May 2015 EsTsheence of Nursing - American Nurse...patient and family better than any other healthcare provider, learning their wishes, fears, ca - pabilities, and challenges. It’s

This supplement was funded by anunrestricted educational grant from Hill-Rom.

Content of this supplement was developedindependently of the sponsor and all articles

have undergone peer review according toAmerican Nurse Today standards.

TheEssenceof Nursing

Advancing the Art and Science of Patient Care,

Quality, and Safety

Supplement to

www.AmericanNurseToday.comMay 2015

www.AmericanNurseToday.com May 2015 The Essence of Nursing 1

The Essence of NursingCONTENTS

2 The essence of nursing By Melissa A. Fitzpatrick

Putting basic nursing care back in the spotlight means emphasizing high-touch care in today’s high-tech, evidence-based care environment.

4 Creating the environment for nursing excellence By Lillee Gelinas

Learn how nursing leaders and staff can collaborate to create anenvironment where the essence of nursing thrives.

6 Enhance patient engagement through sharing By Susan C. Hull

Uncover your patients’ full story to keep them engaged in their care while helping you tailor the care plan to each individual.

8 Reducing functional decline in hospitalized older adultsBy Denise M. Kresevic

For the elderly, hospitals harbor hidden dangers that can lead to functionaldecline. Find out how to prevent, detect, and manage these threats.

11 Get your patients moving—now! By Amanda Veesart and Alyce S. Ashcraft

Learn about early progressive ambulation protocols that help preventblood clots, pneumonia, delirium, and other complications of immobility.

14 Keeping patients safe from falls and pressure ulcers By Amy Moore and Rebecca Geist

The authors discuss how to prevent falls, promote skin integrity, andadvocate for policies that prevent “never events.”

18 How nurses can help reduce hospital readmissions By Joan M. Nelson and Laura Rosenthal

Starting at admission, you can mitigate patients’ readmission riskthrough efficient care coordination, communication, planning, and education.

21 A bold move to improve collaboration By Susan Blackmer Tocco, Darwin K. Clark, MD, and Amy C. DeYoung

Returning to the basics of nursing care doesn’t mean the nurse does it all. One hospital successfully tapped into collective knowledge from an interdisciplinary care team.

24 The essence of nursing This illustrated, at-a-glance “snapshot” summarizes key points to helpyou focus on delivering the essence of nursing care.

Supplement to

www.AmericanNurseToday.com May 2015

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2 The Essence of Nursing May 2015 www.AmericanNurseToday.com

he essence of nursingIt's time to put basic nursing care back in the spotlight. By Melissa A. Fitzpatrick, MSN, RN, FAAN

In health care today, techno-logical advances grab head-lines while clinicians’ docu-

mentation duties mount almostdaily. Is basic nursing care re-ceding into the background?

Recently, American Nurse To-day’s Editorial Advisory Board(EAB) had a spirited discussionon the current state of nursingand patient-care delivery. Weconcluded we need to shift thefocus back to basic nursingcare. Hence, the special supple-ment you’re now reading—TheEssence of Nursing: Advancingthe Art and Science of PatientCare, Quality, and Safety.

So what is the essence of nurs-ing? It’s what some people call“high-touch” nursing, where thenurse has plenty of face-to-facetime and a personal connectionwith patients and their families. In a sense, the essence of nursing

is the very heart of nursing.During our discussion, EAB

members shared examples of ex-traordinary nurses who’ve had asignificant impact on patient out-comes and the patient-family ex-perience. We also shared anec-dotes in which nurses didn’tbehave like the compassionate,competent caregivers we all as-pire to be. This dichotomy under-scored our belief that nursesneed to get back to the basics—to living and breathing theessence of nursing in every pa-tient encounter to realize the fullpotential of our profession.

Certain characteristics andcompetencies set nursing andnurses apart from other profes-sions and practitioners. As EABmembers discussed the essenceof nursing, we asked each other:What’s distinctive about a nurse’sDNA? How does that distinctionmanifest when it comes to provid-ing safe, high-quality patientcare? How can nurses deliver theessence of nursing to its fullest ex-tent possible—especially whencaring for such vulnerable pa-tients as low-birth-weight infantsand elderly adults? What factorsor circumstances enable or pro-hibit nurses from doing this? In to-day’s fast-paced, high-acuity, mul-tidimensional, and penalty-drivenhealthcare delivery system, it’scrucial that we find answers tothese and related questions.

Nursing presence The nurse is the key to providingsafe, effective, and compassion-

ate care at both the individualand organizational levels. De-spite the rapidly changinghealthcare environment, oneconstant remains: The nurse, in acollective sense, is the health-care professional who’s with thepatient and family 24/7/365.

The nurse creates and nur-tures an intimate bond with thepatient and family through aconstant presence and hands-oncare. She or he gets to know thepatient and family better thanany other healthcare provider,learning their wishes, fears, ca-pabilities, and challenges. It’sthe nurse in whom the patientconfides in the middle of thenight and to whom the patient’sloved ones turn for information,support, and solace.

When a patient experiencesovert distress or deteriorates sud-denly, the nurse is likely to bethe first one on the scene, initiat-ing rescue procedures. More of-ten than not, it’s the nurse whodetects subtle changes in vitalsigns or behavior that signal aserious or life-threatening event.The literature tells us that whennurses have the right prepara-tion and are present at the rightplace and the right time, patientoutcomes improve. In collabora-tion with interdisciplinary col-leagues, nurses’ highly skilled,competent, compassionate carecan help prevent the patient’sfunctional decline, eliminateknowledge deficits for the pa-tient and family, and promotetheir engagement in health care.

T


Presence and vigilance are keyelements of the essence of nurs-ing. But along with the privilegeof being “the one who’s there”comes a tremendous responsibili-ty and accountability. Nurses are,and always have been, the pa-tient’s first and last line of de-fense. Keeping the patient safefrom preventable adverseevents—such as falls, pressure ul-cers, infections, and immobilitycomplications—are high on nurs-es’ priority list as they manageand coordinate the patient’s careto ensure safe passage throughthe care-delivery system.

Spotlighting basic nursingcare This supplement puts basic nurs-ing care back in the spotlightwhere it belongs by:

• revisiting key elements ofpatient care, updating themin the context of today’shealthcare environment

• emphasizing the nurse asthe patient’s sentinel, whoprotects the patient from in-jury and acts quickly whenpotential danger arises

• stressing the nurse’s role inmarshalling appropriate re-sources to ensure optimalpatient outcomes

• highlighting the significanceof nursing observation andevaluation of the patient.

Where the topic of technolo-gy arises in this supplement, theauthors make it clear that itsmost important role is to supportthe decision making of nursesand other clinicians. Althoughtechnology can help improve pa-tient care, it also can distract usfrom basic care. If we getcaught up in technology, we can

lose sight of the higher purposeof health care.

The essence of nursingand the organization Many of the indicators that drive ahealthcare organization’s perform-ance, profitability, and image inthe community it serves hinge onhow well its nurses practice theessence of nursing, The essentialelements of nursing care are cru-cial in reducing lengths of stay,cost per case, adverse events, andlitigation. Nurses have a measura-ble and significant impact not juston safety, quality, and economicoutcomes but also on patient sat-isfaction and engagement, asshown in scores on Hospital Con-sumer Assessment of HealthcareProviders and Systems surveys.

Who better than the nurse tocoordinate the many disciplinesinvolved in a patient’s care? Toconsider the multiple facets ofthe patient-family dynamic whenexploring care needs across thecare-delivery system? Effectivenursing care is critical in pre-venting readmissions and ensur-ing that patients successfully nav-igate the many hand-offs thatoccur during their stay.

With today’s focus on qualityand cost and the financial penal-ties of suboptimal care, validatingand quantifying nurses’ impactand recognizing their value tohealthcare organizations andcommunities at large is crucial. Aswe work to enhance the patientexperience and promote careacross the continuum, our abilityto uphold the essence of nursingwill make or break our efforts.

Recipe for success The essence of nursing encom-passes a fundamental set of in-

gredients that serves as the“recipe” for success at many lev-els—the individual patient andfamily experience, an organiza-tion’s success as measured inoutcomes and costs, and thehealth of our nation and theglobal community. Multiple fac-tors influence how successfullythis recipe turns out:

• Everyone involved must un-derstand what it takes tocreate an environment thatfosters full expression of theessence of nursing.

• Healthcare organizationsmust learn and replicate bestpractices that validate, ap-preciate, and recognize theessence of nursing. This, inturn, helps raise the standardof patient care while nurtur-ing nursing staff and makingtheir work more satisfying.

• The art of nursing must co-exist with today’s technolo-gy-driven, evidence-basedscience of nursing. To en-sure such coexistence, nurs-es must manifest the essenceof nursing in every patientand family encounter.

To a large degree, the futureof healthcare delivery hinges onour ability to optimize the workof nurses and enable them topractice the essence of nursing.We believe this supplementgives you the tools you need toachieve that optimization andthe power that comes with it. c

Selected referenceAiken LH, Sloane DM, Bruyneel L, et al. Nursestaffing and education and hospital mortality innine European countries: a retrospective observa-tional study. Lancet. 2014;383(9931):1824-30.

Melissa A. Fitzpatrick is vice-president and chiefclinical officer at Hill-Rom and a member of theEditorial Advisory Board at American Nurse Today.

It’s not easy to define basicnursing care in terms relevantto academia, research, and

practice. Yet ensuring the deliveryof basic care has never beenmore important. As Pipe and col-leagues wrote in 2012, “As thework of nursing becomes increas-ingly more complex and signifi-cantly more technical…, nursesare beginning to find that the ba-sic nursing interventions that wereonce the hallmark of good nurs-ing care are being left behind.”

