“Long periods of immobility have ravaging effects on your body,” says University of Arizona College of Nursing Clinical Associate Professor Laura McRee, DNP, ACNP-BC, LMT, RNFA. People who are confined to bed rest or who have other mobility limitations are prone to an array of adverse reactions, including rapid reduction of muscle mass and bone density that decreases a patient’s muscle strength over time. One of the direct consequences can be deep vein thrombosis (DVT), which creates a risk of pulmonary embolism, a condition that is responsible for 60,000-100,000 deaths in the United States each year. Currently, the only treatments available to treat DVT in health-care settings are anti-coagulant injections with potentially serious side effects or expensive sequential compression devices.
McRee, who has focused the bulk of her research on preventing such conditions, may hold the keys to a better way with her new invention, the Bed-Sled. The innovative resistance training device promotes movement for a patient’s lower legs using a spring-loaded footpad to create resistance, thereby preventing muscle de-conditioning and the formation of blood clots. Equipped with a sensor to record the amount of pressure applied and the number of depressions of the footpad, the Bed-Sled tracks the progress of a patient’s lower extremity strength.
Laura McRee, DNP, ACNP-BC LMT,RNFADesigned to be both portable and affordable, McRee’s device currently exists in a small-scale prototype format, but plans are underway with the help of Tech Launch Arizona and their National Science Foundation Innovation Corps (NSF I-Corps) Site Program to create a full-size version that can undergo clinical testing. “We have found nothing like it available in the marketplace right now,” says McRee, who has already filed for a provisional non-provisional utility patent. “This isn’t strictly for institutionalized use. It can be used for anybody in the commercial market. The electronic part is basic, the set-up is easy and because of that it will be cost-effective."
McRee’s invention could ultimately save billions of dollars through use in hospitals for physical therapy, but the average consumer stands to benefit as well. Thanks to her participation in the current NSF I-Corps cohort, she is gaining the expertise to expand commercial possibilities for the Bed-Sled and to target a broader base of customers. “Bed-Sled has the potential to appeal to a global market,” says McRee, pointing out that accessibility and ease of use can benefit anybody in an immobile state, young or old. “Sometimes, it doesn’t have to be a complex change that makes a profound difference to prevent adverse consequences and promote health.”
Code Lavender: Mary O’Connell Ushers Integrative Health Therapies into the Classroom
As a fellow in the University of Arizona College of Nursing’s inaugural 2016-2017 Integrative Nursing Faculty Fellowship (INFF), faculty member Mary O’Connell, MA, RN, PHN, has enthusiastically incorporated elements of the science, theory and practice of integrative health into her classroom curriculum. In September, fulfilling the Fellowship’s mission to help nurse-educators creatively and effectively incorporate integrative nursing into education programs, O’Connell launched a new classroom mindfulness initiative called Code Lavender. Designed for the BSN senior students to personally experience integrative health techniques, she helps them engage in different integrative therapies as a form of self-care and to learn potential ways to help the patients for whom they care.
What did you learn from the INFF?
The experience opened my eyes to the different therapies that we can apply as a compliment to the usual therapies not only for our patients but also for our students and their own self-care and wellbeing. As fellows, we were asked to explore a therapy or two in depth on our own, and I chose to delve into acupressure and acupuncture as well as some aromatherapy. While I might not yet be skilled in acupressure or acupuncture, I am able to help people know about them and can appropriately recommend when they can be tried.
What was the biggest takeaway from your experience?
That you should always start with the least intensive modality and build from there. For example, if I had a patient in pain, rather than getting the oxycodone, I would probably begin with some visualization, a mindfulness technique intended to help realize centering, calmness and wellbeing and assess the effects. This might reduce the need for strong painkillers – and help alleviate the public health problem we have with opioid addictions. I’m also a big believer in another principle of integrative nursing: the healing powers of nature. For example, making sure that patients get outdoors and exposed to natural light have a powerful effect on relieving negative mood and mental decline. For me, helping students learn the core six integrative principles and translate them into nursing healing approaches is very gratifying.
How did Code Lavender come to be?
