The Road to First-Rate Nurses: Where Both Sides Meet
On one side of the street: a university health care system with national rankings for superb performance in quality, safety, efficiency and service that place it among UHC’s top university medical systems in the nation. Across the street: a flagship nursing program, also with national rankings, with BSN graduates who consistently exceed the national first-time pass rate on the famously rigorous National Council Licensing Examination (NCLEX-RN) for new nurses, including December 2013’s graduating class of 88 students who finished with a 100 percent pass rate on their first attempt.
The level of excellence mirrored on both sides is no coincidence, say nursing leaders from UK HealthCare® (UKHC) and the academic nursing program that prepares the majority of its new BSN nurses each year. Over the past decade, a remarkably productive feedback loop has developed between the two—and it’s making a measurable difference in the health and well-being of Kentuckians and beyond.
“We have the patients and they have the students,” says UKHC’s Kathy Isaacs, PhD, RN, director of nursing professional development. What they share, she says, is a desire to lead change and a willingness to explore new ways to do it. “Many of us have roles in both places, and we know who to see and where to go,” she says. “We help them with their clinical placements, and they help us by reinforcing in the curriculum some of the current practice issues we’re seeing and helping prepare nurses for an advanced, medically complex environment like ours.”
That kind of collaborative give and take has paid off in a number of ways, says Patty Hughes, DNP, RN, NE-BC, director, oncology and interim assistant chief nurse executive, Ambulatory Services. “Over time, the partnership has developed into something pretty amazing, actually.”
Dr. Hughes is responsible for everything related to nursing in her departments, including 350 staff nurses who work with patients from across the region seeking high-level treatment and care from Kentucky’s leading medical center. She also sees students from nursing programs across the region who come to her units for in-depth clinical experiences. Is there a noticeable difference among students from different programs? A decade ago, she might have said no. Today, she says, it’s a definite yes. “The caliber of student coming from the College of Nursing far exceeds the average,” she says. “Over the last 10 years, there’s been a concerted effort from the College, in my opinion, to improve and improve and improve. It’s paid off.”
Patricia Burkhart, PhD, RN, is associate dean for undergraduate studies at the College and oversees the undergraduate nursing curriculum. “Our goal is to graduate high-quality nurses who are safe, responsible, accountable and practice-ready,” she says. “UK HealthCare’s vision is ‘leading the way for every patient, every time’ and that’s the vision we have for our students, too.”
Every patient, every time is a very high standard, admits Dr. Burkhart, but as students learn early on, there is no room for error.
“Med math” is what students call the critical mathematical formulas nurses need to know to accurately calculate prescribed medication dosages for patients. Several years ago, the College added a new component to the curriculum to reinforce today’s critical focus on medication management safety.
At the beginning of every semester with a clinical course, students are required to take a medication calculation exam based on the level of “med math” knowledge they’ve gained in previous clinical courses. Each exam has 10 questions and students get three chances to pass it, says Dr. Burkhart. The only passing score? One hundred percent. Students who miss the mark the first time or even the second have plenty of support and tutors to help, including First Aid Friday study hall in the College where faculty, registered nurse teaching assistants and undergraduate skills lab interns assist students. But there is no wiggle room on the score. “Sometimes students will say, ‘but I just missed one—I got 90 percent’,” says Dr. Burkhart, who then patiently explains to them, “You’re thinking of this as 10 math questions. Think of it as 10 patients. Think what missing ‘just one’ means for that person.”
The focus on enhanced medication safety is something faculty takes very seriously, says Dr. Burkhart.
“Again, it’s that vision—every patient, every time, whether it’s medication management or the effectiveness of a student’s clinical skills or a particular skill proficiency— it’s leading the way for every patient, every time.”
Historically, the contribution of nursing to the inpatient care model has been difficult to quantify. How do you know what to measure when the discipline itself, with its holistic, patient-centered approach and collaborative practice tradition, is so deeply integrated and interwoven into the overall care experience?
