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Feature Article Leading Change Evidence-Based Transition Brennan Lewis, MSN, RN, CPNP, PCNS n Stephanie Allen, MS, RN, CNS Purpose/Objectives: The purpose of this article was to provide a framework for evidence-based transition of patient populations within an acute care pediatric institution. Background: Transition within a hospital is foreseeable, given the ever-changing needs of the patients within an evolving healthcare system. These changes include moving patient populations because of expansion, renovation, or cohorting similar patient diagnoses to provide care across a continuum. Over the past 1 to 2 years, Children’s Health Children’s Medical Center Dallas has experienced a wide variety of transition. Rationale: To provide a smooth transition for patients and families into new care areas resulting in a healthy work environment for all team members. Description: The planning phase for patient population moves, and transition should address key aspects to include physical location and care flow, supplies and equipment, staffing model and human resources (HR), education and orientation, change process and integrating teams, and family preparation. It is imperative to consider these aspects in order for transitions within a healthcare system to be successful. During a time of such transitions, the clinical nurse specialist (CNS) is a highly valuable team member offering a unique perspective and methodological approach, which is central to the new initiative’s overall success. The themes addressed in this article on evidence-based transition are organized according to the CNS spheres of influence: system/organization, patient/family, and nursing. Outcome: An evidence-based transition plan was developed and implemented successfully with the support from the CNS for Author Affiliations: Pulmonary Clinical Nurse Specialist (Ms Lewis) and General Medicine Clinical Nurse Specialist (Ms Allen), Advanced Practice Services, Children’s Health Children’s Medical Center Dallas, Texas. The authors report no conflicts of interest. Correspondence: Brennan Lewis, MSN, RN, CPNP, PCNS, 7601 Preston Rd, Plano, TX 75024 ([email protected]). DOI: 10.1097/NUR.0000000000000102
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3 patient populations. Organizational leadership gained an increased awareness of the CNS role at the conclusion of each successful transition. Conclusions: The CNS plays a pivotal role as clinical experts and proponents of evidence-based practice and effects change in the system/organization, nursing, and patient/family spheres of influence. While transitions can be a source of stress for leaders and bedside staff, it is also a time that allows for growth and new opportunities for staff and may result in development of a healthier work environment. Implications: The CNS is able to provide leadership while working collaboratively to oversee the moves with a forward-thinking approach. There are key components to consider during times of transition. These include (1) organize, plan, and improve work efficiencies during a construction build; (2) identify the key elements for improvement in nurse and patient satisfaction; (3) develop or maintain healthy work environment standards; (4) establish adequate staffing levels and staff education to successfully care for patient populations following transition; and (5) support the staff and patients during transition. KEY WORDS: change, clinical nurse specialist, evidence-based practice, organizational innovation, transition
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ransition within a hospital is foreseeable, given the ever-changing needs of the patients within an evolving healthcare system. These changes include moving patient populations because of expansion, renovation, or cohorting similar patient diagnoses to provide care across a continuum. Children’s Health Children’s Medical Center Dallas has experienced a wide variety of transition in the past 2 years. During each of these processes, lessons were learned, and these were utilized during the next transition or patient population move. Drawing from the experience of the team approach during the design of the Centers of Neurosciences and Pulmonology will aid in future development of other inpatient hospital units. The process provided
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Feature Article a successful avenue to design efficient and effective units allowing for better customer service and improving care provided to the patients. To prepare for these transitions, equipment and supply lists and a comprehensive education plan were developed. Identifying the impact of change is another important aspect to consider during these processes. This awareness was key to the success of future moves. This was highlighted from the transitions of the endocrine population moves. Not only did the change impact the patients and families, but it also impacted the healthcare staff caring for them. The experience gained from relocations was useful to the subsequent moves of General Medicine and the Centers of Neurosciences and Pulmonology. To better meet the needs of the population served, hospitals often undergo facility expansion or population moves to meet increasing demands. ‘‘Transitions have been defined as passages or movements from one state, condition, or place to another.’’1 During a time of such transitions, the clinical nurse specialist (CNS) is a highly valuable team member offering a unique perspective and methodological approach, which is central to the new initiative’s overall success. In addition, the CNS is often referred to as a change agent providing support and guided leadership from start to finish as well as playing a pivotal role in the sustainability of the plan. The CNS is the best qualified person to lead the group through transition when a project manager is not available. The themes addressed in this article on evidencebased transition are organized according to the CNS spheres of influence: system/organization, nursing, and patient/ family. Whereas the transitions of care were highly successful, there were noteworthy lessons learned (Table).
BACKGROUND Children’s Health Children’s Medical Center Dallas, a large, private, not-for-profit academic pediatric hospital has undergone several initiatives to improve the opportunities for patients and families. Some of these initiatives include the closing of older inpatient units, relocating patients with endocrine and general medicine needs, and renovating these areas to increase the space for children with blood and cancer disorders as well as nephrology conditions. Outcomes associated with transition include improving the quality and safety of care, eliminating unnecessary care, and reducing the costs of care. Clinical nurse specialists are uniquely positioned because of their evidence-based expertise and intrinsic leadership abilities to direct change as systems move forward with new models of care. The new space developed for these specialties not only allowed for more room to accommodate more patients, but it also allowed for the patients to be cohorted in order to receive care across a continuum from outpatient (OP) to inpatient within the same service line. Other initiatives included the opening of 2 new floors to house the Center of Neurosciences and the Center of Pulmonology. These 2 units E2
Table. Lessons Learned System/organizational sphere of influence 1. Keep relocation plans for use in future transitions. 2. Consider additional audible and visual alarms in common meeting spaces or classrooms to ensure alarms can be heard when away from the nurse’s station. 3. When transitioning into a larger space, ensure central monitors are audible and visible from all areas of the nurse’s station. Additional monitoring may be needed. 4. Assign team member roles and responsibilities when adding new features to a unit, such as the stocking of bedside carts or supplies outside the Omnicell. 5. Engage bedside staff in establishing a plan for location and organization of supplies. Nursing sphere of influence 1. Throughout transition, consider staffing to include a resource nurse whose role is to assist with timely staff competency validation and completion. 2. Identify and provide education to all disciplines impacted by transition. 3. Develop and make available resources for staff to utilize following education. 4. Trust building takes time, and each group’s time frame is different. 5. System-wide assessment and planned interventions yield improved outcomes and reduces errors. Patient/family sphere of influence 1. Collaborate with service lines both inpatient and outpatient to implement and sustain new practice initiatives. 2. Family involvement during process changes empowers them to support the change and facilitates coping with new practices.
were also strategically designed to cohort patients with similar disease processes in an area with expertly trained staff to care for them. In a large facility, transitioning patients requires a team approach in the planning and execution of processes to ensure success. Key members or stakeholders of the team should be inclusive of all affected disciplines as to avoid rework or changes prior to implementation. In addition, emergency department (ED), pediatric intensive care unit (PICU), and OP service systems should be addressed to create a seamless system for these patient populations. Important considerations in the planning should include the design of the physical environment, new patient care flows, impact on staffing and the integration of teams, incorporating the change process for success, and required education and competency development for staff. Orientation to the new patient care areas for staff, patients, and families must take place prior to the move of patients into a new unit, or hospital location is a must.