Within my INFF cohort, one of our projects was to develop our own curriculum change that would educate students about aspects of integrative nursing. Often in health care, when a code is called, it is in response to a need (e.g., adverse event). Code Lavender was designed as a call to action for students to treat themselves and others, using compassionate, healing acts. So far, we’ve done a Code Lavender with mindfulness and an aromatherapy activity as ways to alleviate stress before exams. I have asked students to conduct their own version of an individual Code Lavender exercise with another student in their cohort.
Tell us more about changes to the classroom experience.
All students keep a self-care journal over the span of eight weeks. They interface with a buddy each week about how things are going so they can support each other. Based on their interests, students may also choose to create something visual that’s a powerful reminder of personal wellness for them, present it and then provide a write-up concerning their choices of the medium. For quieter students who may not like getting up in front of a group, they have chosen to do gratitude journaling over the period of a month, with an evaluation at the end.
What are your hopes for bringing integrative nursing and health to the fore in future teaching?
I plan to continue to expose students to learning the integrative principles, and applying them both inside the classroom and when caring for patients. One of the things I’ve done during their clinical rotations is give them an assignment when they’re out there in practice, doing three twelve-hour shifts each week for a five-week period. During that time, they really get a taste of what it’s like to be a registered nurse handling a whole team of patients. Each student carries a laminated card printed with the six integrative nursing principles, and then in a weekly journal reflects on the question, ‘What integrative nursing principle did I apply on behalf of my patients this week?’ Therefore, rather than just preaching about these different therapies, students embed integrative care principles and actions into their clinical practice. It’s a way to continue the work launched in 2014 by my faculty colleague, Dr. Mary Koithan and University of Minnesota faculty member, Dr. Mary Jo Kreitzer with their landmark Integrative Nursing guide. My long-term hope is that UA nurse graduates, after becoming registered nurses, will continue to learn about integrative nursing and health and to enrich their care for themselves and their patients by applying their integrative health knowledge and skills throughout their careers.
Established to bring essential medical and dental care to remote El Rosario, Mexico, the Tucson Chapter of Flying Samaritans Arizona is an all-volunteer organization dedicated to improving the health and wellbeing of patients in high need. Once a month (except during monsoon season), the group takes to the skies in small passenger planes loaded with a cargo of medical supplies and health care providers – nurse practitioners, physicians, dentists, hygienists and nurses – to provide supplemental health care for a local population. The University of Arizona College of Nursing faculty, Dr. Patricia Daly, started volunteering in 2012, and in 2014 became the organization’s medical director.
With her emergency room expertise, Dr. Daly was a perfect choice for the job. In addition to helping people in need, she sees it as an opportunity to enable clinical caregivers to have the experience of delivering care in areas where technology is minimal. “You learn to improvise. It’s critical for the people of El Rosario,” she says. “And it’s enriching for your practice to have that trans-cultural experience. Delivering care without access to usual technology hones your innate physical examination and diagnostic skills. Likewise, limited therapeutics resources make you adapt and invent novel treatments using only available resources.” In the future, Dr. Daly hopes to develop ways for College of Nursing students to participate in the program as part of their clinical learning. Last month Dr. Daly brought along Janay Young, a May 2017 Doctor of Nursing Practice (DNP) program graduate. “She caught on in a flash,” Dr. Daly says of Young. “Having her there doubled the number of patients who could be seen.”
Always interested in the achievements and adventures of our alumni, we caught up with Janay recently to get her thoughts on being with the Flying Samaritans.
Have you participated in anything like this before?
Years ago I was fortunate enough to participate in an international medical outreach to El Salvador as a nurse, so I had an idea of what to expect. I was aware of the differences between the health systems of the U.S. and South America and tried to be as flexible and open as possible. My previous experience with a big organization was very coordinated. We had an itinerary that was carved in stone. But with the Flying Samaritans, we definitely had to be more nimble at adjusting to circumstances. I really appreciated this different kind of experience.
What was the trip like?