Articulating when basic careis not done, termed “missed”care, has advanced work in thisarea. In the last 6 years, studieshave shown that significantamounts of care are missed inacute care hospitals. Missedcare is important not just from

a patient safety and quality ofcare perspective, but also from a business perspective. Hospitalreimbursements are reduced oreliminated for acute care servic-es when any one of a commonset of complications occurs.

To avoid missed care, staffnurses and nurse leaders mustcollaborate to create an environ-ment where basic nursing case isa priority. Here are five evidence-based strategies that can help.

Improve collaboration Collaboration needs to oc-

cur at all levels, from the bedsideto the boardroom. Traditionalcentralized command and con-trol management structures areineffective for today’s transparentand ever-demanding healthcare

market. We must put structures in place that support rapid, multi-directional collaboration andcommunication, and patientsmust be made an integral partof that collaboration. As somehave noted, patients want “part-nership, equity, accountability,and mutual ownership in theirown healthcare decisions andthose of their family members.”

Make basic care a priority for staff as

well as patientsThe 2011 report “Through theEyes of the Workforce” from theNational Patient Safety Founda-tion states, “Workplace safety is inextricably linked to patientsafety. Unless caregivers are given the protection, respect,and support they need, they aremore likely to make errors, failto follow safe practices, and notwork well in teams.”

But instead of protection, re-spect, and support, too oftennurses and other healthcareworkers experience physical andpsychological harm. On-the-jobinjuries are significantly higherin health care than in other in-dustries. And instead of gettingrespect, some nurses suffer emo-tional abuse, bullying, and eventhreats of physical assault.

What can be done? Staff andleaders must shape a safety cul-


reating the environment for nursing excellenceIt’s time for staff nurses and nurse leaders to help create a workenvironment that fosters basic nursing care.By Lillee Gelinas, MSN, RN, FAAN

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ture through practices that showsafety is a priority. We must putsystems in place that engage theworkforce and encourage staff tospeak up and report errors, mis-takes, and hazards that threatensafety—their own or their pa-tients’. When nurses feel valuedand safe, the work environmentimproves and patients are safer.

Implement shared governance

The shared decision-making thatcomes with shared governance isvital not just to patient safety butalso to nursing’s future. Examplesof how to engage frontline staffin shared decision-making in-clude appointing unit-basedchampions for specific issuesand establishing unit, departmen-tal, and organizational practicecouncils, which enhance staffcommunication networks whileincreasing accountability forpractice. Such engagement paysoff. For example, a recently im-plemented CHRISTUS Health Sys-tem shared governance structurefor the emergency services serv-ice line led to quick triage policystandardization by staff nurseson the committee. They accom-plished in record time what usu-ally takes months.

Articulate the businesscase for nursing

Many researchers have madethe business case for nursingthrough effective nurse staffing.For example, studies associatebetter nurse staffing with shorterstays and complications, whichresults in lower costs. Such re-sults highlight why hospitalsshould focus on nursing care toimprove clinical quality and pa-tient safety, use research that

links nursing care with clinicaloutcomes, and ensure nurseshave time at the bedside to carefor patients.

Stop wasting nurses’ time

Nurses are the primary hospitalcaregivers. Increasing the effi-ciency and effectiveness of nurs-ing care is essential to hospitalfunction and delivery of safe pa-tient care. Yet evidence showsinefficiency is common in nurs-ing practice. A 2008 study ofmedical-surgical nurses foundthey spend more time document-ing (28% of their shift time) thanon any other activity. How muchof that documentation is reallyrelevant to the patient’s outcomeas opposed to being collectedbecause of legal and regulatoryrequirements? Excessive docu-mentation is a prime example ofwhat’s called type I waste inlean terms: a non-value-creatingactivity made necessary by theway hospitals organize work.

The same study found nurseswalk about an hour per shift. Butvariation in distance traveled wasgreater within a single unit thanamong units of very differentphysical layout. That’s because amajor factor in how far nurseswalk is how closely their patientsare to each other—somethingeasily under our control throughscheduling and assignments.

Nurses in this study also classi-fied 7% of their day as “deadwaste.” If we could eliminate allof the dead waste and half of thetype I waste just from walkingand excessive documentation,we’d free up about one-quarterof all nursing hours. And that’seven if we do nothing about thewaste in the rest of a nurse’sworkday. If properly conducted,redesigning processes and workcan improve worker retention.

Forging a partnershipWith healthcare reform, newtechnology, and a solid base ofevidence for the powerful influ-ence of nursing care over pa-tient outcomes, the time is ripefor staff nurses and nurse lead-ers to partner in creating a workenvironment that fosters solid ba-sic nursing care. c

Selected referencesAiken LH, Clarke SP, Sloane DM, et al. Nurses’reports on hospital care in five countries. HealthAff (Millwood). 2001;20(3):43-53.

Buerhaus PI, Donelan K, DesRoches C, Hess R.Registered nurses’ perceptions of nurse staffingratios and new hospital payment regulations.Nurs Econ. 2009;27(6):372-6.

Hendrich A, Chow MP, Skierczynski BA, Lu Z. A36-hospital time and motion study: how do med-ical-surgical nurses spend their time? Perm J.2008;12(3):25-34.

Kalisch BJ, Landstrom GL, Hindshaw AS. Missednursing care: a concept analysis. J Adv Nurs.2009;65(7);1509-17.

Lucian Leape Institute at the National Patient Safe-ty Foundation. Through the Eyes of the Work-force: Creating Joy, Meaning, and Safer HealthCare. 2013. Boston: National Patient SafetyFoundation. www.patientcarelink.org/uploadDocs/1/Through-Eyes-of-the-Workforce_online.pdf//

Pipe TB, Connolly T, Spahr N, et al. Bringingback the basics of nursing: defining patient careessentials. Nurs Adm Q. 2012;36(3):225-33.

Swihart D, Hess RG. Shared Governance: A Prac-tical Approach to Transforming InterprofessionalHealthcare. 3rd ed. Danvers, MA: HCPro; 2014.

Lillee Gelinas is Editor-in-Chief of American NurseToday.


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5

Staff and leaders

must shape a safety

culture through

practices that show

safety is a priority.


nhance patient engagementthrough sharingSharing stories, health information, and decision making promotesactive engagement. By Susan C. Hull, MSN, RN

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We are in the midst of apatient experience revo-lution. The e-patient

movement is igniting patients tobecome empowered, engaged,equipped, and enabled in theirhealth and healthcare decisions.

At the same time, providersand healthcare organizations arerecognizing that patient engage-ment and participation are essen-tial to achieving the triple aim ofhealth care: improving care, opti-mizing health, and reducing cost.

Achieving these goals requiresa culture that prioritizes patientengagement as a core value.(See Patient engagement andpatient satisfaction: What’s thedifference?) This requires prac-tices that include the active col-laboration of providers, patients,

and their families and caregivers.Here are some ways nurses canlead the way.

Discover and share yourpatient’s story Patients have complex life andhealth stories that run deeperthan the reasons they seek care.Put your patient’s voice first andlearn what matters most to the in-dividual and what he or shewants to accomplish in his or herhealth encounter. Uncovering thefull story will help you to person-alize the best evidence-basedcare plan for that person.

Unfortunately, limited time andextensive forms often encouragedata collection, rather than story-telling and meaningful conversa-tions. This can make barriers tohealth and self-care, such as lackof social support, isolation, andissues at home, hard to detect.

Patient stories can also betrapped in provider “silos” and notget shared across collaborativecare teams. Strategies to helpyou discover and share your pa-tient’s story include:

• Practice health story conver-sations with the entire careteam using forms or comput-er screens as a guide, but not the medium. For exam-ple, begin a conversation with “Tell me about thehealth patterns or issues you

are most concerned abouttoday, such as gettingenough rest, tolerating exer-cise, or breathing easily.”

• Encourage and support pa-tients to tell their stories tobetter articulate their ownhealth goals and challenges.Make the patient feel atease by asking open-endedquestions, such as “What’sthe most important healthgoal you have for yourselfover the next month?”

• Create “living” documenta-tion, not just a one-time ad-mission data form. Livingdocumentation is easily ac-cessible and updateable byall members of the collabora-tive team, rather than siloedin a paper chart or electronichealth record. Personal de-tails that are learned by nurs-es and others can be addedas multiple entries over timeas more is learned about thepatient and family.

• As a patient’s story unfolds,update all appropriate care team members. Do this asneeded and routinely duringrounds and shift changes.

Learn the story ofcaregivers and family Engage and learn the story of sig-nificant others in a patient’s life.This includes the history, needs,

Patient engagementand patient satisfaction:What’s the difference? Patient satisfaction is a patient’sown subjective rating of health-care experiences. Patient en-gagement, on the other hand, as defined by the Institute forHealthcare Improvement, refersto actions people take for theirhealth and to benefit from care.Engagement spans the continu-um of experiences within health-care settings, including the com-munity and the home.


and expectations of family andother caregivers. In many cases,learning their stories reveals hid-den barriers to health and recov-ery. Sharing this informationacross disciplines helps the careteam address them promptly.

Here are some tips:

• Assess how the caregivingteam is supporting the pa-tient. Who is the primarycaregiver? Who is responsi-ble for coordinating commu-nication with the care team?

• Evaluate what barriers aremost significant to continuedrecovery. Ask how well rest-ed the team is, and consid-er their capacity for contin-ued physical and emotionalcaring. For example, askwhat caregivers do to relaxand recharge.

Share health data Effective patient engagement in-cludes exchanging data before,during, and after health encoun-ters. Federal programs for themeaningful use of health informa-tion technology (HIT) require of-fering secure electronic messag-ing. Patients must be able toview, download, and transmittheir health information.

Here are some HIT tools thatsupport patient engagement.

