precept, knowledge, example, or experience Guardian: Someone who protects or oversees Reprinted with permission: Reis, M. D., Rempel, G. R., Scott, S. D., Brady-Fryer, B. A., and Van Aerde, J., JOGNN, Wiley-Blackwell Publisher, 2010.
• • • •
Care coordination Clinical judgment Expert practice Quality & Safety
Physical presence Ongoing contact Mindfulness Consistency
Nurse/Patient Relationship
Knowledge: • • • •
Familiarity Meaning Informed thinking Early Identification
Caring Attitude: • Congruence with patient needs & wishes • Intentional • Individualized
Fig. 2. Elements of a nurse/patient relationship. Author's rendition.
74
C.T. Spruill, A. Heaton / Newborn & Infant Nursing Reviews 15 (2015) 72–76
• Committed to working in the pilot area for each PDSA cycle to test the evolving model of care to reduce caregivers/patient.
Continuity of Care Index (CCI): CCI = # of Different Nurses (LOS x 2 shifts)
Fig. 3. Continuity of Care Index (CCI).3
goal is to demonstrate a 25% improvement in the Continuity of Care Index (CCI) within 6 months. The CCI is defined as the total number of nurses caring for an individual patient divided by length of stay in days times 2 shifts per day (Fig. 3). Setting The setting was a 118 bed NICU IV in a large metropolitan medical center where six-bed rooms serve as the patient care areas.
The Safety Attitudes Questionnaire (SAQ) was used to assess nursing and medical staff attitudes toward interdisciplinary communication, teamwork, collaboration and satisfaction with the pilot nursing care model. In addition, as baseline data, we measured the CCI on a group of 55 patients in our NICU. Using data from the staff SAQ survey, our Continuity of Care Improvement Team developed a nursing model based on geographic pods as microsystems so that teams of nurses would be responsible for staffing each pod, and nursing assignments made within this team. The plan was to implement this staffing model as a 6-week pilot in one patient pod area. The team model emphasizes: consistency in patient assignments for nurses, nursing assignments made by nursing team versus charge nurse to improve nursing shared governance, nursing team huddles to enhance communication and a daily goal sheet that will enhance nurse participation in interdisciplinary team rounds. Following the pilot period, data were analyzed to assess the effectiveness in reducing the CCI and NICU medical and nursing administration as well as the Clinical Quality and Safety team approved the project. Measures
Mechanisms Highly functioning, interdisciplinary teams that provide continuity and effective care transitions for patients and families greatly decrease the incidence of adverse events and increase staff and family satisfaction. Effective continuity is complicated in larger NICUs with a high number of nursing staff. Several different nursing care delivery models have been described which result in improved continuity of nursing care Methods Utilizing the model for improvement, a project plan was developed and implemented and twenty-four nurse volunteers: • • • •
Joined “Continuity of Care Taskforce” Reviewed relevant literature Performed pre- and post-data collection Participated in care model development
Improvement in continuity of care, specifically consistency in nursing caregivers, was measured by collecting the CCI of patients in the NICU pre and post implementation of the pilot model. The CCI divides the total number of different nurses caring for a patient by the number of nursing shifts during that hospitalization (see Fig. 3). A high number for a CCI indicates less consistency in caregiving, the opposite being true for a low CCI which means higher consistency in nurse caregivers. Nursing, medical team, and family satisfaction survey data and feedback were also analyzed. Data were analyzed using Excel and Minitab©16. Results Pre implementation CCI of 55 patients prior to pilot showed that wide variation in CCI exists among the 55 patients (see Fig. 4). The CCI allows analysis of consistency in nurse caregivers. The boxplot shows the percent change in CCI mean of pre-data and concurrent audit to pilot data indicates a linear downward trend in nurses to patients
Fig. 4. Wide variability in number of nurses per infant and subsequent CCI. Assignment process is not in control.
C.T. Spruill, A. Heaton / Newborn & Infant Nursing Reviews 15 (2015) 72–76
75
Fig. 5. PDSA #1 pre- and post data comparison. A linear decrease in CCI was observed in the pilot pod compared to pre-data and random audit.