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SYSTEM/ORGANIZATIONAL SPHERE OF INFLUENCE Physical Location/Care Flow The chance to design a new patient care area within a healthcare facility is an opportunity that allows innovative ideas to be incorporated into the evidence-based design.2 Recent literature suggests that using an evidence-based design for hospital environments allowed for efficient, safe, and productive care of the patients while improving patient and staff satisfaction.3 A multidisciplinary group should be established prior to the design phase.4 This group may include frontline staff from the following areas: nursing, respiratory therapy, providers, pharmacy, nutrition, child life, care coordination, members of the various therapies such as speech therapy, occupational therapy, and physical therapy. The frontline members of the planning group provide a reallife perspective, allowing for the design to incorporate the essentials of patient care into the evidence-based plan. Senior leaders and hospital executive sponsors involved must partner in the process and participate in planning meetings from start to finish. Patients and family involvement also offers a unique patient-centered focus that is different from the hospital team in an effort to ensure their comfort and acceptance of the new space.2 The CNSs participated as team members in the design of 2 new acute care inpatient units. These units were created to house the Centers of Neurosciences and Pulmonology. Hospital leadership picked a core group of staff consisting of frontline staff caring for the designated populations from all affected disciplines. Once the planning group was assembled, the designing of the units began. This project was on a tight deadline, so the core planning group made a commitment, supported by leadership, for weekly and ad hoc meetings as needed to ensure that the project was going to be completed on schedule. The initial phase of designing the units consisted of several brainstorming sessions led by a consultant group and project manager. The architects and construction team also were involved in the initial design discussions to promote effective communication of the needs and wants in the new spaces. The brainstorming sessions included discussions about issues with current patient care areas including flow processes and inefficiencies in care due to the layout or design of those areas. Patients and families also participated in brainstorming sessions to gather input for imperative design elements. Once the issues were identified, discussions focused on ways to improve flow processes, inefficiencies, and comfort for patients and families. The physical environment impacts patient care and outcomes as well as staff satisfaction. Errors are often related to inability to concentrate or frequent distractions. Nelson et al3 discussed the various factors making the hospital setting a stressful environment for staff as well as patients. These stressors include various noises of alarms, phones, and pagers impacting patient rest and healing as well as staff concentraClinical Nurse Specialist
tion. A quiet environment is necessary for a family to focus on learning to care for their child with new diagnoses such as diabetes or an airway issue requiring a surgically placed tracheostomy for ventilator support. Poor hospital signage leading to feelings of being lost by family members was also addressed. Delivering efficient patient care is affected by the workflow within the patient care area. Clearly, there are many environmental factors that impact the care provided to the patient. With efficient and effective workflow in mind for the staff, the following design elements were essential: lighting at the workstations, equipment and supplies at the bedside to reduce walking time, medication rooms within the nursing stations, adequate amount of printers, increased workstations to accommodate team members from multiple disciplines, and improvement in headwall designs to house necessary equipment. Mittal et al5 conducted a study to examine pediatric hospitalist rounding practices, finding that family-centered rounds (FCRs) was the most commonly used method of rounding. Perceived benefits associated with FCRs were family involvement and understanding, effective communication among team members, and trainee role modeling. Bedside staff involvement is crucial in FCR in order to plan and implement best practices with complex patients. Daily interdisciplinary huddles also facilitate care progression in order to reach specific discharge dates. A unit-based team room allows for interdisciplinary meeting attendance with an overall goal of increasing opportunities for communication, especially goal setting and care planning. For example, the outcome of reducing seizure frequency requires participation of physicians, the patient’s caregivers, bedside nurse, charge nurse, CNS, pharmacist, and dietitian in the plan of care for a patient in the epilepsy monitoring unit starting on ketogenic diet. This environment has also facilitated the ability of pulmonologists to round with a multidisciplinary team that includes providers, nurses, a case manager, pharmacist, CNS, and dietitian to develop the plan of care for children with complex diagnoses, such as cystic fibrosis or chronic lung disease requiring long-term mechanical ventilation. The patient- and family-focused needs were also incorporated into the design of the floor and rooms. Noise was an important consideration; therefore, noise reduction elements were designed throughout the floor layout, and the use of noise reduction materials was chosen. The ‘‘way finding’’ system was improved, and locations clearly marked. Families were provided space for personal belongings and areas for respite outside their child’s room. Natural lighting was incorporated into the patient rooms and hallways, and convenient lighting options for the patient rooms were also made available. In addition to direct patient care necessities, meeting spaces were designed. These included patient and family education classrooms, a staff classroom, consultation areas, on-call rooms for providers, and staff offices. Many of these design element decisions were based on evidence-based design that involved detailed planning and
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Feature Article mapping of workflow in the newly designed floor space. The architecture and construction teams involved in the process worked closely with the direct care staff. They constructed several mockup areas based on the team’s design such as a patient room or the nurse’s station in the actual physical space, allowing staff the opportunity to visually see the layout and test the functionality of the space with actual equipment. This allowed the direct care staff involved in the planning process time to assess the feasibility and success of the design that they had envisioned. Supplies and Equipment Specific equipment and supplies for each patient population must be identified and stocked to adequately care for the patients served in those areas. The CNSs worked with the managers and team leaders for each respective area to determine specialty items and medications required. Space in the newly renovated or constructed areas had to be fitted with the proper storage units, and in this case, the Omnicell systems were used. In addition, each room within the Centers of Neurosciences and Pulmonology were designed with a bedside cart that consisted of a locked drawer for medication storage and several additional drawers to allow for storage of nonbillable, frequently used items and larger patient items and linens. This part of the unit design has aided in the efficiency of the bedside staff in the care provided to the patients.