• OpenNotes, Our Notes, andother electronic documenta-tion tools. These tools givepatients electronic access totheir entire record. Patientsare encouraged to viewtheir records and make cor-rections, in conjunction with their providers, as needed.This promotes transparencyand puts provider and pa-

tient on the same page. • Patient-Generated Health

Data (PGHD). These tools include a variety of healthinformation created, record-ed, and gathered by pa-tients or their designees. Patients, not providers, areprimarily responsible forcapturing or recording suchdata, which are distinct fromdata generated in clinicalsettings. Patients direct thesharing to recipients of theirown choosing.

• Patient-Reported Outcomes(PROs). These tools documentoutcomes important to pa-tients. PROs reflect how welltheir needs have been metand their care coordinated.PROs are collected through aseries of questionnaires sentto a patient electronically(SMS text message) to quan-tify medication adherenceand describe the nature ofside effects and reasons fornonadherence.

Share decision-making Care planning and outcomeevaluation should include thevoice of the patient and homecaregiver team. Shared decision-making (SDM) brings providersand patients together as collabo-rators. Techniques that supportSDM include:

• Ask the patient what his orher care goals are for today, the care episode, for dis-

charge, and overall health.Compare these goals tothose set by the clinical team.

• Clarify what decision pointscan be shared, what actionsthe patient and caregiverscan take and what they canexpect from the team.

• Establish continuity with ashareable care plan. Showthe patient the design of theplan, how ownership isshared, and who can makechanges or updates.

For more patient engagementideas, see Tap into a patient-engagement resource.

Heart of nursing Assessing a patient’s knowledge,skills, and assets for self-care hasalways been at the heart of nurs-ing. You can help take patientengagement to the next level. c

Selected referencesAbout Us. e-patients.net, a project of the Societyfor Participatory Medicine. 2014. www.e-patients.net/about-e-patientsnet Greene J, Hibbard JH, Sacks R, Overton V, Parrot-ta C. When patient activation levels change,health outcomes and costs change, too. HealthAff. 2015;34(3):431-7.Oldenburg J, Chase D, Christensen, KT, Tritle B, eds.Engage! Transforming Healthcare Through DigitalPatient Engagement. Chicago: Healthcare Informa-tion Management and Systems Society; 2013.

Ricciardi L, Mostashari F, Murphy J, Daniel JG,Siminerio EP. A national action plan to supportconsumer engagement via eHealth. Health Aff.2013;32(2):376-84.

Susan C. Hull is an independent nursing consult-ant and co-chairs the Alliance for Nursing Infor-matics Consumer e-Health Task force in partner-ship with the American Nurses Association.

Tap into a patient-engagement resource The Guide to Patient and Family Engagement in Hospital Quality andSafety is a tested, evidence-based resource developed by the Agency for Healthcare Research & Quality (AHRQ). The com-prehensive guide offers opportunities and guidance for meaning-ful engagement that can improve quality and safety. The guide is available at: www.ahrq.gov/professionals/systems/hospital/engagingfamilies/guide.html.

Older adults make up 13%of the U.S. population butaccount for 36% to 50%

of hospital admissions and 44%of hospital charges. About 20%of Medicare patients are read-mitted within 30 days; an esti-mated 75% of these readmis-sions are preventable.

A dramatic event at any age,hospitalization poses uniquechallenges for older adults. Hos-pitals harbor such dangers asadverse drug events, restraint in-juries, and falls, which can belethal in the elderly. For thesepatients, hospitalization also islinked to a significant risk fordelirium, malnutrition, infection,and loss of functional independ-

ence—possibly leading to per-sistent disability, nursing homeplacement, and death. Evidence-based nursing care models toprevent these complications con-tinue to gain support. Many ofthese models embrace multidisci-plinary assessment, communica-tion, and coordination.

Hospitalized older adultshave an uncertain trajectory;many never regain their previousmobility. Some studies show upto 35% of older hospitalized pa-tients experience a decline inbaseline activities of daily living(ADL) after admission.

As a nurse, you can help pre-vent patients from leaving thehospital with worse function than

they came in with. You’re in apivotal position to observe theirindependence level in perform-ing basic ADLs. A standardizedscreening instrument, such as theKatz Index of Independence inActivities of Daily Living (bath -ing, dressing, toileting, eating,and transfer), can help the healthcare team identify deficits andplan posthospital care. Mobilityroutines that include getting thepatient up for meals or sitting ina recliner or rocking chair mayimprove mobility among weakor fatigued older adults.

This article discusses some ofthe hidden dangers of hospitaliza-tion for older adults—delirium, re-duced mobility and falls, malnutri-tion, dehydration, and infections.

Delirium The hallmark of certain acute ill-nesses, delirium or acute confu-sion is the leading complicationof hospitalization in older adults.It affects 25% to 60% of olderhospitalized adults in the UnitedStates and costs about $8 billionyearly.

The complex pathophysiologyof delirium includes neurotransmit-ter alterations. Processes that maycontribute to delirium include hy-poxia, infection, electrolyte imbal-ance, constipation, and pain.

The good news: Delirium maybe preventable in at least 40%


educing functional decline in hospitalized older adultsLearn how to detect and prevent hidden dangers of hospitalization for these patients. By Denise M. Kresevic, PhD, RN, APN-BC

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of cases. Assess all hospitalizedolder adults for confusion duringeach shift, noting inattention orfluctuating mental status. Askthem what brought them to thehospital and ask them to namethe days of the week or monthsof the year forward and back-ward. If you note changes, docu-ment these and discuss themwith all care team members.

Try to identify the cause ofdelirium. Know that restraintsand certain medications can pro-long or worsen this condition. Ifyou note sudden or worseningconfusion in a patient withknown cognitive impairment,evaluate for potential acute re-versible causes.

The following interventionscan help prevent delirium in old-er adults:

• Use appropriate pain med-ications in dosages tailoredto older adults.

• Avoid sleeping medica-tions.

• Correct sensory deficits,such as hearing and visionloss.

• Encourage increased visitsfrom family members andvolunteers.

• Provide access to musicand art therapy.

• Create a quiet environmentfor sleep at night.

An “aging tool kit” that includeshearing amplifiers and magnifyingglasses can be assembled to en-hance communication and pro-vide safe options for distraction,including books and puzzles.

Reduced mobility and falls The hazards of immobility andprolonged bed rest have beenknown for decades. Many

healthcare professionals havenoted the negative effects of bedrest, including orthostatic hy-potension, atelectasis, decreasedmuscle strength, increased boneloss, constipation, incontinence,pressure ulcers, and confusion.

Maintaining the patient’s mo-bility is the best way to preventfalls. Provide opportunities to en-hance mobility safely. Consult aphysical therapist, who can as-sess for balance and gait abnor-malities and provide exercisesand equipment to help the pa-tient regain strength, avoid com-plications, and promote return tobaseline function. Use devicessuch as slings and lifts as need-ed to move patients so you pro-tect them (and yourself) from injury while still providing oppor-tunities for mobility.

Ensure that the patient has as-sisted or supervised ambulation(especially to the bathroom).Provide ongoing education tothe patient and family, using theteach-back technique, to identitythe patient’s safe level of func-tion and encourage exerciseand use of mobility aides. Forexample, tell the patient, “Showme what you would do if youhad to go the bathroom.” Orask, “What would you do if youcalled for the nurse and she did-n’t come immediately?” Suggest

that plan B might be to call forthe nurse again.

Another way to help preventfalls is proactive rounding toprovide assistance for toiletingand ensuring a safe environ-ment. Such rounds strongly en-courage and assist older adultsto go to the bathroom beforethey feel the urge and need torush. Other effective interven-tions include:

• placing frail patients in roomsnear the nurse’s station

• keeping the bed in the lowposition

• keeping the call light, water,and accessories within reach

• using dim lighting at night• placing furniture in nonobtru-

sive positions• raising the toilet seat.

Malnutrition anddehydration At least half of older adults areadmitted to the hospital with de-hydration and malnutrition. Bothconditions are independent riskfactors for falls, confusion, pres-sure ulcers, impaired immunity,longer stays, and even death.

Assess your patient’s nutrition-al status on admission to identifyand correct nutritional deficits ina timely manner. For lethargicolder adults, assess safe swal-lowing ability at the bedside.During an acute illness, avoidaggressive restricted diets (in-cluding nothing-by-mouth) forprolonged periods.

Preventing constipation is cru-cial. Prevention strategies includeproviding adequate fluids andwarm prune juice and promotingmobility. In some older adults,nutrition can become critical, sig-naling depression and end-of-life


Ensure that the

patient has assisted

or supervised

ambulation

(especially to the

bathroom).

issues. Feeding-tubeplacement must beevaluated carefully.

Provide nutritionaland speech re-sources to help man-age nutritional prob-lems. As needed,arrange for an ethicsconsultation to givethe patient and family the infor-mation they need to set realisticgoals. Be sure to honor the pa-tient’s wishes.

Other interventions to pre-vent malnutrition and dehydra-tion include:

• assessing and honoring thepatient food’s preferences

• providing a “liberal kitchen”with snacks available 24/7

• performing oral care be-fore meals to help the pa-tient maintain nutrition andprevent infections.

• getting the patient out ofbed for meals and for 20minutes afterward, if possi-ble, to prevent indigestion.

Infections Older adults with decreased im-mune function are at special riskfor infection. Urinary tract infec-tions and pneumonia commonlynecessitate hospital admission inolder adults. However, antibiotictherapy to treat infection can be particularly complex in olderadults who may have unique illness presentations, are at in-creased risk for resistant organ-isms, or are receiving multiplemedications that may increaseadverse effects.