We flew out of Ryan Airfield on a Friday morning and landed in Nogales to pick up three other volunteers, a dentist and two fluent Spanish speakers who planned to help with translating and triaging at the clinic. When we got to the airport in Mexico we met with the rest of the group who had also flown over in smaller planes and then we drove to the clinic. We worked Friday afternoon and all day Saturday and then flew back on Sunday. It was definitely a whirlwind experience: busy but gratifying.
What kind of care did you provide?
The Flying Samaritan organization has an agreement with Mexico that providers licensed in the United States may provide equivocal care in Mexico. Many of the patients that sought care were farm workers or laborers, so a lot of what we saw was what you would anticipate would be trouble for really hard-working people: sore joints or musculoskeletal injuries. One of the cases that stands out to me was a woman who was not able to get regular treatment for depression. She said she had had ongoing depression for several years, had been able to take medication at one time but was no longer on it, and her depressive symptoms were returning. In talking further with her, I learned that she had a non-verbal 10-year-old son and she had to manage his special needs with no local or affordable services. In the States, people with intellectual disabilities get hooked into services quickly regardless of socio-economic status, so it was sad to realize there wasn’t much that I could do on that one day to help. Dr. Daly calls it Wilderness Medicine in the sense that we can’t follow up with patients long-term because different providers come every month, and weather can sometimes cancel trips. It was very much, ‘What can we do today,’ so for that particular patient I talked about some stress management techniques and I was able to give her some supplements and melatonin to help with her sleep issues.
What did you learn from this experience?
It’s so humbling that these individuals came and waited for services all day for hours. I did my best to listen and try to communicate with my limited Spanish. Even with the finite skills and resources I had available, people were still grateful for and receptive to them.
Going forward, how will this experience inform your approach to nursing?
You can’t just sit down and say, ‘Okay, tell me what’s going on and ignore context.’ You really have to take some time to establish a rapport. I’ve been a nurse for a while so I had that sense already, but this experience definitely reinforced the importance of taking the time to ascertain where somebody is coming from within the uniqueness of their culture or environment, taking the time to listen and gain their trust. This is essential to making a difference in whether they are likely to follow your suggested therapies.
For people having trouble with their bodies cooperating with their desire to engage in regular, low-impact exercise like yoga, chair yoga may be a wise solution. A gentle form of yoga, chair yoga is ideal for people unable to engage in traditional yoga classes due to the effects of aging or disabilities. For that reason, it was one of the first integrative health modalities to be launched at The Hacienda at the River, the latest senior residential community initiated by the Watermark Retirement group.
“It’s a truly adaptable health therapy,” says Dr. Leah Stauber, University of Arizona College of Nursing faculty member, who teaches The Hacienda’s weekly chair yoga class. “You don’t need to be in any particular space, you don’t need any props or even an instructor once you’ve had some practice. Since many of the guests at The Hacienda rely on a cane or a wheelchair to be mobile, the beauty is it’s accessibility because it cane be performed anywhere, anyplace, anytime.” Among several benefits, evidence indicates positive effects on breathing, range of motion and mood/mental state.
Leah S. Stauber, PhD, Clinical Assistant Professor
Dr. Stauber, with her more than 10 years of experience in teaching chair yoga, has also taught traditional yoga to high school students, social workers, expectant and new mothers, nurses, memory care patients and professional athletes. On a recent Thursday morning, six Hacienda residents gathered in a peaceful, inviting sunlit living room, surrounded by leather-bound books, plants and comfortable furniture. to participate in Dr. Stauber’s class. Following Dr. Stauber’s class, residents commented on appreciating the opportunity for exercise as well as the social pleasure of engaging with a group.
With a focus on independent living, assisted living and memory care communities, The Hacienda residents are helped to advance their personal wellbeing in ways that are physical, spiritual and emotional. For example, aromatherapy, reflexology, acupressure and acupuncture have been woven into care, but the special value of chair yoga is that it is active and helps residents accustomed to a sedentary existence to become more mobile. Dr. Stauber points to the fact that The Hacienda’s caregivers also have attended her class to learn stretches and therapeutic movements they can then do one-on-one with their family or loved one.