NURSING SPHERE OF INFLUENCE Staffing Model/Human Resources To achieve optimal staffing models, hospital administrators often considered different staffing needs across the system during specific shift times.6 Thus, staffing needs are reevaluated frequently, where high-acuity patients are cohorted, and admissions/transfers from the PICU, ED, and OP service lines occur frequently during one 12-hour shift. Utilizing the Nursing Teamwork Survey, Kalisch and Lee7 studied the relationship between nurse staffing and teamwork and found that higher levels of nurse staffing were related to better teamwork. In many pediatric hospitals, diabetics in diabetic ketoacidosis on insulin drips are cared for in PICUs, where the nurse staff-to-patient ratio is 1:1 or 1:2. Children’s Health Children’s Medical Center Dallas provides care to many of these patients who are cohorted on 1 specific general medicine unit where they can be staffed 1:3 by following a consistent management protocol. White and Dickson8 reported that ‘‘when compared with data in recent consensus statements, the Dallas protocol is associated with extremely low rates of death and disability (0.08% vs 0.3%) from DKA.’’8(p761) Opportunities for staff to expand their knowledge and skills were realized during the closing and opening of several patient care areas. Managers and senior leaders worked with the HR department to determine appropriate staffing levels E4
for each of the areas impacted by the patient population moves. The CNS served as a consultant to the leadership team offering expert opinion and evidence-based practices for the designated patient populations involved in the transitions. Once the appropriate staffing needs were defined, the leadership team and an HR representative met with staff to offer the options available. Each staff member was presented a letter describing the changes and asked to rank the area they would prefer to work based on the patient population in order of first preference to last. This time of transition allowed bedside staff to move to a new area and broaden their expertise or allowed them to continue to care for a similar patient population. Additional opportunities to move to a higher-acuity area, such as the PICU or ED, were available. During this time of decision making, the CNS mentored, supported, and provided guidance to nursing staff to aid in their professional development. Decisions were made by the leadership team with thoughtful consideration of the staff’s preferences and matching of the patient needs while maintaining the staffing needs for each individual patient care area. This process ensures development of a healthy work environment. Education The expansion of several patient care service lines as well as relocation of patient populations allowed the nursing and unlicensed staff the opportunity to expand their knowledge and skills. Wright9 pointed out that organizations evolve over time, requiring staff to maintain their competencies to care for patient populations in order to achieve success for the organization. Competency assessment during recent times of transition included evaluating the patient needs and matching it to the nurse’s skills. For example, ensuring the knowledge and competence of the nurse allows for the care of a patient with a newly placed tracheostomy after the first tracheostomy change or care for a patient with diabetic ketoacidosis on an insulin drip. Preparing the staff to be able to care for the patients safely was a priority during these times of transition and organizational change. In order to meet the evolving changes and needs of the staff as well as the patients, the CNSs completed a needs assessment survey. The data were analyzed to identify gaps that in turn determined the required skills and behaviors needed to care for each of the patient populations involved in the transitions. The CNS is often the content expert within the area that is directly impacted by the transition, making him/her the ideal person to complete this assessment. Once the information needed and required skills were identified through the needs assessment survey, education plans for each of the population moves were developed collaboratively by the CNS and the clinical educator. A thorough yet feasible education plan for the staff caring for these complex patients is equally paramount to the success of the
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transition process. The clinical educator verified current staff competencies and developed new competencies based on the needs identified for each patient population. In addition, the time needed to become competent in the newly required skills to care for the patient population must also be decided prior to a patient population move. Updates should also be provided to the unit managers to ensure support for the time that staff will need to be away from the bedside in order to participate in the needed education. All involved participants must remain informed of the plan throughout the implementation phase. The education plan for the staff working in the Center of Pulmonology was developed in collaboration with the pulmonology clinical educator and CNS by identifying what types of patient populations would be admitted to the areas within the center. To better understand this, the following is a description of how the Center of Pulmonology was designed: the center is divided into 2 separate freestanding units connected by a common area for the patients and families. One unit accommodates 22 patients admitted with a lung, airway, or endocrine diagnosis. The other unit accommodates 24 patients admitted with a lung or airway diagnosis. Each unit has a core staff that primarily works together, but could float to either side as needed to care for the patients. Education was based on cohorting of patient populations. Therefore, each unit within the Center of Pulmonology provided care for patients with similar diagnoses as well as for patients unique to its particular unit. For example, patients with asthma could be cared for on either unit, whereas patients who require invasive ventilation or who have a primary endocrine disorder would be admitted to the unit specializing in the care of that patient population. Education of staff members was based on the new care delivery design. Competencies were designed that reflected the needs of the newly cohorted patients and families. This initiative matched nicely with the standards outlined in the American Association of Critical Care Nurses’ Healthy Work Environment document.10 The education plan consisted of 2 education tracks, and attendance depended on the education and competency needed by the nurse. There were 7 total education sessions, and 4 of those sessions were offered with the combined staff from each unit. All sessions occurred within 1 to 2 months of the anticipated move to the new units. The education tracks consisted of lecture-style education as well as hands-on skills laboratory. An education plan also was developed for nurses who would be caring for the endocrine patient population for the first time. Again, the nurses must attain and maintain specific endocrine competencies to safely care for this patient population. In addition to the disease-specific information required, the patient and family needs were considered and provided to the new team members prior to the transition to the new unit. These nurses received an 8-hour workshop that provided them with a foundation to care for the various Clinical Nurse Specialist
endocrine diagnoses. This venue provided the endocrinologists, CNSs, certified diabetic educators, social workers, child life specialists, and dietitians an opportunity to meet the new staff who would become a part of their team. This group of team members emulated the findings of Kalisch and Lee’s7 research findings: the greater the skill mix, the higher the level of teamwork. In our experience with the formation of new teams, there were 2 significant puzzle pieces: effective communication and professional accountability. Establishing and maintaining these attributes within teams expedited safe and effective workflow. A new team’s functionality is based on the establishment of trust. Interdisciplinary healthcare teams included both licensed and unlicensed personnel. An additional 3-hour workshop was provided for unlicensed personnel regarding the unique needs of these patients that would require a collaborative effort between the unlicensed staff and the nurse. Integrating the unlicensed personnel into the team utilizes each discipline to their full capacity and acknowledges the importance of their role. In fact, the unlicensed personnel completed an evaluation of the education provided, stating that the additional training helped them feel valued as new endocrine team members. Orientation to New Space/Staff Preparation The staff transitioning to the Center of Pulmonology and the Center of Neurosciences were provided opportunities throughout the building processes to see the progress of their new units. Allowing staff to get a sneak peak at frequent intervals during that process created excitement among the staff that would be transitioning to those areas. Once the construction was completed, and the floor was near opening, the staff was provided the opportunity to tour their new units and become familiar with the new equipment and unit layout prior to the transition to their new work areas. The clinical educators developed a ‘‘seek and find’’ to encourage the staff to discover the locations of the crash carts, linen carts, clean and dirty storage areas, medication rooms, stairwells, staff meeting areas, break rooms, and classrooms, among many other components of the new units. The vendors for specific equipment such as new hospital beds, new nurse call system, and new defibrillator were present during those visits to provide in-services to the staff. A grand-opening celebration for the bedside staff, unit leadership, and senior leadership was held once the moves to the new units were made. A newsletter written by the CNSs for the new units was provided to staff with helpful tips about the unit, phone numbers, and locations of supplies and equipment. Change Process/Integrating Teams The CNS is knowledgeable in the change process and supports leadership as well as the bedside staff through periods of transition. ‘‘Organizational change in healthcare is a complex,