Also, know that certain hospi-tal routines may pose undue riskof infection. To help decrease therisk of atelectasis and pneumonia,

avoid bed rest when possible.Carefully evaluate the need for in-dwelling urinary catheters, consid-ering their risks, benefits, and al-ternatives. Discontinue thesecatheters as soon as possible.

Consider the following inter-ventions as well:

• Remind older adults to per-form ongoing oral care, in-cluding teeth or denturebrushing, mouth rinsing,and lip care for dryness. Asneeded, assist them withthis care.

• Be sure staff and visitorswash their hands beforeand after contact with thepatient.

• Instruct older adults to per-form daily hygiene, includ-ing hand washing.

The value of dischargeplanning Appropriate discharge planninghelps avoid functional decline inolder adults. Planning for the pa-tient’s discharge begins at thetime of admission and must beintegrated into daily care by allcare providers. Due to insurancerequirements and financial con-straints, discharge planning hasbecome increasingly complex.

Choices for posthospital caredepend on the patient’s healthstatus and illness trajectory, aswell as available support per-

sons and resources. The interdis-ciplinary team must be able togive the patient and family a re-alistic trajectory of recovery aswell as recommended options.

Nurses in all care settings, par-ticularly acute-care hospitals, arewell placed to help older adultsavoid functional decline. In somecases, this may require a changein the hospital culture and addi-tional education for nurses regard-ing older adults’ unique needs.Special areas of focus include thepatient’s particular needs, caretransitions, and possible changesin hospital routines, such as bedrest and restraint use. c

Selected referencesAgency for Healthcare Research and Quality.National Guideline Clearinghouse. www.guideline.gov/search/search.aspx?term=older+adults

American Academy of Nursing’s Expert Panelon Acute and Critical Care. Reducing Func-tional Decline in Older Adults During Hospi-talization: A Best Practice Approach. TryThis®: Best Practice in Nursing Care to OlderAdults General Assessment Series; Issue 31,2012. Hartford Institute for Geriatric Nurs-ing. www.consultgerirn.org/uploads/File/trythis/try_this_31.pdf

Asher R. The dangers of going to bed. BrMed J. 1947 Dec 13;2(4536):967-8.

Inouye SK, Bogardus ST, Charpentier PA, etal. A multicomponent intervention to preventdelirium in hospitalized older adults. N EnglJ Med. 1999;340(9):669-76.

Landefeld CS, Palmer RM, Kresevic DM,Fortinsky RH, Kowal J. A randomized trial ofcare in a hospital medical unit especially de-signed to improve the functional outcomes ofacutely ill older patients. N Engl Med. 1995;332(20):1338-44.

The NICHE Program. Nurses Improving Carefor Healthsystem Elders (NICHE). 2015.www.nicheprogram.org/program_overview

Denise M. Kresevic is a geriatric clinical nursespecialist III at University Hospitals Case MedicalCenter in Cleveland, Ohio, and a geriatric nursepractitioner and nurse researcher at the LouisStokes Cleveland VA Medical Center.


To keep patients on themove, healthcare profes-sionals need to make

planned mobility a priority inter-vention. Progressive mobility (also known as early mobiliza-tion) starts slowly and moves thepatient toward more range-of-motion exercises, longer sittingtimes in a chair, and more fre-quent and longer walks in thehallway.

Although progressive mobilityisn’t a new concept, one aspectis relatively new—the initialstart time. Traditionally, patientshaven’t been encouraged to am-bulate or sit up early duringtheir stays or after surgery. In-stead, clinicians viewed bedrest as an important aid to heal-ing, especially during an acuteillness. For example, patientsused to be placed on 3 days ofbed rest after an uncomplicatedacute myocardial infarction. Butwith research now supportingearly mobilization, this nolonger happens. Today, mostpatients are encouraged tomove from the beginning oftheir stay, to prevent negativebed-rest outcomes, such asblood clots, pneumonia, deliri-um, and ultimately, patient dis-satisfaction and longer stays.

How can nurses get patientsmoving earlier? Ambulation isthe most common way. If your

patient is unable to ambulate,consider other methods, such aselevating the head of the bed,passive range of motion (ROM),manual turning, dangling, andassistance to a chair. No setstandard of care exists on when

to start the mobilizationprocess. What’s more, in somesituations, barriers exist. (SeeBarriers to mobilization.)

As a standard of care, mobi-lization requires planning. If theprovider hasn’t given orders to


Get your patients moving—now!Learn about early progressive ambulation protocols thatpromote better outcomes.By Amanda Veesart, MSN, RN, CNE, and Alyce S. Ashcraft, PhD, RN, CNE, ANEF

mobilize your patient, contacthim or her to validate the mobi-lization plan. Normally, thisisn’t a major issue—just onethat takes precious nursing time.But forgetting to contact theprovider or relegating this taskto the bottom of your to-do listisn’t an option.

Get assistance—andassistive devices Mobilizing patients also requiresaccess to staff and resources.Some patients are unable tomove or ambulate without assis-tance. For these patients, turn todevices such as lifts and slings totransfer patients and use assistivetools such as gait belts and walk-ers to help them move. As need-ed, recruit other team members tohelp mobilize patients.

Keep in mind that lack of assis-tive devices isn’t an excuse for fail-ing to implement mobility proto-cols. Advocate within your organi-zation to obtain these devices,which protect patients and staff.

Progressive ambulationprotocols Progressive ambulation protocols

serve as implementation guidesin setting mobility expectationsfor a specific patient populationthroughout the hospital stay. Be-cause these protocols standard-ize bed, transfer, and ambula-tion activities, they eliminate theneed for nurses to wait for physi-cian rounds or new orders toprogress patients to the next stepin the protocol.

Early mobilization in the ICU In the ICU, the first step in pro-gressive mobility is assessingthe patient for mobility initia-tion. The healthcare team evalu-ates the patient to ensure earlymobility isn’t contraindicatedand communicates all steps ofthe process to the patient. Con-traindications for early mobilityin the ICU include one or moreof the following:

• unstable blood pressure(mean pressure below 65mm Hg)

• heart rate below 60 orabove 120 beats/minute

• respiratory rate less than 10 or more than 32 breaths/minute

• oxygen saturation below90%

• anxiety or agitation requir-ing sedation

• insecure airway device• difficult airway access.

Be aware that patient de-vices, active intubation, or con-tinuous I.V. medication infusionsare not contraindications.

The scenario below illustratesan early progressive mobiliza-tion protocol for an ICU patient.

Mr. Jones,age 52, justhad coronaryartery by-pass surgery.Awake andstill intubat-ed, he is re-ceiving I.V. infu-sions, with sequentialcompression devices applied tohis legs. His plan of care in-cludes early progressive mobi-lization.

Before mobilization begins,the nurse explains the processto Mr. Jones and instructs himon how to signal anxiety, pain,or a feeling that something ischanging. To ensure he is fullyprepared for mobilization, adesignated team member is as-signed a communication-onlyrole. Charged with instructingthe patient, this team memberstays directly in front of himduring the entire exercise.

After assessing Mr. Jones forcontraindications to early mobil-ity and explaining the processto him, the team determines ifearly progressive mobility cansafely begin. To ensure the pa-tient, healthcare team, andequipment are secure and safe,


Barriers to mobilization Barriers to early mobilization of hospital patients include:• patient (or family) refusal due to patient pain and discomfort• large patient size• lack of personnel • lack of safe-patient handling and mobilization equipment• lack of provider orders• failure to make mobilization a priority.

If moving causes pain or the patient lacks the will to move, takethe time to inform the patient and family of the importance of mo-bilization, explain its benefits, and provide pain medication (if re-quired and ordered). Some patients may be reluctant to begin mobilization. But in

many cases, they later admit that moving made them feel better,even though it caused discomfort at the time. Remember that thefamily must be on board with the importance of mobility. Other-wise, they could sabotage the plan of care to avoid “hurting” theirloved one.

the nurse assesses all devicesfor secure attachments, stopsunnecessary I.V. infusions, andmoves indwelling devices to theside of the bed. Other teammembers verify that the wheel-chair is secure and close to thebed for the transfer. The respi-ratory therapist confirms thatthe mechanical ventilator isswitched to a transport ventila-tor and the endotracheal tube issecure.

After verifying the safety of alldevices, the team assists Mr.Jones to the side of the bed.Then they implement activerange-of-motion (ROM) exercisesin this position before transfer.The designated communicatoruses one-sentence commands toensure that the patient and allteam members understand eachstep of the transfer process.

Early mobilization on theorthopedic unit Early progressive mobility onthe orthopedic unit resemblesthe process used in the ICU. Af-ter joint- replacement therapy,progressive mobility starts bymoving the patient to the side ofthe bed or implementing activeROM exercises. Patients who’vehad this type of surgery or otherleg surgery typically have diffi-culty at this stage and mayneed pain medication beforemobilization. Remember—al-though progressive mobilityshould begin early, this doesn’tnecessarily mean the patientshould ambulate quickly.

The scenario below describesan early progressive mobilityprotocol on the orthopedic unit.

Mrs. Smith, age 65, is recov-ering from right total knee re-

placement sur-gery. Herplan of careincludesearly pro-gressive mo-bility. Thenurse assess-es her for con-traindications tomobility. She knows that pa-tients who’ve just had joint re-placement may progress to am-bulation more slowly than otherpatients.

After the nurse determines it’ssafe for Mrs. Smith to move,she has her perform activeROM exercises three times. Be-fore advancing her to standing,the nurse recruits a second staffmember to assist her for addedsafety.

Once Mrs. Smith has mas-tered standing, the nurse helpsher ambulate with a walker orother assistive device. Duringambulation, one staff memberis designated to communicatewith Mrs. Smith to avoid confu-sion or mixed messages abouther next step. To promote earlydischarge and enable her toremain in her home, teammembers provide thorough in-structions on proper ambula-tion techniques and the assis-tive device she’ll be using athome.