The integrative health and well-being is a focus for the special partnership between The Hacienda and the UA College of Nursing, with its integrative health focus and one-of-a-kind Integrative Nursing Faculty Fellowship (INFF). “The College of Nursing Integrative nursing faculty fellows are advancing best practices for educating nurses and nurse educators in the art and science of integrative health and well-being,” says Dr. Stauber. “The goal is to teach them to implement various modalities as well as the principles of integrative nursing itself, and bring them together in a sustainable way. It’s a teach-the-teacher model.”
“Yoga helps return us to the ways in which our bodies worked at healthier points in our lives,” Stauber says. “The movements bring our bodies back into a fuller range of motion, one closer to when we were young. Most importantly, it helps remind us of the ways in which we breathed, before we started sitting at desks, for example, before everything got compressed in the chest, and our breath became really shallow. Shallow breathing is known to have many adverse effects on our bodies, including on blood flow, various hormones and the central nervous system.”
Third-semester senior in the bachelor of science in nursing (BSN) program; from Tucson, AZ
Why did you decide to pursue a nursing degree?
My interest in nursing was first cultivated during high school, when I learned what a rewarding career nursing could be. I have always had a passion to serve others and have done so through volunteer service and previous work experiences; however, I strongly desired to serve at a greater capacity. Nursing provides the opportunity fulfill this passion while challenging me daily to grow in knowledge and skill to care for patients. After high school, I started a family and my dream to become a nurse was put on hold. During this time, life experiences including the birth of my three children and helping to care for my grandfather further showed me the great impact that a nurse can have on a person’s health care experience. I want to become a nurse because I want to provide compassion, advocacy and positivity to patients and families in some of their most difficult times.
What drew you to the UA College of Nursing?
I believe that nursing education is crucial to providing excellent care. During my search for nursing programs, the University of Arizona stood out to me as a school that strives to shape exceptional nurses. I value the college’s emphasis on teaching nurses to utilize research in their practice, as I feel that it provides understanding and support for nursing care. I was also drawn to the colleges support and encouragement during my search for schools. I recognized that the program ahead would be challenging, but I was welcomed, even during the stressful time of nursing school applications, with great support from the College of Nursing.
What features of your program are you especially passionate about?
Within the College of Nursing, there is an emphasis on caring for the patient as a whole person and not just treating the medical condition. The program teaches students to support patients socially, emotionally, and physically. I love that the College of Nursing also provides excellent opportunities to learn how to support and care for people in some of the most difficult times of their lives. The instructors have brought in many members of the community to share their personal health experiences, including living with a disability to experiencing loss of a loved one. This has allowed me to have a greater perspective on how to listen to the patient and care for the individual.
Share your favorite memory from your time at the CON.
My favorite memory in the College of Nursing was the last simulation day of second semester in which a team of my classmates and I cared for a patient in the lab. We had been working together all semester in clinical and lab and had really learned how to work as a unit. During this stimulation, we complimented each other, which allowed us to provide exceptional care for the patient. During this moment, I recognized the full value of working with an excellent team of health-care providers.
How do you intend to Build Better Futures?
I believe that education can make a strong impact on the community’s health; thus, I intend to become active in the community and promote health through providing culturally appropriate education and resources. I also strongly believe that it is important for nurses to continue learning and following current research to be able to implement it in their practice. I personally desire to continue my education, so that I may become a more effective nurse to provide exceptional care to my patients.
Medicare Graduate Nurse Education Demonstration Increases Primary Care Workforce
The number of advanced practice registered nurse students and graduates increased under the Centers for Medicare & Medicaid Services’ Graduate Nurse Education demonstration project, according to a new report to Congress by the Department of Health and Human Services. “The GNE demonstration had a positive impact on APRN growth, and helped transform clinical education within participating GNE schools of nursing,” the evaluation report concludes.