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Feature Article nonlinear process that must evolve in response to shifts in social, economic, and political environments.’’11(p164) In response to these shifts, organizations must change. In fact, 1 patient population was relocated twice only 1 year apart in order to meet the organization’s needs. The staff comfort level survey completed in 2012 resulted in an average comfort level on a 0- to 5-point scale as a 3 (0 being the lowest and 5 being the highest). The second transition seemed to progress more smoothly as evidenced by the 2013 staff comfort level result of 4.07. The endocrinologists commented that the nursing staff seemed happier with the second move. It was recognized during transitions that staff acceptance of change does not have a defined time frame, and members progress at their own speeds. This process cannot be forced, and individuals must be supported along the way. Staff often viewed the CNSs as a ‘‘safe’’ person to voice concerns to and to seek answers or support. According to Melnyck and Fineout-Overholt,12 the 2 essential elements for successful organizational change are vision and goals with the belief and confidence in one’s ability to accomplish the outcome. ‘‘Positive change requires a great deal of positive energy and emotions, including confidence, hope, belief, creativity, and persistence.’’13(p18) This statement was certainly true during the transition as the endocrine population moved units in 2012 and again in 2013. The CNSs provided a second set of educational workshops for new team members being added during the second move. Confidence grew as new team members practiced their new skills and had positive experiences when caring for newonset diabetic patients and their families. Experienced endocrine nurses mentored new team members and assisted them in completing their competencies. When comparing the results of the 2012 staff survey to those from 2013, staff expressed an overall higher level of comfort related to caring for the endocrine population after the second relocation. Change runs more smoothly if team members are prepared for potential issues they may encounter due to change.14 As transitions occurred and new peer groups were formed, managers and team leaders were redistributed based on the future needs of the newly formed unit. New team formation and acceptance of new leadership were received with mixed responses. Each new team attempted to learn from their successes as well as their failures. Team building support from HR, manager retreats, and team Leader boot camps helped to form support networks and introduce additional coping strategies for stress management. Effective change includes the establishment of both practice and culture.15 Staff team members have to be willing to make an effort and commit to invest the time and emotional energy it will take to effect successful change. Members should contemplate what they stand to gain or lose with a new way of working. Innovation may be difficult to embrace when feelings of loss are present. The anticipated organizational outcome is for the new group to assimilate into a cohesive team that supports each other. E6
Edmonstone16 described the PRINCE2 approach to managing change, which involves a 7-step approach: (1) set the goal, (2) set a final deadline, (3) identify the subtasks, (4) order the subtasks, (5) set targets, (6) assign subtasks, and (7) monitor progress. When following these steps, problems may be encountered. A few examples that we encountered and worked through were Omnicell malfunction and short staffing. According to McLean,17 navigating the journey through change and transition should include a plan for sustainability with a focused intent on outcomes. The 2 successive endocrine moves within a 2-year time frame presented an opportunity to examine practices at every entry point of an admission and discharge. By addressing causes for high-risk medication errors causing harm through a multidisciplinary Medication Safety Committee, insulin errors fell off the top 10 list in 2013. Even with planning, leaders of change often encounter its complex effects as chaotic and convoluted.18 On the actual day of the patient relocation moves, our census deviated from its usual trend, and staffing needs were adjusted accordingly.
PATIENT/FAMILY SPHERE OF INFLUENCE Family Preparation In a family-centered environment, preparation for both the patient and the family is important particularly when they are admitted during the time of the move from one unit to another. Consideration should also be made for patients and families with long-term chronic care needs resulting in frequent admissions to the unit. Orientation to the units included tours for the patients and families with the bedside staff, leadership, and CNS just prior to the moves. This allowed them time to see the new unit, patient rooms, playroom space, and common areas designed for respite. In addition to the tour of the new unit, the families with children with cystic fibrosis were provided a letter drafted by the CNS and cystic fibrosis provider team. Given that these children were admitted frequently, the team of healthcare providers wanted to ensure they were informed of the move. The letter also provided a venue to highlight the exciting changes and special additions made within the Center of Pulmonology. Some of these additions include a designated infection control playroom and a pulmonary function testing laboratory within the unit. CONCLUSION Clinical nurse specialists are recognized as advanced practice nurses who are prepared to implement evidence-based transitions. They play pivotal roles as clinical experts and proponents of evidence-based practice and effect change in the system/organization, nursing, and patient/family spheres of influence. Based on these spheres, refer to the Table for lessons learned during transition. It is imperative for the CNS to develop tools such as an organizational plan and timeline to guide transitions safely throughout the change
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process. These tools were beneficial for use in similar projects involving population moves. Organizational leadership gained an increased awareness of the CNS role at the conclusion of each successful transition. While transitions can be a source of stress for leaders and bedside staff, it is also a time that allows for growth and new opportunities for staff and may result in development of a healthier work environment. Implications The CNS is a valuable member to include in an interdisciplinary team during times of organization restructuring and patient population transition. Given the scope of practice, the CNS is able to provide leadership while working collaboratively to oversee the moves with a forward-thinking approach. Key components to consider during times of such transition are identification and improvements in work efficiencies, awareness of nurse and patient satisfaction, development and maintenance of a healthy work environment, planning for adequate staffing, innovative staff education, and providing leadership support during transition. References 1. Duchscher J. A process of becoming: the stages of new nursing graduate professional role transition. J Contin Educ Nurs. 2008; 39(10):441Y450. 2. Trochelman K, Albert N, Spence J, Murray T, Slifcak E. Patients and their families weigh in on evidence-based hospital design. Crit Care Nurse. 2012;32(1):e1Ye10. 3. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: AHRQ Publication, The Leewin Group, Inc; 2005.
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4. McCullough C. Evidence-Based Design for Healthcare Facilities. Indianapolis, IN: Sigma Theta Tau; 2010. 5. Mittal V, Sigrest T, Ottolini M, et al. Family-centered rounds on pediatric wards: a PRIS Network survey of US and Canadian hospitalists. Pediatrics. 2010;126(1):37Y43. 6. Knudson L. Nurse staffing levels linked to patient outcome, nurse retention. Nurse Staff. 2013;97(1):7Y9. 7. Kalisch B, Lee K. Nurse staffing level and teamwork: a crosssectional study of patient care units in acute care hospitals. J Nurs Scholarsh. 2011;43(1):82Y88. 8. White P, Dickson B. Low morbidity and mortality in children with diabetic Ketoacidosis treated with isotonic fluids. J Pediatr. 2013; 163(3):761Y766. 9. Wright D. The Ultimate Guide to Competency Assessment in Health Care. 3rd ed. Minneapolis, MN: Creative Health Care Management; 2005. 10. American Association of Critical Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments. Aliso Viejo, CA: AACN; 2005. 11. Richer M, Ritchie J, Marchionni C. Appreciative inquiry in health care. Br J Healthc Manag. 2010;16(4):164Y172. 12. Melnyck B, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. 13. Brooks J. Engaging staff in the change process. Nurs Manag. 2011;18(5):16Y19. 14. Davies N. Onwards and upwards. Nursing Standard. 2010; 24(20):62. 15. Hewitt-Taylor J. Planning successful change incorporating processes and people. Nurs Stand. 2013;27(38):35Y40. 16. Edmonstone J. A new approach to project managing change. Br J Healthc Manag. 2010;16(5):225Y230. 17. McLean C. Change and transition: navigating the journey. Br J Sch Nurs. 2011;6(3):141Y145. 18. Stichler J. Leading change; one of a leaders most important roles. Nurs Womans Health. 2011;15(2):166Y170.