Obtaining appropriate assis-tive devices is important for bothpatients’ and employees’ safety.After discharge, these devicescan help the patient ambulate athome and in the community.

Although some nurses may beuncomfortable about moving a pa-tient only a few hours after majorsurgery, receiving training in pro-gressive early mobility protocolscan give them more confidence.These protocols promote better pa-tient outcomes and help reduce hospital stays and readmissions. So getyour patients moving—now! c

Selected referencesBalaguras J, Holly V. Get moving—Clinicalnurse specialist-led implementation of a nurs-ing-driven progressive mobility protocol [ab-stract]. Clin Nurse Spec. 2009;23(2):101.

Campbell MR, Fisher J, Anderson L, KreppelE. Implementation of early exercise and pro-gressive mobility: steps to success. Crit CareNurse. 2015;35(1):82-8.

Current Topics in Safe Patient Handling andMobility. Supplement to American Nurse To-day. September 2014.

Klein K, Mulkey M, Bena JF, Albert NM. Clin-ical and psychologic effects of early mobi-lization in patients treated in a neurologicICU: a comparative study. Crit Care Med.2015;43(4):865-73.

Mikkelsen LR, Mechlenburg I, Soballe K, et al. Effect of early supervised progressive re-sistance training compared to unsupervisedhome-based exercise after fast-track total hipreplacement applied to patients with preoper-ative functional limitations. A single-blindedrandomised controlled trial. OsteoarthritisCartilage. 2014;22(12):2051-8.

Morris PE, Griffin L, Berry M, et al. Receivingearly mobility during an intensive care unitadmission is a predictor of improved out-comes in acute respiratory failure. Am J MedSci. 2011;341(5):373-7.

The authors work at Texas Tech UniversityHealth Science Center in Lubbock. AmandaVeesart is an assistant professor and clinical di-rector. Alyce S. Ashcraft is a professor and asso-ciate dean of research. (Names in scenarios arefictitious.)


Early progressivemobility on theorthopedic unitresembles theprocess used in

the ICU.

Keeping hospital patientssafe from untoward eventsis a crucial aspect of the

essence of nursing. Every health-care organization is accountablefor the care and safety of its pa-tients. Patient falls and pressureulcers are costly—in time, money,and lives. (See The high toll offalls and pressure ulcers.) What’smore, falls and pressure ulcersare “never events”—health careerrors that should never occur, asdefined by the National QualityForum. Considered preventableand serious, “never events” re-flect a problem in the healthcaredelivery system. In this article, wepresent a case study to illustratehow to help prevent falls andpressure ulcers.

Anna Roberts, age 75, is ad-mitted to the orthopedic-surgical

unit on yourshift to recov-er from sur-gery for afracturedpatella. Af-ter misjudg-ing a smallstep when enter-ing a store, she fell and injuredher left knee and was taken tothe hospital by ambulance.

Mrs. Roberts arrives on yourunit with a dressing, a long softsplint, and I.V. access for pain-control medication. When you as-sess her, you find her alert andoriented to time, person, andplace. She states she is a widowand has been living independent-ly at home. She is able to driveand keeps busy with various hob-bies. Her daughter lives nearbyand visits often. She tells you she

has been planning a trip to Eu-rope with friends next year. Nowshe worries her knee injury couldprevent her from going.

You know that for Mrs. Robertsand other elderly patients, a fallmay lead to a functional decline.You also know she has multiplerisk factors for falls and skinbreakdown. Naturally, you wantto help her avoid another falland prevent skin breakdown.Risk factors for falls include ad-vanced age, certain medications,and inactivity due to medicalconditions that cause weaknessor dizziness. Because of her in-jury, Mrs. Roberts is at increasedrisk for falls due to the new painmedications she’s taking, clumsi-ness caused by her leg splint, theneed for crutches, and her de-creased activity level. Splint useand decreased mobility alsoraise her risk for pressure ulcers.

To promote her recovery in thehospital and plan her return toprevious activities, you set the fol-lowing care goals: preventingfalls, keeping her active whilecontrolling her pain, promotingskin integrity, and helping her feelcomfortable about going homewithout fearing she’ll fall again.

Assessing your patient’sfall riskMultiple tools are available tohelp clinicians assess patients forfall risk:


eeping patients safe from fallsand pressure ulcersIn your patient advocate role, push for hospital policies that helpprevent these “never events.”By Amy Moore, DNP, RN, FNP-C, and Rebecca Geist, MSN, RN, APHN-BC

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The high toll of falls and pressure ulcers According to the Centers for Disease Control and Prevention, fallsin elderly persons are among the most serious safety issues forhospitals, with costs expected to reach nearly $68 billion by 2020.Each year, about one-third of adults older than age 65 fall. About20% to 30% of older adults who fall suffer injuries that alter theirability to perform activities of daily living. Although many patientsrecover from their injuries, they may return home with decreasedmobility due to fear of falling again.Pressure ulcers are the fourth leading cause of preventable er-

rors in the United States, with medical costs ranging from $2,000to $70,000 per ulcer. Pressure ulcers increase the risk of readmis-sion and death.

• The Timed Up and Gotest is a short, simple, andreliable screening test forbalance problems. The eval-uator times the patient asshe rises from a chair,walks 3 meters, turns, andwalks back to the chair. Per-formance is graded on ascale of 1 to 5, with 1 indi-cating normal and 5 denot-ing severely abnormal. Ascore of 3 or higher indi-cates an increased fall risk.

• The Balance EvaluationSystems Test differenti-ates among balancedeficits. It consists of 36items in six underlying sys-tems that affect balance,helping clinicians focus ontreatments for specific bal-ance problems. It takes 30minutes to complete.

• The Tinetti Scale evaluatesbalance and gait to deter-mine the patient’s risk forfalling in the home. Assess-ing both gait and balance,it’s useful for patients with ahistory of or high risk forfalls. A healthcare provideror family member may ad-minister the Tinetti Scale.

Preventing fallsUniversal fall precautions, whichapply to all patients regardless offall risk, revolve around keepingthe patient’s environment safeand comfortable. They focus onkeeping all patients SAFE: Safeenvironment, Assist with mobility,Fall risk reduction, Engage thepatient and family. (You can readmore about risk assessment else-where in this supplement.)

In the hospital, engagementincludes promoting communica-

tion among employees, familymembers, and friends regardingthe patient’s need for help get-ting to the bathroom, nonskidsocks, and use of a walker orbed alarm when no one is withhim or her. A bed alarm signalsthe healthcare team that the pa-tient is getting out of bed. Spe-cial floor mats that protect pa-tients if they fall out of bed alsomay be appropriate. Thesemeasures can be especially help-ful with confused patients.

In some facilities, at-risk pa-tients wear colored armbands toalert others of their fall potential.This helps caregivers determinehow much assistance the patientneeds during transport andwheth er to house him or her in a room near the nurses’ station.Some facilities assign different lev-els of fall risk, indicated by color-coded armbands or markers onthe outside of the patient’s door.

Keeping the bed rails down isimportant, too. When all railsare up, the patient is more likelyto try to crawl over them to getout of bed, increasing the risk offalling. In rare cases, a confusedpatient must be restrained. How-ever, restraints should be usedonly as a last resort becausethey can increase patients’ agita-

tion and cause serious injury.Make sure you’re familiar withyour facility’s restraint policiesand procedures. If your patientis restrained, check the restraintthroughout your shift for appro-priate tightness and skin irrita-tion. Ensure the patient has easyaccess to the call button.

Before discharge, evaluatethe patient’s risk for falling in thehome. (See Reducing risk factorsfor falls at home.)

Promoting skin integrityStarting on admission, assesspatients daily for potential skinbreakdown. Unless existingbreakdown is documented onadmission, the insurer will as-sume skin breakdown occurredafter admission and won’t reim-burse the hospital for relatedmedical costs.

Use the Braden Scale to eval-uate the patient’s risk for pres-sure ulcers. This scale assessesskin breakdown risk using sixcriteria—sensory perception,moisture, activity, mobility, nutri-tion, and friction and shear.Scores range from no risk tovery high risk. For more informa-tion on the Braden scale, seehttp://consultgerirn.org/uploads/File/trythis/try_this_5.pdf. You


Reducing risk factors for falls at home Risk factors for falls in the patient’s home include slick floor sur-faces, rugs, cluttered pathways, and poor lighting. Also, someonewho has fallen in the previous 6 months has a high risk of fallingagain. Communicating with family members is essential and should in-

clude education on preventive measures, such as an optional homeassessment; family members should communicate assessment find-ings to the nursing staff. Together, the family and nursing staff candetermine what changes need to be made in the home. For in-stance, they may consider use of a fall monitor to alert them incase the patient falls. Monitoring systems vary in price and canhelp prevent more serious harm if a fall occurs. Some systems au-tomatically call a family member or emergency services if the pa-tient falls or activates the system.

also can use the Norton scale to identify at-risk patients (seewww.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool7b.html).

Evaluate the patient’s age,mobility, and type of illness orinjury. Elderly patients are athigh risk for skin breakdown—especially those with hip frac-tures and others who must en-dure long periods of immobility.

To help prevent pressure ulcers,use a special mattress and turnthe patient at least every 2 hours;patients at high risk may need tobe repositioned and turned moreoften. Caregivers’ failure to rec-ognize the need for an appropri-ate bed or mattress for a high-riskpatient can lead to skin break-down. A patient who is expectedto be on prolonged bedrest mayneed a special air mattress tohelp prevent skin breakdown.