Fig. 6. The pilot pod (elephant) had the lowest CCI compared to all other NICU patient pods in 2nd PDSA cycle.
with LOS of 45 days or less. No clear reason has been determined that clarifies the decrease in CCI from early preliminary data to final pilot CCI (see Fig. 5). Results from PDSA cycles after the 6 month pilot period:PDSA #1: First pilot of 6 months • 13% decrease in total number of RNs per infant during hospital stay • 24% decrease in CCI in pilot pod from pre-pilot data collection
• 32% decrease in CCI from preliminary data to pilot data • 10% decrease in CCI in non-pilot NICU pods (non-pilot nurses began to take more interest in primary care of patients during the pilot) After the 6-month pilot was completed, a focus group discussed lessons learned from the experience. They agreed to trial some changes to the project with another PDSA cycle where nurses worked on schedules and made assignments. All of the nurses from the first pilot volunteered
Table 2 Staff pre-survey compared to pilot team post-safety surveys showed that perceptions regarding teamwork, communication, and conflict resolution were improved in the pilot team nurses. Safety survey
NICU pre-survey (agree)
Pilot team post-survey (agree)
% Change
During rounds, my input is important to the plan of care. Communication between the team during care transitions in NICU is effective Nurse input is well-received in this area In this area, it is difficult to speak up if I perceive a problem in patient care. Disagreements are resolve appropriately (not who is right, but what is best for patient) Physicians and nurses here work together as a well-coordinated team.
85% 80 82 66 61 77
90% 100 90 90 90 100
6% 25% 10% 36% 47% 30%
76
C.T. Spruill, A. Heaton / Newborn & Infant Nursing Reviews 15 (2015) 72–76 Table 3 Fewer nurses per patient and family during the hospital stay of patients with lower CINC.
Fig. 7. Parents expressed their feelings regarding CINC. “I feel much more comfortable going home when I know my baby is in the care of a familiar nurse” (NICU parent).
to continue in the second pilot. The data show the pilot pod (elephant) with the lowest CINC out of the groups (n = 39 each pod) and the range was tighter than most of the groups (Fig. 6). PDSA #2: Pilot nurses developed schedules and made assignments • 36% decrease in pilot pod compared to pre-data values • 15% change from 1st pilot CCI Not only was the CCI lower in the pilot area, but also the staff in that pod had better scores on the SAQ survey (Table 2). Volunteer staff in the pilot began to feel strongly that continuity was essential to the care of infants and families. In the focus group and in the comments section added to the survey, volunteer pilot nurses were able to express their opinions about continuity of caregiving. One pilot team volunteer RN commented, “…it is not about us; it is about the babies and their families and providing them with the very best care possible, of which continuity of care is a very big part.” Discussion The NICU care model project combines a validated culture survey to inform our improvement team to help us transform our culture and
LOS days
Total no. of nurses
CCI
25 14 69 6 382
33 18 42 9 89
0.66 0.64 ↓0.30 0.75 ↓0.23
develop a patient-centric microsystem approach to care delivery. By creating a model of care that improves caregiver and family relationships and maximizes team collaboration, we expect that our pilot will result in improved parent and staff satisfaction, and ultimately, patient outcomes (Fig. 7). It is possible to decrease the number of staff caring for infants in a small area of a large NICU so the next step is dividing the NICU in half and conducting more PDSA cycles to test the model with more patients and families. Once the model has evolved and refined, actual research needs to be done to determine the effects of COC compared to traditional nursing care delivery. The positive experience of physicians, neonatal nurse practitioners, families and nurses staffing the pilot pod suggests that this model may be an effective means to providing a small community atmosphere within the overwhelming environment of an extremely large, complex NICU. Families articulate the burden of the constant change in their infant's nurse and have been heard to say that is difficult to leave their infant with strangers in the NICU (Table 3). The nurse volunteers received many accolades as physicians, nurse practitioners, and family members all gave positive comments in the surveys and interviews. Future research on this topic needs to address both the quantitative and qualitative aspects of COC to understand its impact on patients, families, teamwork, handoffs and clinical outcomes. References 1. Reis MD, Rempel GR, Scott SD, Brady-Fryer BA, Van Aerde J. Developing nurse/parent relationships in the NICU through negotiated partnership. JOGNN. 2010;39:675-83. 2. Siow E, Wypij D, Berry P, Hickey P, Curley MAQ. The effect of continuity in nursing care on patient outcomes in the pediatric intensive care unit. JONA. 2013;43:394-402. 3. Curley MAQ, Hickey PA. The Nightingale Metrics. Am J Nurs. 2006;106:66-70. 4. Waibel S, Henao D, Aller MB, Vargas I, Vazquez ML. What do we know about patients perceptions of continuity of care? A meta-synthesis of qualitative studies. Int J Qual Health Care. 2011;24:39-48. 5. Zolinierek CD. An integrative review of knowing the patient. J Nurs Scholarsh. 2013;46: 3-10.