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Feature Article Leading Change Evidence-Based Transition Brennan Lewis, MSN, RN, CPNP, PCNS n Stephanie Allen, MS, RN, CNS Purpose/Objectives: The purpose of this article was to provide a framework for evidence-based transition of patient populations within an acute care pediatric institution. Background: Transition within a hospital is foreseeable, given the ever-changing needs of the patients within an evolving healthcare system. These changes include moving patient populations because of expansion, renovation, or cohorting similar patient diagnoses to provide care across a continuum. Over the past 1 to 2 years, Children’s Health Children’s Medical Center Dallas has experienced a wide variety of transition. Rationale: To provide a smooth transition for patients and families into new care areas resulting in a healthy work environment for all team members. Description: The planning phase for patient population moves, and transition should address key aspects to include physical location and care flow, supplies and equipment, staffing model and human resources (HR), education and orientation, change process and integrating teams, and family preparation. It is imperative to consider these aspects in order for transitions within a healthcare system to be successful. During a time of such transitions, the clinical nurse specialist (CNS) is a highly valuable team member offering a unique perspective and methodological approach, which is central to the new initiative’s overall success. The themes addressed in this article on evidence-based transition are organized according to the CNS spheres of influence: system/organization, patient/family, and nursing. Outcome: An evidence-based transition plan was developed and implemented successfully with the support from the CNS for Author Affiliations: Pulmonary Clinical Nurse Specialist (Ms Lewis) and General Medicine Clinical Nurse Specialist (Ms Allen), Advanced Practice Services, Children’s Health Children’s Medical Center Dallas, Texas. The authors report no conflicts of interest. Correspondence: Brennan Lewis, MSN, RN, CPNP, PCNS, 7601 Preston Rd, Plano, TX 75024 ([email protected]). DOI: 10.1097/NUR.0000000000000102
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3 patient populations. Organizational leadership gained an increased awareness of the CNS role at the conclusion of each successful transition. Conclusions: The CNS plays a pivotal role as clinical experts and proponents of evidence-based practice and effects change in the system/organization, nursing, and patient/family spheres of influence. While transitions can be a source of stress for leaders and bedside staff, it is also a time that allows for growth and new opportunities for staff and may result in development of a healthier work environment. Implications: The CNS is able to provide leadership while working collaboratively to oversee the moves with a forward-thinking approach. There are key components to consider during times of transition. These include (1) organize, plan, and improve work efficiencies during a construction build; (2) identify the key elements for improvement in nurse and patient satisfaction; (3) develop or maintain healthy work environment standards; (4) establish adequate staffing levels and staff education to successfully care for patient populations following transition; and (5) support the staff and patients during transition. KEY WORDS: change, clinical nurse specialist, evidence-based practice, organizational innovation, transition
T
ransition within a hospital is foreseeable, given the ever-changing needs of the patients within an evolving healthcare system. These changes include moving patient populations because of expansion, renovation, or cohorting similar patient diagnoses to provide care across a continuum. Children’s Health Children’s Medical Center Dallas has experienced a wide variety of transition in the past 2 years. During each of these processes, lessons were learned, and these were utilized during the next transition or patient population move. Drawing from the experience of the team approach during the design of the Centers of Neurosciences and Pulmonology will aid in future development of other inpatient hospital units. The process provided
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Feature Article a successful avenue to design efficient and effective units allowing for better customer service and improving care provided to the patients. To prepare for these transitions, equipment and supply lists and a comprehensive education plan were developed. Identifying the impact of change is another important aspect to consider during these processes. This awareness was key to the success of future moves. This was highlighted from the transitions of the endocrine population moves. Not only did the change impact the patients and families, but it also impacted the healthcare staff caring for them. The experience gained from relocations was useful to the subsequent moves of General Medicine and the Centers of Neurosciences and Pulmonology. To better meet the needs of the population served, hospitals often undergo facility expansion or population moves to meet increasing demands. ‘‘Transitions have been defined as passages or movements from one state, condition, or place to another.’’1 During a time of such transitions, the clinical nurse specialist (CNS) is a highly valuable team member offering a unique perspective and methodological approach, which is central to the new initiative’s overall success. In addition, the CNS is often referred to as a change agent providing support and guided leadership from start to finish as well as playing a pivotal role in the sustainability of the plan. The CNS is the best qualified person to lead the group through transition when a project manager is not available. The themes addressed in this article on evidencebased transition are organized according to the CNS spheres of influence: system/organization, nursing, and patient/ family. Whereas the transitions of care were highly successful, there were noteworthy lessons learned (Table).
BACKGROUND Children’s Health Children’s Medical Center Dallas, a large, private, not-for-profit academic pediatric hospital has undergone several initiatives to improve the opportunities for patients and families. Some of these initiatives include the closing of older inpatient units, relocating patients with endocrine and general medicine needs, and renovating these areas to increase the space for children with blood and cancer disorders as well as nephrology conditions. Outcomes associated with transition include improving the quality and safety of care, eliminating unnecessary care, and reducing the costs of care. Clinical nurse specialists are uniquely positioned because of their evidence-based expertise and intrinsic leadership abilities to direct change as systems move forward with new models of care. The new space developed for these specialties not only allowed for more room to accommodate more patients, but it also allowed for the patients to be cohorted in order to receive care across a continuum from outpatient (OP) to inpatient within the same service line. Other initiatives included the opening of 2 new floors to house the Center of Neurosciences and the Center of Pulmonology. These 2 units E2
Table. Lessons Learned System/organizational sphere of influence 1. Keep relocation plans for use in future transitions. 2. Consider additional audible and visual alarms in common meeting spaces or classrooms to ensure alarms can be heard when away from the nurse’s station. 3. When transitioning into a larger space, ensure central monitors are audible and visible from all areas of the nurse’s station. Additional monitoring may be needed. 4. Assign team member roles and responsibilities when adding new features to a unit, such as the stocking of bedside carts or supplies outside the Omnicell. 5. Engage bedside staff in establishing a plan for location and organization of supplies. Nursing sphere of influence 1. Throughout transition, consider staffing to include a resource nurse whose role is to assist with timely staff competency validation and completion. 2. Identify and provide education to all disciplines impacted by transition. 3. Develop and make available resources for staff to utilize following education. 4. Trust building takes time, and each group’s time frame is different. 5. System-wide assessment and planned interventions yield improved outcomes and reduces errors. Patient/family sphere of influence 1. Collaborate with service lines both inpatient and outpatient to implement and sustain new practice initiatives. 2. Family involvement during process changes empowers them to support the change and facilitates coping with new practices.
were also strategically designed to cohort patients with similar disease processes in an area with expertly trained staff to care for them. In a large facility, transitioning patients requires a team approach in the planning and execution of processes to ensure success. Key members or stakeholders of the team should be inclusive of all affected disciplines as to avoid rework or changes prior to implementation. In addition, emergency department (ED), pediatric intensive care unit (PICU), and OP service systems should be addressed to create a seamless system for these patient populations. Important considerations in the planning should include the design of the physical environment, new patient care flows, impact on staffing and the integration of teams, incorporating the change process for success, and required education and competency development for staff. Orientation to the new patient care areas for staff, patients, and families must take place prior to the move of patients into a new unit, or hospital location is a must.