The Affordable Care Act authorized the Medicare demonstration to test whether paying eligible hospitals to help offset the costs of clinical training for APRN students could help increase the nation’s primary care workforce. In 2012, CMS selected five hospitals affiliated with 19 university schools of nursing (including the University of Arizona College of Nursing) and hundreds of community clinical partners and collaborating health systems to participate in the program: Duke University Hospital in Durham, NC; Hospital of the University of Pennsylvania in Philadelphia; Memorial Hermann-Texas Medical Center in Houston; Rush University Medical Center in Chicago; and HonorHealth Scottsdale (AZ) Osborn Medical Center. The AHA’s American Organization of Nurse Executives subsidiary played a significant role in developing the original concept for the demonstration.
CHAP Leadership Team Audrey Russell-Kibble, DNP, FNP-C, FAANP, CHA Project Coordinator at the College (author), Theresa Allison, DNP, FNP-C, CHAP Assistant Project Coordinator, and Allen Prettyman, PhD, FNP-BC, FAANP, Director of Practice Innovations
Background & History
The CHAP was the inaugural nurse practitioner (NP) faculty practice opportunity at the College of Nursing. The notion of a college providing practice opportunities for NP faculty was novel in 2012. To promote the vision and innovation of faculty NP practice, Dean Joan Shaver, PhD, FAAN outlined strategic plans to support unique faculty NP practice opportunities. Five years ago, during a lively discussion with Thomas Ball, MD, Medical Director of the University of Arizona Health Plans (UAHP) the vision of faculty NP practice at the UA CON became a reality.
CHAP Staffing Structure
The CON developed an agreement with the UAHP to perform Comprehensive Health Risk Assessments for their Medicare Advantage Plan members. The CON nurse practitioner faculty are given workload credit and are assigned to the CHAP to accomplish the comprehensive health risk assessments in the community using a home health care delivery model. Because the assessments are scheduled in the home they allow scheduling flexibility for the faculty allowing faculty members to work in the program part-time to accommodate faculty/teaching responsibilities. The part-time hours benefit the faculty by providing clinical practice hours required for APRN licensure. Most importantly the NP faculty mentor NP students and support Doctor of Nursing Practice (DNP) student projects.
CHAP Scheduling Efficiency
CHAP visits are scheduled for one hour with an additional hour allotted for completing the extensive documentation. The visits are clustered within a zip code to provide efficiency as the NPs travel from home to home.
Language translation services are provided by the UAHP through phone translation. If the faculty NP is fluent in the language of the member, they are matched for a visit. Various faculty NPs have demonstrated fluency in Spanish, German, and Russian languages. ASL translation services are also available with an ASL translator assigned to accompany the faculty NP to the home.
The CHA Documentation
The Office of Learning and Innovation Technology Innovations (LHTI) at the CON and CHAP developed an electronic documentation system to capture the elements of the member appointment. The data gathered to complete the CHA is entered into an electronic secured SQL database. The raw data is easily de-identified, stored, and is available for research activities.
CHA Data Elements
• Demographic data
• Health history
• Surgical history
• Listing of the member’s specialists
• Documentation of the member’s completion of advance health care directives
• Medications review
• Recent Emergency Department (ED) and hospital admission history
• Comprehensive social history
• Family history
• Screening Tools include the PHQ-4 to assess for depression and anxiety, the Timed Up and Go test that is a falls risk assessment, the CDC-HRQOL-4 Modified to assess quality of life, a Modified PAR to review physical activity, a MINI-COG to evaluate for changes in memory.
• Physical assessment data that includes a complete neurological examination
• Functional assessment of activities of daily living (ADL) and instrumental activities of daily living (IADL)
• Adaptive equipment used and needed
• Health maintenance: Screenings, tests, immunization review
• Chronic conditions: Screenings, tests, exams, medication review
• Case management referral options are reviewed
An Assessment is provided that outlines all diagnoses, problems, symptoms, and potential problems, for example: a high risk for falls. The assessment describes the current status of each problem, current meds used to treat the problem, and identification of further testing or assessment needed. Plans are formulated and specific follow-up is suggested.
A detailed Plan and Recommendations for the Primary Care Provider (PCP) are outlined and a copy of the entire CHA is sent to the PCP.
