The Online Newsletter for Children's Nurses
e-Edition, Issue 12
Innovations in Nursing Practice
Like all exemplary hospitals designated as Magnet® organizations, Children's Hospital Central California has “an ethical and professional responsibility to contribute to patient care, the organization, and the profession in terms of new knowledge, innovations, and improvements.”1
Innovations in Nursing Practice may reflect any one of the many processes and structures within the Nursing Professional Practice Model. Several programs that reflect creative innovations to meet patient care needs are highlighted below.
Clinical Practice Specialist – Innovative Nursing Role
Patient Care Support and Accreditation and Regulatory Compliance provide organizational support for professional practice and scope of practice. Their linkage includes clinical interpretation of practice in the context of regulatory and legal requirements. These accountabilities are supported by RNs in specialty roles. The complexity of clinical practice continues to evolve with new technology, systems, processes, roles and regulations. Specialty roles have been and will continue to be critical to our ability to support and promote a professional practice environment. These roles have a history of development and reclassification to meet the evolving needs of clinical practice and healthcare.
Members of the team participated in the evaluation and redesign of the role. Upon analysis of organizational needs, it was identified that the existing job description needed to expand and further delineate role accountabilities related to clinical practice versus program and/or task management. Understanding the scope of the work also determined that a nurse with advanced academic preparation was needed. A new role and associated job description, Clinical Practice Specialist, was developed to meet the evolving needs of the organization. The master’s-prepared role has accountability in the areas of:
- Professional practice including supporting the Magnet® program, care delivery model, professional practice model, national certification program, clinical linkage with policy and procedure development, and involvement in associated governance committees.
- Outcomes and quality including management of the National Database of Nursing Quality Indicators (NDNQI) program, nursing-sensitive indicators and patient classification system, supporting the linkage between the Outcomes and Patient Care Divisions and involvement in the Restraint Committee, Tracer Team, outcomes audits, medical record reviews and Nursing Peer Review Committee.
- Research and evidence-based practice through active research activities, presentations and publications, and involvement in the Institutional Research Board (IRB) and Nursing Research Council.
- Education and mentorship of leadership and interdisciplinary team members in the areas noted above.
- Leadership through the evaluation of practice and patient care activities; examples include new techniques, work environment, patient care processes and roles and accountabilities.
- Consultation regarding scope of practice; regulatory, legal and professional policies and standards interpretation; and application to promote quality patient care.
The advocacy, evaluation and development of an innovative solution by the VP/CNO, nursing Director and Program Manager Nursing Practice, resulted in the establishment of a new role for the organization. Currently, three Clinical Practice Specialists provide support to the organization.
Hypothermia Therapy – Innovative Care
The Neonatal Therapeutic Hypothermia Program was implemented at Children's Hospital in November 2010. Therapeutic hypothermia involves whole body cooling to 33.5 C for 72 hours and has been shown to improve outcomes for term infants who suffer from hypoxic ischemic encephalopathy (HIE).
HIE can be a serious brain dysfunction that may present shortly after birth. It is characterized by symptoms of central nervous system dysfunction, such as decreased level of consciousness and altered spontaneous activity of abnormal posture, tone or reflexes. High mortality has been reported. However, studies demonstrate that when therapeutic hypothermia is initiated within six hours of birth, the incidence of death or severe disability is reduced.
The neonatal Clinical Nurse Specialists were integral in the development of this program. They utilize published results from the largest trials and conferred with centers for best practices to develop policy and procedures, identify equipment and program needs, and develop proposals and competency training for staff. These efforts led to a successful first year of the program with 18 patients benefiting from this new therapy.
COMAS – Innovative Education Planning Tool
In fall 2007, the Clinical Education and Informatics department, Clinical Educators and Clinical Education Specialists identified the need to establish a process to consistently anticipate/identify when new or changed practice, standards, procedures or equipment would require staff training or education. An objective process to identify and rate the complexity of educational needs was identified as an opportunity. A process was needed to aid in the prioritization and planning of education and training requests. The need was further supported by the identification of numerous “random acts of education” or last minute/unplanned education/training that overlapped and/or competed with other strategic or required training. This resulted in large amounts of information presented to nursing staff simultaneously that perhaps could be strategically sequenced and/or timed to promote greater learning and enculturation into practice.
The first step in the development of the tool was to select the metrics, behaviors or events that make up a composite score. In the case of education, the process can be used to identify the methodologies and/or resources needed to provide education to staff on a topic. The composite score is best when it includes quantitative and qualitative measures. Two educators brainstormed the components that affect education/training outcomes, singularly and together, using education and adult learning theories. Using the nursing governance process, the Professional Development Council members participated in the initial brainstorming.