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SYSTEM/ORGANIZATIONAL SPHERE OF INFLUENCE Physical Location/Care Flow The chance to design a new patient care area within a healthcare facility is an opportunity that allows innovative ideas to be incorporated into the evidence-based design.2 Recent literature suggests that using an evidence-based design for hospital environments allowed for efficient, safe, and productive care of the patients while improving patient and staff satisfaction.3 A multidisciplinary group should be established prior to the design phase.4 This group may include frontline staff from the following areas: nursing, respiratory therapy, providers, pharmacy, nutrition, child life, care coordination, members of the various therapies such as speech therapy, occupational therapy, and physical therapy. The frontline members of the planning group provide a reallife perspective, allowing for the design to incorporate the essentials of patient care into the evidence-based plan. Senior leaders and hospital executive sponsors involved must partner in the process and participate in planning meetings from start to finish. Patients and family involvement also offers a unique patient-centered focus that is different from the hospital team in an effort to ensure their comfort and acceptance of the new space.2 The CNSs participated as team members in the design of 2 new acute care inpatient units. These units were created to house the Centers of Neurosciences and Pulmonology. Hospital leadership picked a core group of staff consisting of frontline staff caring for the designated populations from all affected disciplines. Once the planning group was assembled, the designing of the units began. This project was on a tight deadline, so the core planning group made a commitment, supported by leadership, for weekly and ad hoc meetings as needed to ensure that the project was going to be completed on schedule. The initial phase of designing the units consisted of several brainstorming sessions led by a consultant group and project manager. The architects and construction team also were involved in the initial design discussions to promote effective communication of the needs and wants in the new spaces. The brainstorming sessions included discussions about issues with current patient care areas including flow processes and inefficiencies in care due to the layout or design of those areas. Patients and families also participated in brainstorming sessions to gather input for imperative design elements. Once the issues were identified, discussions focused on ways to improve flow processes, inefficiencies, and comfort for patients and families. The physical environment impacts patient care and outcomes as well as staff satisfaction. Errors are often related to inability to concentrate or frequent distractions. Nelson et al3 discussed the various factors making the hospital setting a stressful environment for staff as well as patients. These stressors include various noises of alarms, phones, and pagers impacting patient rest and healing as well as staff concentraClinical Nurse Specialist
tion. A quiet environment is necessary for a family to focus on learning to care for their child with new diagnoses such as diabetes or an airway issue requiring a surgically placed tracheostomy for ventilator support. Poor hospital signage leading to feelings of being lost by family members was also addressed. Delivering efficient patient care is affected by the workflow within the patient care area. Clearly, there are many environmental factors that impact the care provided to the patient. With efficient and effective workflow in mind for the staff, the following design elements were essential: lighting at the workstations, equipment and supplies at the bedside to reduce walking time, medication rooms within the nursing stations, adequate amount of printers, increased workstations to accommodate team members from multiple disciplines, and improvement in headwall designs to house necessary equipment. Mittal et al5 conducted a study to examine pediatric hospitalist rounding practices, finding that family-centered rounds (FCRs) was the most commonly used method of rounding. Perceived benefits associated with FCRs were family involvement and understanding, effective communication among team members, and trainee role modeling. Bedside staff involvement is crucial in FCR in order to plan and implement best practices with complex patients. Daily interdisciplinary huddles also facilitate care progression in order to reach specific discharge dates. A unit-based team room allows for interdisciplinary meeting attendance with an overall goal of increasing opportunities for communication, especially goal setting and care planning. For example, the outcome of reducing seizure frequency requires participation of physicians, the patient’s caregivers, bedside nurse, charge nurse, CNS, pharmacist, and dietitian in the plan of care for a patient in the epilepsy monitoring unit starting on ketogenic diet. This environment has also facilitated the ability of pulmonologists to round with a multidisciplinary team that includes providers, nurses, a case manager, pharmacist, CNS, and dietitian to develop the plan of care for children with complex diagnoses, such as cystic fibrosis or chronic lung disease requiring long-term mechanical ventilation. The patient- and family-focused needs were also incorporated into the design of the floor and rooms. Noise was an important consideration; therefore, noise reduction elements were designed throughout the floor layout, and the use of noise reduction materials was chosen. The ‘‘way finding’’ system was improved, and locations clearly marked. Families were provided space for personal belongings and areas for respite outside their child’s room. Natural lighting was incorporated into the patient rooms and hallways, and convenient lighting options for the patient rooms were also made available. In addition to direct patient care necessities, meeting spaces were designed. These included patient and family education classrooms, a staff classroom, consultation areas, on-call rooms for providers, and staff offices. Many of these design element decisions were based on evidence-based design that involved detailed planning and
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Feature Article mapping of workflow in the newly designed floor space. The architecture and construction teams involved in the process worked closely with the direct care staff. They constructed several mockup areas based on the team’s design such as a patient room or the nurse’s station in the actual physical space, allowing staff the opportunity to visually see the layout and test the functionality of the space with actual equipment. This allowed the direct care staff involved in the planning process time to assess the feasibility and success of the design that they had envisioned. Supplies and Equipment Specific equipment and supplies for each patient population must be identified and stocked to adequately care for the patients served in those areas. The CNSs worked with the managers and team leaders for each respective area to determine specialty items and medications required. Space in the newly renovated or constructed areas had to be fitted with the proper storage units, and in this case, the Omnicell systems were used. In addition, each room within the Centers of Neurosciences and Pulmonology were designed with a bedside cart that consisted of a locked drawer for medication storage and several additional drawers to allow for storage of nonbillable, frequently used items and larger patient items and linens. This part of the unit design has aided in the efficiency of the bedside staff in the care provided to the patients.