Be sure to assess skin areas un-der clothing, dressings, splints (aswith Mrs. Roberts in our casestudy), or other devices. Remem-ber—skin can start to break downwithin hours of compression. (SeePreventing, detecting, and man-aging pressure ulcers.)

Adequate skin care may ne-cessitate readjusting a splint orusing special padding, such asunder the patient’s heels. Cleanthe skin regularly; as you dothis, evaluate skin under thepadding for signs of breakdown.

Communication countsBe sure to convey the patient’srisk for skin breakdown to otherhealthcare team members, par-ticularly during handoff to otherclinicians—especially if the skinhas already started to redden.Improving communication


Preventing, detecting, and managing pressureulcers Nurses must stay vigilant and act promptly to prevent and managepressure ulcers.

Prevention Wash the patient’s skin with warm water as needed. Avoid usingrough edges of the washcloth. Pat the skin gently to dry. Also fol-low these guidelines:• Check for incontinence and perform perineal care daily.• Provide an appropriate support surface for the bed and thewheelchair or other sitting surface. Use a lateral rotation bed asindicated.

• Create individualized turning and repositioning schedules.• Help patients stay as mobile and active as possible.• Keep the heels elevated from the bed in patients who aren’t mobile.• Assess for nutrition and hydration needs. Provide a referral to adietitian, as needed.

Detection To help identify pressure ulcers early, perform a comprehensiveskin assessment that includes observing and touching the skin fromhead to toe. Consider temperature, color, moisture level, turgor,and skin integrity. Stay especially alert for signs of pressure andfriction on these areas:• back • under splints• buttocks • areas affected by wrinkled bedsheets• heels • areas under clothing buttons.

To find time for a thorough skin assessment, incorporate it intoyour daily care. For example, when auscultating lung sounds orturning the patient, inspect the patient’s shoulders, back, andsacral/coccyx regions.

Management If a pressure ulcer or other type of skin breakdown occurs, takethese steps as appropriate: • Advise the patient to increase calorie intake and consume ade-quate amounts of protein, vitamins C and D, and zinc. Encour-age the patient to stay well hydrated.

• Consult a wound care clinician to ensure that the patient re-ceives the proper care.

• When bathing the patient, use a soft sponge and avoid scrub-bing. Try to bathe the patient every other day (rather than everyday) to avoid drying the skin.

• Make sure the patient stays hydrated.• Avoid placing a pillow under the knees. Instead, place it underthe calves to relieve pressure on the heels.

Documentation If a pressure ulcer develops, evaluate for and document the fol-lowing:• pressure ulcer category or stage • erythema• location • blanching• depth • drainage• size • odor.

among healthcare professionals,as by using the TeamSTEPPS®

and SBAR (Situation, Back-ground, Assessment, and Recom-mendation) methods, can helppatients stay safe.

Patient educationPatient education plays a keyrole in preventing pressure ul-cers. From the time of patients’admission, teach them about therisk of potential skin breakdownand how to prevent it at homeafter discharge.

Promoting adequate nutritionNutrition helps maintain skin in-tegrity and healing. Energy re-quires protein; during hospitaliza-tion, patients with a poor appetitemay replace protein foods withsimple carbohydrates. Some pa-tients may make meals out of“junk” food instead of healthyproteins; for instance, they mayeat a breakfast bar thinking it’sfull of protein when it’s actuallyfull of sugar, empty calories, and little protein. Healthy adultsshould consume 0.8 g of pro-tein/kg/day. Many hospitalizedpatients need more—as much as1.5 g/kg/day.

Proper wound healing re-quires amino acids, such asarginine and glutamine (foundin red meat, fish, nuts, anddairy products) and a good mul-tivitamin supplement containingvitamins A, B complex, C, andE, as well as magnesium, man-ganese, selenium, and zinc. Al-though nutrition research in thearea of pressure ulcer care islimited, we know vitamin D iscrucial to skin proliferation andplays a potential role in ulcerprevention. To help ensure yourpatient is obtaining adequate

hydration and nutrition, arrangefor a dietary consult, and edu-cate the patient and familyabout proper nutrition.

The nurse’s advocacy roleFalls and pressure ulcers in eld-erly patients are nothing new,but these “never events” are get-ting more attention. They alsohave potential legal ramifica-tions: A pressure ulcer that de-velops during a patient’s hospitalstay may be grounds for a pro-fessional liability lawsuit. Hospi-tals may suffer financially be-cause their reimbursements maydecrease if safety measuresaren’t carried out properly.

Acting as a patient advocatefrom admission through dis-charge can help you keep yourpatients safe. Advocate for hos-pital policies that help ensurepatients stay safe. For instance,policies for fall-risk assessmentprograms with comprehensiveguidelines for reducing and pre-venting falls can be created andimplemented through fall-preven-tion teams and quality-improve-ment or risk-management teams.

Of course, nurses alone aren’tresponsible for patient safety. Allhospital employees must makepatient safety a goal, includinghouse keeping, food services staff,certified nurse aides, and adminis-trators. We often criticize patientsfor being nonadherent when thereal problem may be lack of avail-able services or inability to accessthem. Such services include ahome hazards assessment, imple-mentation of a fall-proofing plan,an at-home exercise program, andinstallation of a fall-proof alert sys-tem. Preventing falls both in thehospital and at home and increas-ing your knowledge of pressure

ulcer prevention and manage-ment can help you keep patientsin good health.

Before Mrs. Roberts is dis-charged, family members assessher home for fall risks. They re-move throw rugs, install safetybars in her bathroom and show-er, and purchase an affordablefall-alert system. Nine months af-ter her surgery and discharge,Mrs. Roberts is back to her nor-mal routine and is planning herupcoming trip to Europe. c

Selected referencesAssessment Tools: Try This® tools. 2015. Hart-ford Institute for Geriatric Resources. www.hartfordign.org/practice/try_this/

Ayello EA. Predicting pressure ulcer risk. Best Prac-tices in Nursing Care to Older Adults. Hartford In-stitute for Geriatric Resources. Revised 2012. con-sultgerirn.org/uploads/File/trythis/try_this_5.pdf

Berlowitz D, VanDeusen Lukas C, Parker V, et al.Preventing Pressure Ulcers in Hospitals: A Toolkitfor Improving Quality of Care. Agency for Health-care Research and Quality. (n.d.).www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putoolkit.pdf

Costs of falls among older adults. Centers for Dis-ease Control and Prevention. Page last reviewedand updated September 22, 2014.www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html

Marco S. Wound and Pressure Ulcer Manage-ment. Johns Hopkins Medicine. (n.d.). www.hopkinsmedicine.org/gec/series/wound_care.html

Kalava UR, Cha SS, Takahashi PY. Associationbetween vitamin D and pressure ulcers in olderambulation adults: results of a matched case-control study. Clin Interv Aging. 2011;6:213-9.

Lundgren J. Preventing pressure ulcers starts onadmission. Wound Care Advisor. 2013;2(5).woundcareadvisor.com/preventing-pressure-ulcers-starts-on-admission-vol2-vol5/

Mancini M, Horak FB. The relevance of clinical bal-ance assessment tools to differentiate balance defi -cits. Eur J Phys Rehabil Med. 2010;46( 2): 239-48.

Serious Reportable Events in Healthcare – 2011Update: A Consensus Report. National QualityForum. 2011. www.doh.wa.gov/Portals/1/Documents/2900/NQF2011Update.pdf

The authors work at the School of Nursing atTexas Tech University Health Sciences Center inLubbock. Amy Moore is an associate professor.Rebecca Geist is an instructor.


For too many patients, thehospital door is a revolvingone. About 20% of Medi -

care patients leave the hospitalonly to be readmitted within 30days. Failure to create standarddischarge processes, adequatelyprepare patients and familycaregivers for discharge, edu-cate patients about medications,and communicate effectivelywith postdischarge providerscontribute to preventable read-missions. The Hospital Readmis-sion Reduction Program (part ofthe Affordable Care Act) re-duces payments to hospitals withhigh readmissions rates within30 days of discharge.

Through efficient coordination,communication, planning, and ed-ucation, nurses and nurse casemanagers (NCMs) can play a piv-otal role in reducing readmissions.Starting at admission, we can miti-gate readmission risk at multiplepoints during the predischargeand postdischarge periods by:

• appropriately determiningthe patient’s readiness fordischarge

• compiling a comprehensiveand accurate dischargesummary

• helping to determine an ap-propriate postdischargecare setting

• coordinating care with multi-ple settings and providers

• involving the patient andfamily caregivers in the planof care

• conducting postdischargefollow-up phone calls.

Nursing interventions onadmissionProject BOOST® (Better Outcomesby Optimizing Safe Transitions) rec-ommends interventions begin at ad-mission. To help identify concernsthat may warrant additional inter-ventions during the patient’s hospi-tal stay, be sure to evaluate keypsychosocial issues, including cog-nitive status, substance abuse or de-pendence, abuse or neglect, anddocumentation of advanced careplanning. Communicate areas ofconcern to the NCM for potentialinterventions and referral to appro-priate resources and referrals.

The General Assessment ofPreparedness (GAP) tool helpsnurses and NCMs with early pa-tient evaluation. This simplechecklist, which various health-care team members can com-plete, addresses potential logisti-cal and psychosocial issues. To learn more about GAP, visitwww.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/BOOST_Interven-tion/BOOST_Tools.aspx.

Nursing interventionsthroughout the stayIt’s crucial to identify who willprovide care for the patient afterdischarge and to involve this per-son in discharge planning. To in-crease the chance that familycaregivers will be involved inplanning, write the name of thepostdischarge caregiver on thewhiteboard in the patient’s room.Preparing the patient and homecaregiver for discharge through-out the hospital stay can ease in-formation overload and confu-sion during the dischargeprocess. Readmission rates de-cline when patients and familycaregivers participate in dis-charge planning as active careteam members. (See IDEAL dis-charge planning method.)

