Children’s Hospital of Los Angeles
Team: Cardiothoracic Intensive Care Unit
Entry submitted by: Nida Oriza, BSN, RN, and Victoria Winter, MSN, RN, CNS, CCRN, clinical nurse IV
Our defining moment came 10 years ago in 2005. Our 15 bed unit averaged 1200 surgeries a year and was confronted with a number of challenges: staff turnover rate was at 30%; we had 46% satisfaction on NDNQI scores; and the unit’s morale was low.
The nursing leaders and management collaborated with front line nurses at the bedside to address these problems. The principles of AACN Healthy Work Environment (HWE) were utilized as a guide to transform the unit. The nursing staff and management team worked together to transform the unit into a HWE one component at a time. We started by looking within ourselves. We all took the Meyers Brigg Inventory to learn about our own unique values and character. This assisted in providing a common framework and starting point as unit issues was discussed. We hold each other accountable for our own actions, attitudes, and behavior.
We identified the need for a Mission Statement to guide us to achieve excellence among ourselves with the end goal of providing the best care to our patients and their families. After several town hall meetings, small group discussions, and multiple revisions we are proud as a team to define our statement as: We are thoughtful and compassionate advocates for children and their families through patient care, education, and research in an innovative, professional, and emotionally supportive environment.
We realized that as nurses, to make our optimal contributions for our patients we have to take responsibility and accountability to establish and sustain a healthy work environment. We looked to AACN’s HWE initiative to implement those principles in our unit. The principles are: skilled communication; true collaboration; effective decision making; appropriate staffing; meaningful recognition; and authentic leadership.
Effective skilled communication is key to developing a culture of patient safety. Team communication breakdowns contribute to sentinel events. Disruptive and intimidating behaviors endanger patients; contribute to higher costs, and drives turnover among healthcare professionals.
We utilize different strategies for team building. These include
Weekly rounding for outcomes that initiates discussion between staff and unit leaders regarding patient safety issues and staff dis-satisfiers
Brief unit huddle prior to shift to aid in throughput and patient follow-up
Creation of a unit share drive accessible by all staff where information that affect patient care, as well as their work environment are posted and frequently updated;
Open door policy wherein the office doors of the managers remain open during office hours to encourage staff to communicate any concerns in a timely manner and work on resolution
The unit leadership model also requires strong communication and true collaboration between nursing and physicians. To ensure this relationship, the following systems are in place. On a daily basis in the multidisciplinary team rounds, the presentation for each patient is done by the bedside nurse. During the nurse led rounds the plan of care and goals for the day are discussed. At the end of rounds, the nurse reports back the goals for the day to ensure no miscommunication among the team. Formalized handoff reports occur when the nurse is going on break and when the patient is transferred to another unit using the SBARQ format. We collaborate with anesthesia team utilizing a hand-off communication tool for sign out which facilitated more effective transition of care.
Performance Improvement Committee is multidisciplinary. Discussions include patient events, such as medication errors, HAIs, codes, and deaths. Root cause analysis of a problem is discussed and information is utilized for system improvements. Staff driven projects are identified and carried out in collaboration with other disciplines. Accountability for improved outcome is shared, education needs identified and programs are developed to prevent such events.
Effective decision making ensures that nurses are valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. The nursing staff has opportunities to influence decisions that affect the quality of patient care. The leadership of the unit consists of nurses performing both formal and informal leadership roles.
The unit made a deliberate effort to provide leadership development and training. A workshop known as “The Road to Leadership” was developed and sustained by informal nursing leaders to identify and train bedside staff nurses to advance to roles such as: charge nurse; resource nurse; and advancement nurse.
Accountability of leaders in critical care settings is crucial. Bedside nurses are empowered to develop clear requirements, expectations, and guidelines for leadership roles in the unit. The unit established a shared governance model that flows from the collaborative governance structure of the hospital. This model assures that all staff members are represented in patient focused decision making process.
The unit cares for the highest average acuity patients. Our staffing practices are designed to meet the needs of patients and families, address the needs of the nursing workforce and promote the health and well-being of everyone involved. Guidelines are based upon:
Changing conditions of patient acuity / severity of illness or patient needs
Nurse skills, training and experience
Availability of support staff,
Physical layout of the unit
The staffing guidelines are based on AACN Staffing Blueprint: Constructing Your Solutions and Synergy Model. The unit also adapted the RN Safe Staffing Act (S.58/ H.R. 876) introduced in Congress. The charge nurse determines the amount of nursing support for the oncoming shift and makes the assignment prioritizing patient safety, consistency of care, and clinical and professional growth.
Recognition of the value and meaningfulness of one’s contribution to the organization’s work is a fundamental human need and essential and an essential requisite to personal and professional development. It’s an ongoing process and must become a norm within the work culture. Our unit has been very active in creating an environment that rewards and recognizes outstanding behavior and contribution to sustain a HWE.
Our goal is for nurses to be recognized for their professionalism, expertise, and unique contribution they bring to the team. Ten years later, we have achieved: < 10% turnover rate; fully staffed unit; 90% BSN; and a Healthy Work Environment.