The Members
The health plan members are dual eligible for Medicare/Medicaid. This year the members range in age from 21 to 97 years. The majority (63%) are over 65 years of age and over half are female (57%).
Potential Savings to the Health Plan/Medicare
The nurse practitioners repeatedly refer members to case management in the health plan for assistance with care. Some examples of specific case management referrals are for members at risk of falls, members who need urgent home health care assistance, members who have severe depression. Within the home the NPs have helped members with the use of a Holter monitor, how to use DME, how to make their homes safe.
Members are educated on services available to them such as eye exams with optometry, dental services, transportation to care, and over the counter (OTC) medications.
There is no doubt that there are innumerable times that ED and hospital readmissions are averted by the timely accomplishment of the risk assessments by our faculty NPs.
Summary
The CHAP is providing excellence in assessment, caring, and collaboration with the UAHP to provide assessments that benefit: (a) the Medicare Advantage Plan members by way of a comprehensive health assessment visit at their home with knowledgeable faculty NPs, (b) the faculty NPs who have specific dedicated practice hours to fulfill the obligation of clinical practice hours for continued certification, (c) DNP students who are given the opportunity to have faculty NPs work with them one-on-one to tune up their assessment skills, as well as, increase their knowledge of complex care management of chronic disease, and (d) the UAHP by way of fulfilling their obligation to offer the risk assessment to their dual eligible members on an annual basis.
The UAHP is very pleased to have this collaborative care relationship within the University community. The CHAP and faculty NPs are given kudos by the UAHP leadership, case management, and members in the Medicare Advantage plan, for a job well done.
National Hartfold Center of Gerontological Nursing Excellence
National Hartfold Center of Gerontological Nursing Excellence
TUCSON, Ariz. – Two faculty members at the University of Arizona College of Nursing were selected for fellowship in the prestigious American Academy of Nursing (AAN), one of the highest honors in the nursing profession.
Dr. Jane Carrington, PhD, RN, associate professor and Kate Sheppard, PhD, RN, FNP, PMHNP-BC, FAANP, clinical associate professor, join the existing group of 16 AAN fellows at the UA College of Nursing.
Drs. Carrington and Sheppard join 173 national and international nurse leaders who were inducted as fellows Oct. 7 during the Academy’s annual meeting and conference in Washington, D.C. Chosen by top leaders in the field, selection criteria include evidence of significant contributions to nursing and health care and influence on health policies and the health and wellbeing of all.
Dr. Carrington is a 2008 graduate of the UA College of Nursing PhD program and she was inducted as a fellow of the Western Academy of Nurses in 2016. A nationally recognized expert in nursing informatics and health-care technology, Dr. Carrington is conducting a three-year study funded by the National Institutes of Health, National Institutes of Biomedical Imaging and Bioengineering, to increase patient safety by enhancing nurse-to-nurse communication. By sophisticated augmenting of the electronic health record, clinical data is analyzed and used to trigger alerts that herald an imminent or emerging serious clinical event linked to a higher risk of unexpected patient death. She and her team aim to improve nurses’ identification and reporting of clinical events to prevent adverse consequences and save lives.
As an educator, Dr. Carrington is known for her innovative teaching methods that include using Twitter assignments to engage her students and using game theory as the foundation for several of her online courses. A highly sought-after mentor, during the Western Institute of Nursing conference, Dr. Carrington has led symposiums with her PhD and DNP students that showcases their work focused on innovations to engage nurses, providers and patients in effective communication.
Dr. Sheppard has made significant, sustained contributions to the field by transforming nursing and Advanced Practice Registered Nurse (APRN) education programs, vastly improving rural emergency health-care access, and applying interventions directly into clinical practice. Furthering emergency health in rural Northeast California, she worked as a mobile intensive care nurse (MICN), family nurse practitioner and educator; developed regional educational programs for fire departments, pre-hospital providers and nurses; and taught all their didactic and clinical courses, including courses for first responders, paramedics and MICNs. She procured grants to purchase advanced life support equipment, including on ambulances. Her efforts moved patient care from basic stabilization to highly skilled care delivered by paramedics and MICNs.