In 2004, the National Quality Forum (NQF) identified 15 performance measures for nursing-sensitive care based on a large and growing body of evidence on their relationship to patient outcomes. Pressure ulcers, patient falls, catheter- and central line-associated infections and other issues related to safety and quality were identified as Nursing-Sensitive Indicators (NSI), measurable factors that nurses “own” because they’re in direct control of them. Tukea Talbert, DNP, RN, interim director of the Office of Enterprise Quality and Safety, says the enterprise has a robust data collection system in place for measuring and evaluating Nursing-Sensitive Indicators, which are reported and included in national databases that rate the nation’s hospitals for quality and safety. “There are nurse-driven protocols to prevent falls, to prevent infections, to prevent those things that impact quality and safety,” says Dr. Talbert. “Avoiding preventable harm and conditions improve patient outcomes and that’s always the goal. Nurses play a major role in helping us achieve that goal.”
A new nurse graduate shouldn’t be hearing how critical Nursing-Sensitive Indicators (NSI) are when they’re starting out in practice, says Dr. Isaacs. “We need them to be building those skills while they’re learning so that once they’re hired in they’re a step ahead.” Over the past few years, the undergraduate curriculum has been reinforced with more evidence-based, NSI-related content in the classroom and more hands-on training in the best practices that impact NSI-related outcomes in their clinicals. “We involve students in every activity at the bedside,” says Lisa Thornsberry, MSN, RN, nursing director, UK Good Samaritan Hospital. “Our nurses explain why they’re doing what they’re doing and what the impact is on patient outcomes.”
Inpatient injury due to falls is a problem in hospitals across the nation. So are pressure ulcers and hospital-acquired infections. Their negative health impact is not only potentially devastating to the patient but also a costly, non-reimbursable expense for hospitals. In the classroom, students are learning the science behind evidence-based practices that prevent patient falls and then practicing them in the College’s 10,000-squarefoot simulation center. They’re studying the literature on preventing pressure ulcers and practicing the principles behind infection control with high-fidelity mannequins and other valuable teaching tools. By the time they’re on the floor for their clinical experiences, they’re ready to use the knowledge and clinical skills they’ve gained in a real-world practice setting under the eye of an experienced nurse preceptor. It takes a partnership to create a new BSN nurse who is practice-ready, says Brandy Mathews, MSN, MHA, RN, NE-BC, UK interim assistant chief nurse executive for Good Samaritan Hospital.
“The foundation is laid during education, but it’s in the clinical experience that we see how well a student has integrated what they’ve learned,” she says. “That’s when the light bulb comes on.”
College of Nursing Senior Lecturer Jennifer Cowley, MSN, RN, has been “in the light bulb business” for years. She’s an award-winning educator, preceptor and coordinator for the challenging adult medical-surgical course for third-year nursing students. “In a clinical course like this one, students are out there on the floor living and breathing those Nursing-Sensitive Indicators,” she says. There’s a great dynamic at work, says Dr. Burkhart, between eager, well-schooled students who are passionate about evidence-based theory and practice and their experienced nurse preceptors, many of whom are not only part-time instructors on the faculty but senior nurses on the unit. “Sometimes a student will say, ‘I found this great article’ and the clinical instructor will say, ‘Oh, yes! Can you share that?’ or a nurse on the floor will say, ‘yes, but have you thought about it this way because here’s evidence to support this particular practice.’ It really is a nice give and take.”
Learning a clinical skill is a very tedious, very exacting process, says Ms. Cowley. “Students must learn the skill exactly as it appears on paper and are required to follow it to a ‘T.’” What happens when a student observes a staff nurse performing the same skill but in a slightly different way? “It can throw them to see things rearranged,” admits Ms. Cowley. “But it can also be a good learning experience.” Good nurses know the skill. Great nurses understand the evidence and theory behind it. “I’ll ask a student who sees a practice being performed in a different order to apply their critical thinking skills—are the outcomes the same? Are the principles being maintained? Sometimes step three can come before step two.” To be a leader in a complex health care environment like UKHC it takes critical thinking skills like these and a passion for inquiry. “You have to have that mindset coming in,” says Dr. Isaacs. “The College does a great job of introducing this way of thinking to students. Its graduates have that understanding long before they even step foot in this environment as a new nurse.”