Nursing interventionsduring dischargeMany studies link readmissionswith lack of prompt follow-up byprimary care providers (PCPs) orother healthcare professionals.Ideally, patients should have afollow-up appointment within 48hours to 7 days after discharge.NCMs may use the followingstrategies to increase the chanceof successful follow-up:

• Develop scheduling agree-ments with local clinics,such as system-affiliated ambulatory care clinics.


ow nurses can help reducehospital readmissionsLearn how to help mitigate readmission risk starting from the time of admission. By Joan M. Nelson, DNP, RN, ANP-BC, and Laura Rosenthal, DNP, RN, ACNP-BC

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• Create processes for as-signing patients to a PCP ifthey don’t have one.

• Educate patients and homecaregivers about the impor-tance of timely and appro-priate follow-up.

• Identify and address barri-ers that contribute to can-celled healthcare appoint-ments.

• Give the patient and familycaregivers the dischargingunit’s phone number sothey can call with questionsor concerns.

CommunicationDuring this critical transition time,clear communication must occuramong PCPs, home healthcareagencies, long-term care facili-ties, and other facilities. Nursesand NCMs can assist in gather-ing written chart information aswell as giving verbal report tothe caregiver who’s receiving thepatient.

The National Transitions ofCare Coalition encourages useof a standardized universaltransfer tool to promote transferof necessary patient informationduring care transitions. The Re-ducing Avoidable ReadmissionsEffectively Campaign providestransition information templatesin its Safe Transitions of CareToolkit, which includes checklistsfor important patient information.Available at www.mnhospitals.org/patient-safety/current-safe-ty-quality-initiatives/readmis-sions-safe-transitions-of-care,this tool can be faxed to the receiving facility and review-ed before the patient-reportphone call and patient transferoccur.

Postdischarge nursinginterventions The period immediately after dis-charge is a vulnerable time forpatients—one in which rapidchanges can occur. Following upwith patients and home care-givers soon after discharge can

decrease confusion and reinforcefollow-up plans. Common topicsto discuss during the first postdis-charge phone call include med-ications and pending services orappointments. Healthcareproviders should inform patientsabout the purpose of the call.

IDEAL discharge planning method The Agency for Healthcare Research and Quality has developed aguideline and toolkit to help nurses and other clinicians involvepatients in discharge planning. Using the acronym “IDEAL,” thisguide encourages nurses to use the following strategies with pa-tients and family caregivers.

IncludeInclude the patient as a full partner in discharge planning, bedsiderounds, and shift reports. Review medications daily and at eachdose administration. Have at least one meeting specific to dis-charge planning at least 1or 2 days before discharge. During thismeeting, you can use the “Be Prepared to Go Home Checklist,”available at www.ahrq.gov/professionals/systems/hospital/engag-ingfamilies/strategy4/Strat4_Tool_2a_IDEAL_Checklist_508.pdf.

Discuss Focus on these five key areas to prevent problems at home:• Describe life at home after discharge, including home safety, di-etary changes, activity restrictions. and support services.

• Review medications using a reconciled medication list.• Review red flags for changes in the patient’s condition and ac-tion plans. Ensure that the patient has a contact phone numberto call with questions or if his or her condition changes.

• Review test results, including pending results, and explain howto access this information.

• Highlight required follow-up appointments and provide assis-tance in making them, if needed.

Educate Using plain language, educate the patient and family about thepatient’s condition, discharge process, and next steps on an ongo-ing basis throughout the hospital stay.

Assess Assess the quality and effectiveness of healthcare professionals’explanations of the patient’s diagnosis, condition, and next steps incare. Also assess how often healthcare professionals use teach-back techniques.

Listen Listen to and honor the goals, preferences, observations, and con-cerns of the patient and family caregivers. Provide a whiteboard orother area for the patient and family to write questions as theyarise. Elicit the patient’s goals for the hospital stay.

For more information on IDEAL discharge planning, visitwww.ahrq.gov/professionals/systems/hospital/red/toolkit.


Training nurses or NCMs tomake these calls using a scriptand an electronic documentationtemplate can help ensure impor-tant issues are covered and doc-umented in the medical record.

Discharge to a setting otherthan homeWhen a patient is discharged toa setting other than the home,nurses and NCMs can play acrucial role in preventing transferback to the hospital. Interven-tions to Reduce Acute CareTransfers (INTERACT) is a quali-ty-improvement program thatprovides an evidence-basedguide, web-based educationalmaterials, and tools designed toreduce transfers (including read-missions) from long-term careand assisted living settings toacute-care hospitals. INTERACTcan improve patient safety andsatisfaction and reduce readmis-sions through early identificationand evaluation of changes in thepatient’s condition, optimal doc-umentation and communicationabout these changes, and man-agement of the patient’s condi-

tion in a way that’s consistentwith the patient’s and family’swishes. (See INTERACT tools.)

Halting the readmissioncycleHospital readmissions are costly topatients and healthcare facilities.Nurses and NCMs are naturalcommunicators and educators, put-ting them in an excellent position tohelp prevent readmissions at multi-ple points—from admission throughdischarge and beyond. Becomingfamiliar with and using easily ac-cessible, evidence-based resourcesand tools can help nurses andNCMs manage patient transitionsoptimally and consistently. cSelected references Brooke BS, Stone DH, Cronenwett JL, et al. Early pri-

mary care provider follow-up and readmission afterhigh risk surgery. JAMA Surg.2014;149(8):821-8.

Coleman EA. The Care Transitions Program®:Health Care Services for Improving Quality andSafety During Care Handoffs. (n.d.). www.caretransitions.org/

Hernandez AF, Greiner MA, Fonarow GC, et al.Relationship between early physician follow-upand 30-day readmission among Medicare bene-ficiaries hospitalized for heart failure. JAMA.2010;303(17):1716-22.

Improving Transitions of Care: Findings and Con-siderations of the “Vision of the National Transitionsof Care Coalition.” National Transitions of CareCoalition. September 2010. www.ntocc.org/portals/0/pdf/resources/ntoccissuebriefs.pdf

Overview—Project BOOST Implementation®Toolkit. Society of Hospital Medicine. 2015.www.hospitalmedicine.org/Web/Quality_Inno-vation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/Overview.aspx?hkey=09496d80-8dae-4790-af72-efed8c3e3161

RARE: Reducing Avoidable Readmissions Effectively:Campaign Overview. 2015. Clinical Systems Im-provement, the Minnesota Hospital Association, andStratis Health. http://www.rarereadmissions.org

Readmissions Reduction Program. Page last mod-ified August 4, 2014. Centers for Medicare &Medicaid Services. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

Shepperd S, McClaran J, Phillips CO, et al. Dis-charge planning from hospital to home. CochraneDatabase Syst Rev. 2010;1:CD000313.

Society of Hospital Medicine. Patient Prepared-ness/Project BOOST Implementation Toolkit.2014. http://www.hospitalmedicine.org/Web/Quality_Innovation/Implementation_Toolkits/Project_BOOST/Web/Quality___Innovation/Implementation_Toolkit/Boost/BOOST_Intervention/Tools/Patient_Preparedness.aspx

Strategy 4: Care Transitions From Hospital toHome: IDEAL Discharge Planning. June 2013.Agency for Healthcare Research and Quality, Rock -ville, MD. www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html

Transition Communications - Tools and Resources.The RARE Campaign. Institute for Clinical SystemsImprovement, Minnesota Hospital Association, andStratis Health. 2015. www.rarereadmissions.org/areas/transcomm_resources.html

What Is INTERACT? Page last updated February7, 2011. Interventions to Reduce Acute CareTransfers (INTERACT). Florida Atlantic University.www://interact2.net/

The authors work at the University of ColoradoCollege of Nursing in Aurora. Joan M. Nelson isan associate professor and Laura Rosenthal is anassistant professor.

INTERACT tools The Interventions to Reduce Acute Care Transfers (INTERACT) pro-gram includes the following tools that nurses and nursing assis-tants can use in long-term care and assisted living facilities:• advanced care planning tools• medication reconciliation worksheet• decision-support tools related to specific presenting signs andsymptoms aimed at guiding appropriate information gathering andproviding criteria for calling a nurse practitioner (NP) or physician

• communication tools that support staff can use to notify nursesof changes in the patient’s condition, including a progress note/change-in-condition template for documentation and communi-cation by nurses to NPs or physicians and a documentation tem-plate used to communicate essential information to the acute-care facility in case the patient requires transfer to that setting

• quality-improvement tools that promote consistent incorporationof these tools and standards into daily practice.

To access these tools, visit https://interact2.net/.

Hospital

readmissions are

costly to patients

and healthcare

facilities.


Interdisciplinary collaborationis the cornerstone of high-quality patient care. Several

years ago at Orlando Health(Florida), we made a bold moveand flipped the existing hierar-chy to improve collaboration.The goal was to empower front-line clinicians in all disciplinesto push innovative patient safetyand quality improvement ideasto the forefront. In this article,we share our successful experi-ence in the hope that other or-ganizations can use a similarmodel.

To bring the vision of im-proved collaboration to life, Ja-mal Hakim, MD, chief qualityofficer, partnered with us andother likeminded leaders in theorganization. Together we creat-ed a forum—the CollaborativeQuality Advisory Committee(CQAC)—where nurses, physi-cians, and allied health teammembers could develop andsend quality suggestions to themedical executive committee forapproval.

Building the teamOur hospital system consists ofeight hospitals with more than14,000 team members and2,000 physicians. It was impor-tant for the CQAC to representall hospitals, specialties, and

professional disciplines, so itwas a daunting task to selectmembers for the committee.