Dr. Sheppard’s awards include Regional MICN of the Year, induction as a fellow of the American Association of Nurses Practitioners in 2011, and the Western Academy of Nurses in 2014. She is a multiple recipient of the Excellence in Graduate Teaching Award from the UA College of Nursing (2012 and 2014). As a psychiatric mental health nurse practitioner, Dr. Sheppard focuses her research on compassion fatigue among nurses, which according to available literature, affects 30 to 90 percent of nurses, depending on the specialty in which they practice. Compassion fatigue is evident when being a health-care provider creates more sadness, stress or exhaustion than satisfaction, and providers begin to forego their own self-care.
Through the support of an American Nurse Practitioner Foundation research grant and the UA College of Nursing Laurence B. Emmons Research Award, Dr. Sheppard has developed a program of compassion fatigue awareness and training, which has been integrated into the college’s Doctor of Nursing Practice (DNP) curriculum. In the program, clinicians learn about three key concepts: burnout, secondary traumatic stress and compassion satisfaction, and practice strategies for heightened self-awareness of physical and mental discomfort and reflection on key triggers. She has consulted for more than 25 state, national and international organizations intent on reducing compassion fatigue.
The American Academy of Nursing is comprised of more than 2,200 nurse leaders in education, management, practice, policy and research. With the addition of this newest class, the Academy fellows represent all 50 states, the District of Columbia and 24 countries.
Nursing Informatics Help Nurses Make the Best Decisions for Patient Outcomes
University of Arizona College of Nursing Associate Professor Dr. Sheila Gephart had an epiphany when she realized that unwieldy electronic health systems were impeding the quality of work for nurses on the job. In the midst of creating an international quality registry for babies born with low birthweight, she discovered that a large amount of patient data was slipping unused through the cracks. If the point of electronic health records is to provide quality outcomes for patients, she concluded, then there was clearly room for improvement to support clinical decision-making, especially for nurses.
Last year, Dr. Gephart and her co-author, Dr. Karen Dunn Lopez, published a paper in the Journal of the American Medical Informatics Association (JAMIA) that reported on the state of the science of clinical decision support (CDS) for hospital bedside nurses. Their conclusion contained mixed news: CDS that targets decisions made by bedside nurses improved the processes and effectiveness of care, but the number of nurse decision-making research studies lagged behind physician decision-making CDS studies of CDS, obscuring the evidence to show positive change in patient outcomes.
How do you define nursing informatics?
Nursing informatics lies at the intersection of information science, nursing science and cognitive science. One component of informatics is the study and use of clinical decision support systems. The purpose of CDS is to make it simple for people to have what they need at the time and place of decision-making to deliver the best possible patient care.
Sheila M Gephart , PhD, RN
Tell us about your clinical decision support study.
When I was in practice, I noticed gaps in how we were making decisions in the neonatal intensive care unit and I wanted to help clinicians by providing them better systematic and convenient information about the context of care and the factors that put a baby at risk to develop complications. CDS has been shown to improve the process and outcomes of care delivered by physicians but we need more studies that target the decisions that nurses make. For the paper published in JAMIA, we wanted to discover what the state of the science was for bedside nursing CDS.
Tell us more about CDS for nurses.
Simply put, CDS matches patient characteristics to best recommended care and delivers reminders, alerts or advisory messages to support nursing care that aligns best with expert recommendations. The best and most effective CDS is built on data that comes directly from the electronic health record. It generates context and communicates a recommendation through an alert. So instead of communicating ‘This patient has an early warning score of nine and it’s high-risk,’ the message would say, ‘This patient’s early warning score is nine and you should do this.’ Even better, the message would be delivered directly to the clinician or set of clinicians who can act on the information.
What are some of the decisions nurses make that this work would benefit?
Nurses make decisions all the time. They’re assessing how at-risk a patient is for a fall, to develop an adverse complication, or to develop sepsis. They’re deciding how to prevent a patient from getting a complication they shouldn’t. One critical decision nurses make is about monitoring and communicating signs of a patient getting worse. CDS is especially good at making the decision about care more systematic, expert-informed and consistent. It keeps nurses from missing the simple signs, which is important because their work environments can be very fragmented, interruptive and rapidly changing.