The metrics, behaviors and conditions were then sorted into like groups and five key metrics were identified:
- Methods of Education
- Safety Risk
The first letters of these five metrics spelled COMAS, so the tool was named the COMAS Educational Complexity Scale.
The metrics were placed on a best to worst continuum to come up with a score of 0, 1 or 2. The process considers the score of zero as a low score, 1 as a mid score or default score and 2 as a high score. This scoring range was adapted to the concept of educational complexity with zero being minimal complexity, one being moderate complexity and two being maximal complexity.
The tool was implemented for use by various Nursing Governance Councils and departments to measure educational complexity and identify potential educational methods for education and training.
Donor Breast Milk – Innovative Solution to Challenging Circumstances
Studies have supported that infants fed human milk instead of formula have a lower risk for several specific complications of prematurity. Complications at lower risk include enteral feed intolerance, infection, necrotizing enterocolitis, chronic lung disease, and retinopathy of prematurity. There are also indications that human milk may protect from periventricular leukomalacia. Babies discharged from the Neonatal Intensive Care Unit (NICU) after receiving breast milk score higher on developmental and neurocognitive tests than those who receive formula. The more breastmilk infants receive while in the NICU, the higher their scores on these tests.2, 3, 4
While the mother’s own milk is considered the absolute best nutrition for her baby, it is well understood that significant barriers exist to mothers producing enough breastmilk for their babies in the NICU. Prolonged hospitalizations, bonding issues, lack of stimulation, and unavailability of adequate breast pumps are just a few of the issues mothers may face during the hospitalization of their infant. Children's Hospital Central California serves a 45,000 square mile geographic region. As such, mothers may be challenged with distance as a barrier to providing breastmilk. A mother may have frozen milk at home in Delano or Bakersfield, but transporting the milk to the Hospital may be too difficult given the distance and other transportation issues. While processes exist to mitigate these issues, many mothers choose to discontinue pumping or do not initiate pumping at all. Given these circumstances the NICU at Children's Hospital chose to pursue the use of donor breastmilk for the low-birth-weight infant.
Donor Milk Banks have been in operation since 1909 when the first milk bank was established in Vienna, Austria. By 1919, two additional banks opened – one in Boston and a second in Germany. Over the last one hundred years, the interest in human milk has come almost full circle with the understanding that although artificial feeding products are continually improving, human milk provides factors not replicated in any other source of nutrition. In addition, provision of a safe source of donor milk, supports breastfeeding by clearly indicating that human milk cannot be replaced. In the twenty-first century, donor milk banking is once again emerging. Currently, a limited number of HMBANA (Human Milk Banking Association of North America) member milk banks provide human donor milk to the United States and Canada.
In February of 2011 Children's Hospital began efforts to ensure all patients would have access to breastmilk. Funds were secured for the purchase of a dedicated freezer for the storage of donor breastmilk. The freezer was ordered and policy development began. Initially, it was determined that babies less than 32 weeks gestation at birth until 32 weeks adjusted gestational age would be eligible for donor breastmilk. Recognizing that California law requires Hospitals that dispense donor breastmilk have a tissue bank license, documents were gathered for license submission. Consent was developed to ensure appropriate documentation of parental involvement in the decision to feed donor breastmilk.
An education plan was implemented, including training Patient Care Technicians in the distribution of donor breastmilk. The application was submitted to the state of California and awarded August 1, 2011. It was determined the program would be implemented on September 1, 2011.
Since that time, 2,512 ounces of donor breastmilk have been ordered and 35 babies have received donor breastmilk.
Patient needs are continually evolving. Nursing practice responds through the establishments of innovative roles, programs and processes to support ongoing quality patient care.
1 2012 American Nurses Credentialing Center, Magnet Recognition Program®
Retrieved from http://ancc.nursecredentialing.org
2 Lucas A & Cole TJ. Breast milk and neonatal necrotising enterocolitis (1990). Lancet, 336: 1519−1523.
3 Pinchi S. Srinivasan, Michael D. Brandler, Antoni D'Souza (2008). Necrotizing Enterocolitis. Clinics in Perinatology, Volume 35, Issue 1, Pages 251-272.
4 Schanler, R., Shulman, R., & Chantal, L. Feeding Strategies for Premature Infants: Beneficial Outcomes of Feeding Fortified Human Milk Versus Preterm Formula (1999).Pediatrics Vol. 103 No. 6 June 1, 1999 pp. 1150-1157
In This Issue
Leadership That Transforms
Innovations In Nursing
The Magnet Culture
Meditech Scanning and Archiving