NURSING SPHERE OF INFLUENCE Staffing Model/Human Resources To achieve optimal staffing models, hospital administrators often considered different staffing needs across the system during specific shift times.6 Thus, staffing needs are reevaluated frequently, where high-acuity patients are cohorted, and admissions/transfers from the PICU, ED, and OP service lines occur frequently during one 12-hour shift. Utilizing the Nursing Teamwork Survey, Kalisch and Lee7 studied the relationship between nurse staffing and teamwork and found that higher levels of nurse staffing were related to better teamwork. In many pediatric hospitals, diabetics in diabetic ketoacidosis on insulin drips are cared for in PICUs, where the nurse staff-to-patient ratio is 1:1 or 1:2. Children’s Health Children’s Medical Center Dallas provides care to many of these patients who are cohorted on 1 specific general medicine unit where they can be staffed 1:3 by following a consistent management protocol. White and Dickson8 reported that ‘‘when compared with data in recent consensus statements, the Dallas protocol is associated with extremely low rates of death and disability (0.08% vs 0.3%) from DKA.’’8(p761) Opportunities for staff to expand their knowledge and skills were realized during the closing and opening of several patient care areas. Managers and senior leaders worked with the HR department to determine appropriate staffing levels E4
for each of the areas impacted by the patient population moves. The CNS served as a consultant to the leadership team offering expert opinion and evidence-based practices for the designated patient populations involved in the transitions. Once the appropriate staffing needs were defined, the leadership team and an HR representative met with staff to offer the options available. Each staff member was presented a letter describing the changes and asked to rank the area they would prefer to work based on the patient population in order of first preference to last. This time of transition allowed bedside staff to move to a new area and broaden their expertise or allowed them to continue to care for a similar patient population. Additional opportunities to move to a higher-acuity area, such as the PICU or ED, were available. During this time of decision making, the CNS mentored, supported, and provided guidance to nursing staff to aid in their professional development. Decisions were made by the leadership team with thoughtful consideration of the staff’s preferences and matching of the patient needs while maintaining the staffing needs for each individual patient care area. This process ensures development of a healthy work environment. Education The expansion of several patient care service lines as well as relocation of patient populations allowed the nursing and unlicensed staff the opportunity to expand their knowledge and skills. Wright9 pointed out that organizations evolve over time, requiring staff to maintain their competencies to care for patient populations in order to achieve success for the organization. Competency assessment during recent times of transition included evaluating the patient needs and matching it to the nurse’s skills. For example, ensuring the knowledge and competence of the nurse allows for the care of a patient with a newly placed tracheostomy after the first tracheostomy change or care for a patient with diabetic ketoacidosis on an insulin drip. Preparing the staff to be able to care for the patients safely was a priority during these times of transition and organizational change. In order to meet the evolving changes and needs of the staff as well as the patients, the CNSs completed a needs assessment survey. The data were analyzed to identify gaps that in turn determined the required skills and behaviors needed to care for each of the patient populations involved in the transitions. The CNS is often the content expert within the area that is directly impacted by the transition, making him/her the ideal person to complete this assessment. Once the information needed and required skills were identified through the needs assessment survey, education plans for each of the population moves were developed collaboratively by the CNS and the clinical educator. A thorough yet feasible education plan for the staff caring for these complex patients is equally paramount to the success of the
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transition process. The clinical educator verified current staff competencies and developed new competencies based on the needs identified for each patient population. In addition, the time needed to become competent in the newly required skills to care for the patient population must also be decided prior to a patient population move. Updates should also be provided to the unit managers to ensure support for the time that staff will need to be away from the bedside in order to participate in the needed education. All involved participants must remain informed of the plan throughout the implementation phase. The education plan for the staff working in the Center of Pulmonology was developed in collaboration with the pulmonology clinical educator and CNS by identifying what types of patient populations would be admitted to the areas within the center. To better understand this, the following is a description of how the Center of Pulmonology was designed: the center is divided into 2 separate freestanding units connected by a common area for the patients and families. One unit accommodates 22 patients admitted with a lung, airway, or endocrine diagnosis. The other unit accommodates 24 patients admitted with a lung or airway diagnosis. Each unit has a core staff that primarily works together, but could float to either side as needed to care for the patients. Education was based on cohorting of patient populations. Therefore, each unit within the Center of Pulmonology provided care for patients with similar diagnoses as well as for patients unique to its particular unit. For example, patients with asthma could be cared for on either unit, whereas patients who require invasive ventilation or who have a primary endocrine disorder would be admitted to the unit specializing in the care of that patient population. Education of staff members was based on the new care delivery design. Competencies were designed that reflected the needs of the newly cohorted patients and families. This initiative matched nicely with the standards outlined in the American Association of Critical Care Nurses’ Healthy Work Environment document.10 The education plan consisted of 2 education tracks, and attendance depended on the education and competency needed by the nurse. There were 7 total education sessions, and 4 of those sessions were offered with the combined staff from each unit. All sessions occurred within 1 to 2 months of the anticipated move to the new units. The education tracks consisted of lecture-style education as well as hands-on skills laboratory. An education plan also was developed for nurses who would be caring for the endocrine patient population for the first time. Again, the nurses must attain and maintain specific endocrine competencies to safely care for this patient population. In addition to the disease-specific information required, the patient and family needs were considered and provided to the new team members prior to the transition to the new unit. These nurses received an 8-hour workshop that provided them with a foundation to care for the various Clinical Nurse Specialist
endocrine diagnoses. This venue provided the endocrinologists, CNSs, certified diabetic educators, social workers, child life specialists, and dietitians an opportunity to meet the new staff who would become a part of their team. This group of team members emulated the findings of Kalisch and Lee’s7 research findings: the greater the skill mix, the higher the level of teamwork. In our experience with the formation of new teams, there were 2 significant puzzle pieces: effective communication and professional accountability. Establishing and maintaining these attributes within teams expedited safe and effective workflow. A new team’s functionality is based on the establishment of trust. Interdisciplinary healthcare teams included both licensed and unlicensed personnel. An additional 3-hour workshop was provided for unlicensed personnel regarding the unique needs of these patients that would require a collaborative effort between the unlicensed staff and the nurse. Integrating the unlicensed personnel into the team utilizes each discipline to their full capacity and acknowledges the importance of their role. In fact, the unlicensed personnel completed an evaluation of the education provided, stating that the additional training helped them feel valued as new endocrine team members. Orientation to New Space/Staff Preparation The staff transitioning to the Center of Pulmonology and the Center of Neurosciences were provided opportunities throughout the building processes to see the progress of their new units. Allowing staff to get a sneak peak at frequent intervals during that process created excitement among the staff that would be transitioning to those areas. Once the construction was completed, and the floor was near opening, the staff was provided the opportunity to tour their new units and become familiar with the new equipment and unit layout prior to the transition to their new work areas. The clinical educators developed a ‘‘seek and find’’ to encourage the staff to discover the locations of the crash carts, linen carts, clean and dirty storage areas, medication rooms, stairwells, staff meeting areas, break rooms, and classrooms, among many other components of the new units. The vendors for specific equipment such as new hospital beds, new nurse call system, and new defibrillator were present during those visits to provide in-services to the staff. A grand-opening celebration for the bedside staff, unit leadership, and senior leadership was held once the moves to the new units were made. A newsletter written by the CNSs for the new units was provided to staff with helpful tips about the unit, phone numbers, and locations of supplies and equipment. Change Process/Integrating Teams The CNS is knowledgeable in the change process and supports leadership as well as the bedside staff through periods of transition. ‘‘Organizational change in healthcare is a complex,