What makes your study particularly unique?
Nurses put more information into the electronic health record (HER) than anybody else in the hospital and their needs are the least well met. So far, nurses get very little value for what they put in. In some situations, it has not been designed or adapted to help them do their job easier or more efficiently. With our paper, we showed how little evaluation of nursing CDS is available and how underdeveloped it is to meet nurses’ decision-making and ultimately patients’ needs. The message we came away with is that there’s a huge need for people to study this, and to develop CDS that meets CDS design best practices.
What’s the future of this project?
We proposed some very specific recommendations about what needs to be done to help design better decision support that is aligned with people’s workflow. We recommend expansion of nursing CDS, to integrate it into workflow and to allow shared views of CDS delivered across the health-care team (e.g. nurses to be able to see what CDS was offered to the physician for their patient and how they responded to it). Dr. Dunn-Lopez and I are also both individually developing CDS that targets nurses.
How will the results of your study impact nursing education?
It brings more visibility to the decisions that nurses make and how they need technology to support them to add value to the EHR for them. I’ve taught the methods for systematic reviews to my students and conducted others since then. Systematic reviews are important to make sense of a body of research and to identify next steps. This helps both PhD and DNP nursing students. They need to be able to take in the whole breadth of what’s going on, find the gap, and decide what to do next.
How is this project helping to build better futures?
When we support nursing decisions, we help them to do their work better, which can keep a patient healthy or even save their life. This project showed that more decision support is needed in nursing, especially in the pediatric and maternal child settings, where my work fits. It highlights opportunities to improve the value of electronic health records for nursing. As nursing informatics and CDS develop, trends are pointing toward better integration of EHRs with decision support – making their structure more open. The future is bright for nursing informatics!
Third-year online Doctor of Nursing Practice (DNP) psychiatric mental health nurse practitioner student; from Southern California
Why did you decide to pursue a nursing degree?
As a child, I was a ward of the court. From early on, I witnessed the mistreatment of those suffering from mental illnesses. As I got older and worked my way out of that environment, I felt an intense drive to try to position myself to make a difference. After working for over a decade as a behavioral health technician, I realized I could do much more if I returned to school to obtain an RN. My many years of behavioral health experience afforded me the ability to move into management positions fairly quickly and executive leadership within just four years. I realized I needed to continue my education and worked on my BSN. However, I felt that as an RN, even in executive leadership, I was still limited in my ability to influence policy affecting patient outcomes. I decided that I could make an even greater impact if I returned to school for my DNP.
What drew you to the UA College of Nursing?
I wanted to earn my DNP at a prestigious institution. The UA College of Nursing has a reputation for excellence in both education and research. My wife is a triple alumna and a true Wildcat. We knew we wanted to stay in Tucson, so it was a great opportunity to become an official Wildcat.
What features of your program are you especially passionate about?
I enjoy the discussions with my peers and faculty and learn a great deal from them. However, my passion lies, as always, in the clinical setting. Hands-on hours in the clinic seeing patients have been the highlight of the program for me.
Share your favorite memory from your time at the CON.
In the Spring 2017 semester, I did a focused exam with Dr. Kate Sheppard, the outcome of which would dictate whether or not I could continue in the program. I was a bundle of nerves -- sweating, shaking, heart racing. As I moved through the "patient visit" and examination, what I had learned thus far and the guidance I had received just started to flow naturally. I scored 100% on the focused exam, and I correctly diagnosed pulmonary embolism. This was an ah-ha moment for me, that I was going to be able to succeed in this program and that I really could do this.
How do you intend to Build Better Futures?
Initially, I intend to Build Better Futures by working as a provider and helping people in underserved populations. After gathering some practice experience, I can see myself moving back into executive leadership to help create policy that is beneficial for patients and their families. I will also continue to advocate for the integrated healthcare model, including the mind, body and spirit.
