TL - Transformational Leadership

TL5-Advocacy and Influence-Describe and demonstrate how nurse leaders guide the transition during periods of planned or unplanned change.

Our nursing leaders function as catalysts for change. Our strategic plan promotes the use of change and technology in order to increase the effectiveness and efficiency of nursing practice. Change is integral to improvement in the overall growth of the Division of Nursing. Our nursing leaders, in conjunction with the staff nurses, recognize the need for change and establish goals in order to accomplish the desired outcomes. An overall plan is carefully developed and communicated with their staff in order to insure compliance. Our management team will clearly establish the desired end result. Our leadership team insures that deadlines and priorities are met. They remove barriers and create a climate that is conducive to the change process. They insure that education is provided if needed to insure that an adjustment period occurs among staff members.

Example of planned change on all medical/surgical units

There was recently some concern over PCA usage. The current system possessed old technology and did not have the built-in safety features that the newer systems have. Furthermore, we did not have sufficient pumps for all the units and the manufacturer of the older pump models no longer supported the software of the older units. Rita Smith DNP, RN, NEA-BC, CNO realized that new pumps had to be evaluated and purchased. Winnie Cherubin MSN, RN, CNL, WCC and Janice Kozzi MSN, RN, CNL decided to champion the PCA project. They were joined by Michael Curci, Director of Pharmacy. They chose three companies to evaluate, one being the company that supplied the current pumps. The units that evaluated the pumps were the critical care units, medical-surgical units, emergency department and NICU. The team’s criteria for evaluating new pumps included:

  1. Insure that all safety criteria (including patient and staff) are met
  2. Insure that cassettes can be added so that more than three (3) drips can be run simultaneously
  3. Insure that units are compact in size so that space can be afforded to the addition of pumps
  4. Built-in safety alarms to prevent infusion errors

The team was also interested in a system that was user friendly and addressed the five rights of medication administration which include:

  • Right drug
  • Right dose
  • Right patient
  • Right time
  • Right route

A comparison grid was developed in order to compare the currently used model to the proposed purchased model:

TL1-Table 1

A final selection was made and the company selected met all the safety requirements laid out by the team. They determined to purchase 180 units and place them on the individual units for ease of obtaining the needed units. Rita Smith DNP, RN, NEA-BC, Chief Nursing Officer is an essential component in the Capital Budget Process. Since the cost of these pumps exceeds $100,000.00, it was necessary to present this data to the Board of Trustees Appendix TL4-G. Ms. Smith informed them of the need for these units and the advantage to patients. Organization-wide in-services were arranged to insure that nursing staff was prepared for the new PCA use. The pharmacy programmed the medication libraries. This was a multi-stage process with the nursing leaders guiding the change every step of the way.

Example of planned change in cardiac catheterization unit

Overtime usage in 2011 became problematic in the Cardiac Catheterization Laboratory (CCL). One reason for this was based on the fact that physicians continuously posted and added-on procedures into the evening hours. The operational hours in the CCL were 0700-1700. The Cardiologists, however, did not find these hours to be “user friendly.” Physicians would post procedures and nurses would work late hours into the night to complete these procedures. The nursing staff was accruing many hours of overtime.

The CCL consists of nursing staff as well as cardiac technicians. These staff members work four (4) days per week, ten (10) hours per day, five (5) days per week. The weekend shifts and night shifts are covered by an “on-call” team consisting of two (2) nurses and one (1) cardiac technician.

Larissa Semenoff BSN, RN, CNOR Nurse Manager of CCL discussed the possibility of converting the unit to twelve-hour shifts with Cheryl Owens DNP(c), RN, CNOR, Director of Nursing and Rita Smith DNP, RN, NEA-BC, Chief Nursing Officer. Ms. Semenoffs rationale for this change was that she would achieve more coverage and reduce overtime costs. Ms. Owens and Ms. Smith were in agreement on this issue.

Ms. Semenoff developed a scheduling prototype to insure that sufficient staff was available to implement this nursing model. She than assembled a CCL work team to help with the education and implementation of this model. The team included:

TL1-Table 2

Multiple staff meetings were held during this process with the goal of obtaining everyone’s input into this process. One of the nursing staff’s concerns was the impact this change may make on their families on a daily basis. Ms. Semenoff allowed for a three month period prior to making the change so that staff could make accommodations. The implementation team worked with the staff to address all of their issues and insure a smooth transition into the twelve hour work-day.

On May 1, 2011 the new model was implemented. Below are the overtime savings obtained for a six month period:

Overtime Savings obtained for a six month period

The total savings in overtime amounted to $18,157.00. The total decrease in overtime hours was 204.

Example of unplanned change in critical care units

An issue emerged in the critical care areas which involved throughput of patients requiring critical care beds. The Medical Center recently employed a new open heart surgeon whose goal was to increase the numbers of open heart procedures performed. Year-to-date (January-May) we performed 89 Open Heart Procedures as compared to 69 for the same period in 2011.The critical care unit consists of: 16 Intensive care beds

(both medical and surgical), 10 cardiac care beds and 8 cardiac step-down beds or 34 beds in total. The critical care unit was operating at full capacity, unable to handle the influx of cardiac catheterization laboratory (CCL) patients, trauma patients from the Emergency Department, Rapid Response patients all competing for critical care beds. As a result, the post anesthesia care unit (PACU) would absorb some of the overflow from the critical care areas. This was problematic, because full nursing coverage was not always available at night and required overtime for coverage.

Cathy Rajaram BSN, RN, CCRN, Mikel Herrara RN, Janice Milatante BSN, RN in newly designed open heart recovery
 Cathy Rajaram BSN, RN, CCRN, Mikel Herrara RN, Janice Milatante BSN, RN in newly designed open heart recovery  

The Nurse Manager, Cristina Simeone BSN, RN determined that additional critical care beds were necessary. There was a space available between the cardiac care unit and the intensive care unit that was occupied by office space. Ms. Simeone determined that this space could be converted into 6 additional bays for critical care. She arranged a meeting with Rita Smith DNP, RN, NEA-BC, CNO and William Cook, Director of facilities to discuss the changes within the course of one week, the Facilities Department reconstructed the area and created the additional needed space.

Ms. Simeone determined that the bays would be best utilized as open heart recovery areas. The area was separated from the other areas, was quiet and amenable to these types of patients. The open heart physicians were very happy as well, because they had their patients consolidated in one area. The area opened in March of 2012 and they managed to decrease the numbers of Emergency Department Critical Care holding significantly as demonstrated by the graph below.

Numbers of Emergency Department Critical Care holding