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Feature Article nonlinear process that must evolve in response to shifts in social, economic, and political environments.’’11(p164) In response to these shifts, organizations must change. In fact, 1 patient population was relocated twice only 1 year apart in order to meet the organization’s needs. The staff comfort level survey completed in 2012 resulted in an average comfort level on a 0- to 5-point scale as a 3 (0 being the lowest and 5 being the highest). The second transition seemed to progress more smoothly as evidenced by the 2013 staff comfort level result of 4.07. The endocrinologists commented that the nursing staff seemed happier with the second move. It was recognized during transitions that staff acceptance of change does not have a defined time frame, and members progress at their own speeds. This process cannot be forced, and individuals must be supported along the way. Staff often viewed the CNSs as a ‘‘safe’’ person to voice concerns to and to seek answers or support. According to Melnyck and Fineout-Overholt,12 the 2 essential elements for successful organizational change are vision and goals with the belief and confidence in one’s ability to accomplish the outcome. ‘‘Positive change requires a great deal of positive energy and emotions, including confidence, hope, belief, creativity, and persistence.’’13(p18) This statement was certainly true during the transition as the endocrine population moved units in 2012 and again in 2013. The CNSs provided a second set of educational workshops for new team members being added during the second move. Confidence grew as new team members practiced their new skills and had positive experiences when caring for newonset diabetic patients and their families. Experienced endocrine nurses mentored new team members and assisted them in completing their competencies. When comparing the results of the 2012 staff survey to those from 2013, staff expressed an overall higher level of comfort related to caring for the endocrine population after the second relocation. Change runs more smoothly if team members are prepared for potential issues they may encounter due to change.14 As transitions occurred and new peer groups were formed, managers and team leaders were redistributed based on the future needs of the newly formed unit. New team formation and acceptance of new leadership were received with mixed responses. Each new team attempted to learn from their successes as well as their failures. Team building support from HR, manager retreats, and team Leader boot camps helped to form support networks and introduce additional coping strategies for stress management. Effective change includes the establishment of both practice and culture.15 Staff team members have to be willing to make an effort and commit to invest the time and emotional energy it will take to effect successful change. Members should contemplate what they stand to gain or lose with a new way of working. Innovation may be difficult to embrace when feelings of loss are present. The anticipated organizational outcome is for the new group to assimilate into a cohesive team that supports each other. E6
Edmonstone16 described the PRINCE2 approach to managing change, which involves a 7-step approach: (1) set the goal, (2) set a final deadline, (3) identify the subtasks, (4) order the subtasks, (5) set targets, (6) assign subtasks, and (7) monitor progress. When following these steps, problems may be encountered. A few examples that we encountered and worked through were Omnicell malfunction and short staffing. According to McLean,17 navigating the journey through change and transition should include a plan for sustainability with a focused intent on outcomes. The 2 successive endocrine moves within a 2-year time frame presented an opportunity to examine practices at every entry point of an admission and discharge. By addressing causes for high-risk medication errors causing harm through a multidisciplinary Medication Safety Committee, insulin errors fell off the top 10 list in 2013. Even with planning, leaders of change often encounter its complex effects as chaotic and convoluted.18 On the actual day of the patient relocation moves, our census deviated from its usual trend, and staffing needs were adjusted accordingly.
PATIENT/FAMILY SPHERE OF INFLUENCE Family Preparation In a family-centered environment, preparation for both the patient and the family is important particularly when they are admitted during the time of the move from one unit to another. Consideration should also be made for patients and families with long-term chronic care needs resulting in frequent admissions to the unit. Orientation to the units included tours for the patients and families with the bedside staff, leadership, and CNS just prior to the moves. This allowed them time to see the new unit, patient rooms, playroom space, and common areas designed for respite. In addition to the tour of the new unit, the families with children with cystic fibrosis were provided a letter drafted by the CNS and cystic fibrosis provider team. Given that these children were admitted frequently, the team of healthcare providers wanted to ensure they were informed of the move. The letter also provided a venue to highlight the exciting changes and special additions made within the Center of Pulmonology. Some of these additions include a designated infection control playroom and a pulmonary function testing laboratory within the unit. CONCLUSION Clinical nurse specialists are recognized as advanced practice nurses who are prepared to implement evidence-based transitions. They play pivotal roles as clinical experts and proponents of evidence-based practice and effect change in the system/organization, nursing, and patient/family spheres of influence. Based on these spheres, refer to the Table for lessons learned during transition. It is imperative for the CNS to develop tools such as an organizational plan and timeline to guide transitions safely throughout the change
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process. These tools were beneficial for use in similar projects involving population moves. Organizational leadership gained an increased awareness of the CNS role at the conclusion of each successful transition. While transitions can be a source of stress for leaders and bedside staff, it is also a time that allows for growth and new opportunities for staff and may result in development of a healthier work environment. Implications The CNS is a valuable member to include in an interdisciplinary team during times of organization restructuring and patient population transition. Given the scope of practice, the CNS is able to provide leadership while working collaboratively to oversee the moves with a forward-thinking approach. Key components to consider during times of such transition are identification and improvements in work efficiencies, awareness of nurse and patient satisfaction, development and maintenance of a healthy work environment, planning for adequate staffing, innovative staff education, and providing leadership support during transition. References 1. Duchscher J. A process of becoming: the stages of new nursing graduate professional role transition. J Contin Educ Nurs. 2008; 39(10):441Y450. 2. Trochelman K, Albert N, Spence J, Murray T, Slifcak E. Patients and their families weigh in on evidence-based hospital design. Crit Care Nurse. 2012;32(1):e1Ye10. 3. Nelson C, West T, Goodman C. The Hospital Built Environment: What Role Might Funders of Health Services Research Play? Rockville, MD: AHRQ Publication, The Leewin Group, Inc; 2005.
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4. McCullough C. Evidence-Based Design for Healthcare Facilities. Indianapolis, IN: Sigma Theta Tau; 2010. 5. Mittal V, Sigrest T, Ottolini M, et al. Family-centered rounds on pediatric wards: a PRIS Network survey of US and Canadian hospitalists. Pediatrics. 2010;126(1):37Y43. 6. Knudson L. Nurse staffing levels linked to patient outcome, nurse retention. Nurse Staff. 2013;97(1):7Y9. 7. Kalisch B, Lee K. Nurse staffing level and teamwork: a crosssectional study of patient care units in acute care hospitals. J Nurs Scholarsh. 2011;43(1):82Y88. 8. White P, Dickson B. Low morbidity and mortality in children with diabetic Ketoacidosis treated with isotonic fluids. J Pediatr. 2013; 163(3):761Y766. 9. Wright D. The Ultimate Guide to Competency Assessment in Health Care. 3rd ed. Minneapolis, MN: Creative Health Care Management; 2005. 10. American Association of Critical Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments. Aliso Viejo, CA: AACN; 2005. 11. Richer M, Ritchie J, Marchionni C. Appreciative inquiry in health care. Br J Healthc Manag. 2010;16(4):164Y172. 12. Melnyck B, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. 13. Brooks J. Engaging staff in the change process. Nurs Manag. 2011;18(5):16Y19. 14. Davies N. Onwards and upwards. Nursing Standard. 2010; 24(20):62. 15. Hewitt-Taylor J. Planning successful change incorporating processes and people. Nurs Stand. 2013;27(38):35Y40. 16. Edmonstone J. A new approach to project managing change. Br J Healthc Manag. 2010;16(5):225Y230. 17. McLean C. Change and transition: navigating the journey. Br J Sch Nurs. 2011;6(3):141Y145. 18. Stichler J. Leading change; one of a leaders most important roles. Nurs Womans Health. 2011;15(2):166Y170.
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