CQAC members needed tohave certain personal attributesto make the group’s dynamicsucceed— respect, teamwork,and consistent demonstration ofpatient safety behaviors in clini-cal practice. Members also need-ed good listening skills and theconfidence to offer justifiable op-posing viewpoints to discussions.We wanted two patient and fam-ily representatives for the groupas well. Each hospital’s leader-

ship team recommended mem-bers; the list of potential mem-bers was refined to ensure ap-propriate representation fromhospitals and specialties.

Frontline nurses were wellrepresented on the CQAC andincluded staff from medicaltelemetry, orthopedics, pedi-atrics, labor and delivery, criti-cal care, and intermediate criti-cal care areas. Later, we addeda clinical assistant nurse manag-er, nursing operations manager,and chief nursing officer to part-ner with their frontline colleagues

A bold move to improvecollaborationOne hospital system is empowering frontline clinicians in alldisciplines to move the quality journey forward. By Susan Blackmer Tocco, MSN, CNS, CCNS; Darwin K. Clark, MD; and Amy C. DeYoung, MBA, RRT


in the group’s initiatives. Selecting allied health team

members for the committee wasespecially challenging becauseof the number of potential par-ticipants. This large group in-cludes staff from the cardiovas-cular, clinical nutrition, imaging,laboratory, pharmacy, respirato-ry care, and therapeutics (physi-cal, occupational, and speechtherapy) departments. To chairour allied health executive coun-cil, we added an administratorto be the voice of all the disci-plines. Interestingly, we learnedwe hadn’t been using the cor-rect terminology for some of ourcolleagues. (See A name isn’tjust a name.)

Once our clinician memberswere in place, we asked themfor recommendations of patientsand family members from theirclinical practice to consider forthe committee. Through an inter-view process, we identified twovalued individuals who sharedmany of the same attributes ofthe clinical members. The finalcommittee consisted of about 40regular attendees.

Establishing structure andpriorities Structured to be nimble and bu-reaucracy-free, the CQAC meetsevery other month. Official offi-cers are limited to a chairman(our chief quality officer) andvice chairman. The director ofpatient safety, who traditionallyhas been a nurse, rounds outthe group’s leadership. The di-rector is instrumental in planningthe agenda and promoting dis-cussion during meetings.

It was important to the group’sleadership for members to estab-lish their own strategic priorities.Before their first meeting, mem-bers received an email asking,“What keeps you up at night?”related to patient safety. Theseissues were compiled and usedto form meeting agendas.

It became clear ineffectivecommunication was the root ofmany problems. During interdis-ciplinary discussion, the teamlearned that communicationsthat should be exchanged direct-ly from physician to physicianwere being abdicated to nurs-ing. Examples included the use

of conditional orders, such as“Discharge home if OK withconsultants” and “MRI of brainif OK with obstetrician.”

Physicians and nurses gaveexamples of how these ordersled to patient harm. Some physi-cians stated they’d written theseorders to save time. Patient andfamily representatives said itwas important to them for theirphysicians to take the time tospeak to other physicians asneeded about their care. Nursesstated that being placed in themiddle of physician-physiciancommunication was wastefuland dissatisfying and led to sub-optimal patient care.

Taking action After this discussion, the groupunanimously decided that thistype of communication shouldn’tbe permitted. The group workedwith the chief of the medicalstaff and her team to win med-ical executive-committee ap-proval of this idea. Medical staffbylaws were amended to reflectthis practice change.

Everyone on the team believedthe rationale for the changeshould be communicated to physi-cians by physicians. The physi-cian chief quality officers at eachhospital in our system volunteeredto lead the communication planwith physicians in their buildings.Before the change, they discussedit with the physicians who’d beenwriting conditional orders. Theyalso agreed to talk personallywith physicians who resisted thechange. This relieved nursing ofthe task of “policing” the change.

Allied health team memberswanted an opportunity to identifyhow this change might affect col-leagues. Historically, practice

A name isn’t just a name Names mean a lot. Members of the Collaborative Quality AdvisoryCommittee at Orlando Health learned an important lesson aboutnames in their journey to improve interdisciplinary collaboration.Previously, we’d used the term “ancillary” when referring to ourallied health colleagues. Medline Plus® and Merriam-Webster de-fine ancillary as “being auxiliary to or supplementary.” However, the U.S. Department of Labor, universities, and col-

leges consider allied health disciplines (which include physicaltherapy, pharmacy, and dietitians) far more than just supplemen-tary to high-quality patient care. Merriam-Webster defines allied as“joined in a relationship in which people, groups, countries, etc.,agree to work together.”After learning the true meaning of ancillary, our nurses and

physicians were dismayed that we’d been using this term to referto our valued colleagues. Our healthcare system currently is elimi-nating “ancillary” from job titles and other references. This long-overdue change is a positive step in our effort to respect and em-power our team members.


changes hadn’t been vetted suffi-ciently with allied health in thedominant physician/nurse culture.To address this, a core groupfrom the CQAC and hospitalleadership developed a communi-cation and change plan for imple-mentation that was targeted tophysicians, nurses, and alliedhealth staff. Nursing and alliedhealth leaders communicated thechanges to their teams in a seriesof huddles supplemented withwritten communication about therationale for the change, whichincluded frequently asked ques-tions developed by the team.

Realizing results The implementation plan suc-ceeded. The entire team felt em-powered by their “win” andwere eager to take on additionalmultidisciplinary communicationproblems. The group currently isaddressing physician-to-physiciancommunication for consults andis transforming the process fordisclosing harm to patients.

Our nursing members haveexpressed meaningful personaland professional satisfactionwith their participation in thecommittee, such as:

• “I enjoyed meeting physi-cians and clinicians whopractice outside my ‘silo.’ Wetalk about how we are tryingto be less ‘silo-ed’ as an or-ganization, but this groupwith corporate membershipmade it seem as if we werereally taking action.”

• “I got to learn the big picturefor some of the problems,and now I can speak to mynursing colleagues about the‘why’ behind the changeswe’re implementing.”

Tips for success Our experience over the pastseveral years has taught us valu-able lessons and tips to share. A small core group is crucial tokeeping the committee focusedand action oriented. This struc-ture promotes direct interdiscipli-nary communication within thecommittee and throughout allsystem facilities. In addition, con-ducting the meetings with smallgroup sessions promoted nurses’willingness to share their experi-ence with physician and alliedhealth colleagues. In addition,nurses benefited from feedbackfrom colleagues regarding theirperspectives and experiences.

Other tips include the fol -lowing:

• Keep the atmosphere infor-mal and encourage use offirst names to help level thehierarchies found in manyhealthcare professional meet-ings.

• Be aware of the need forstrong communication withstaff members who aren’t onthe committee. Nurses oftenreported that their coworkerswere unaware of the commit-tee’s existence and function.They also suggested a need

for greater member input insetting the agenda, as wellas guidance for topics thecouncil should discuss and is-sues it should address.

• Consider a structuredprocess for rotating off teammembers and incorporatingnew ones. Nurses suggestedrecommendations from cur-rent members that would im-prove the likelihood of re-cruiting motivated, engagedreplacements.

The CQAC has shown us thatempowering frontline team mem-bers in problem solving is thepath forward in our quality jour-ney. Committee members havesuccessfully tapped into anabundance of collective knowl-edge from a diverse care team.The CQAC has helped bridgecommunication gaps and alignquality and patient-experiencegoals with our organization’sstrategic priorities. c

Susan Blackmer Tocco is the director of opera-tional effectiveness at Orlando Health in Florida.Darwin K. Clark is the chief quality officer formedicine at Orlando Regional Medical Centerand vice chair of the CQAC. Amy C. DeYoung isthe administrator of allied health and supportservices at Orlando Regional Medical Center.

Selected referencesManojlovich M, Kerr M, Davies B, Squires J,Mallick R, Rodger GL. Achieving a climatefor patient safety by focusing on relation-ships. Int J Qual Health Care. 2014;26(6):579-84.

Regan S, Laschinger HK, Wong CA. The in-fluence of empowerment, authentic leader-ship, and professional practice environmentson nurses’ perceived interprofessional collab-oration. J Nurs Manag. 2015 Feb 20.

Weaver AC, Callaghan M, Cooper AL,Brandman J, O’Leary KJ. Original Contribu-tion. Assessing interprofessional teamwork ininpatient medical oncology units. J OncolPract. 2015;11(1):19-22.

Keep the

atmosphere

informal and

encourage use of

first names to

help level the

hierarchies.


The Essence of NursingThese key points can help you provide patients with the essence of good care.

Adva

ncing

theart a

nd science of patient care, quality, and safety.

Above all, be a patient advocate. Remember—the nurse is the only healthcare professional with the patient and family 24/7/365. c

Set expectations

Engage patients

Keep patients moving

Share the organization’s caring mission.

Learn the stories of your patients, their family members, and home caregivers.

Use the acronym IDEAL for discharge planning:

Include, Discuss, Educate, Assess, Listen.

20%

Get patients moving early.

Use assistive devices to keep you and your

patients safe.

Build multidisciplinary teams.

Encourage the use of firstnames to keep a level playing field.

Communicate effectively.

Empower employees to practice to their fullest authority.

Share health data and decisionmaking with patients.

Understand the dangers of hospitalization.

Assess patients. • Promote nutrition.

Keep the patient SAFE: Safe environment, Assist with mobility, Fall risk reduction, Engage patient and family.

Prevent problems Collaborate withother disciplines

Prevent readmissionsMedicare patients readmitted within 30 days

Patient

Success with an Early Mobility Protocol

©2015 Hill-Rom Services, Inc. ALL RIGHTS RESERVED.192596 rev 1 30-APR-2015 ENG – US

Reference: Davis K and Kotowski SE, J Nurs Care Qual, Feb 2015.

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