BSN students at the College are not only learning the science behind evidence-based nursing practice but are being inspired to become change leaders who contribute to it. The BSN curriculum now includes an enhanced research component in the research course that students take as second-semester juniors, says Dr. Burkhart. They choose an area of clinical interest and review the literature to find evidence that supports high-quality, patient-focused care. Topics can cover a wide range, she says, from infection control with indwelling catheters to the efficacy of skin-to-skin “kangaroo care” for mothers and new babies. “We want our graduates to be leaders,” says Dr. Burkhart. “We want them to lead the way in evidence-based nursing practice so that bedside nursing is driven by the science that supports the best care.”
Patricia K. Howard, PhD, RN, CEN, CPEN, NE-BC, FAEN, FAAN, is the enterprise director of emergency services at UKHC. She’s on the College’s adjunct faculty and teaches a popular elective on trauma care. She also leads a research program focused on family presence during resuscitation and has mentored several BSN students in the College’s nationally recognized Undergraduate Research Interns Program. A few years ago, one of those interns assisted Dr. Howard with the literature review and survey development on a study she was leading. This student also requested to do her senior year practicum, Synthesis, in the Emergency Department. “I not only worked with her before she graduated but so did our staff,” says Dr. Howard. “It gave us a chance to get to know her, to see her skills and knowledge and to see how she acclimated into this environment.” Dr. Howard is happy to report that her former intern is doing well as a nurse on her staff. “It’s been fun for us to see her grow and mature in her nursing career.” Last year, 74 percent of new nurse hires were graduates of the College. Typically, UK graduates don’t require as much hand-holding when they come on board as new nurses. They already know the system, say nurse leaders at UKHC.
Every summer, a select group of top nursing students, all rising seniors from programs across the country, participate in UKHC’s prestigious student nurse academic practicum (SNAP). This paid 300-hour clinical immersion experience is another great example of the collaboration between UKHC and the College, says Darlene Welsh, PhD, RN, associate professor at the College who co-coordinates the SNAP course with Cowley. SNAP students are selected and hired through nurse recruitment at UKHC, which gives the units as well as the students an early chance to see if there’s a fit. “Last summer we had 30 SNAP students, and the vast majority of them were from the College of Nursing,” says Dr. Welsh, who also coordinates Synthesis, the required senior practicum for all UK BSN graduating seniors. It, too, involves a clinical immersion experience—225 hours working side-by-side with a preceptor and interacting with staff on a UKHC unit.
“Students know that once they’re in a unit for SNAP or Synthesis, there’s a very good chance they could be hired.”
They’re right to keep that in mind, says Dr. Hughes. “I tell students all the time—when you come in here for clinicals, you are on stage. Everything you do, everything you say, your interactions with the nursing staff, the patients and the physicians, somebody’s watching. It’s a dress rehearsal for working here.”
It’s not enough to produce nurses with an outstanding set of clinical skills, says Thornsberry, nursing director at UK Good Samaritan Hospital. It takes communication skills and the ability to interact effectively as a nurse with other health care providers, practitioners and clinicians within today’s patient-focused care teams. It also takes agility and a willingness to learn in a fast-paced, constantly changing environment. Last year, Good Samaritan instituted bedside shift reporting, says Thornsberry. “It was difficult for some of our experienced nurses who just weren’t used to having the patient and family take part.” As a former bedside nurse herself, Thornsberry understood their feelings and worked with one nurse who was having an especially difficult time. “We sat down and reviewed the literature together and talked about the outcomes and the difference it made to patients, and I rounded with her to demonstrate,” she says. “She ended up taking ownership of that practice and is now a champion of it,” says Thornsberry. “She’s what we call a ‘super-user.’”
In 2013, the University HealthSystem Consortium (UHC) awarded UKHC a Rising Star Award for improvements in patient safety, decrease in mortality, clinical effectiveness and equity of care that ranked it 12th out of more than 100 UHC hospitals nationwide. In 2014, patient satisfaction rates and employee engagement measures were also up. The enterprise is currently on the Magnet journey, a national designation that reflects the quality of nursing care in hospitals. “All of these indicators support Magnet status,” says Dr. Burkhart. “But even more importantly, they support safe, high-quality care and better outcomes for patients.” And that’s the goal on both sides of the street.
