Nursing Education and Nursing Services: Best Partners for Best Practice 2nd Annual Nursing Research & Evidence Based Practice Symposium Promoting Nursing’s Future: Building Bridges from Classrooms to Clinical Settings November 5-6, 2010 Lauren R. Goodloe, PhD, RN, NEA-BC, Director Medical and Geriatric Nursing VCU Health System & Assistant Dean for Clinical Operations VCU School of Nursing, Richmond, VA

Greetings from Richmond, Virginia and Virginia Commonwealth University Richmond is the capital of the Commonwealth of Virginia and the center of a metropolitan statistical area with more than 1.2 million residents. Virginia Commonwealth University is a public, urban research university, supported by the Commonwealth of Virginia to serve the people of the Commonwealth and the nation. With more than $225 million in annual research funding, VCU is ranked by the Carnegie Foundation as one of the nation's top research universities. . VCU is composed of two campuses: the 52.4-acre Medical College of Virginia (MCV) Campus, which includes VCU Medical Center (VCUMC), located near the financial, governmental and retail district in downtown Richmond; and the 88.2-acre Monroe Park Campus situated two miles to the west in the historic Fan District. The University takes its founding date of 1838 from the year in which the Medical College of Virginia (MCV) was created as the medical department of Hampden-Sydney College. MCV became independent from Hampden-Sydney in 1854 and state-affiliated in 1860.

VCU SON VCU SON Founded in 1893 VCU SON – Programs Traditional BS Accelerated BS RN-BS Traditional MS, Accelerated MS and RN-MS Adult Health Primary NP Adult Health Acute NP Adult Health CNS Psychiatric Mental Health NP/CNS Nursing Administration and Leadership Child Health NP Women’s Health NP Family NP Nursing Educator Clinical Nurse Leader Post-MS Certificate PhD BS-PhD

Nursing Education Building

VCU Health System VCU’s MCV Campus has the largest medical complex in the state and the only comprehensive health sciences center. The VCUHS is one of the most comprehensive teaching hospitals in the country. Ranked in the annual study, 100 Top Hospitals: Benchmarks for Success, which identifies U.S. hospitals that deliver the highest quality and most cost-efficient health care. VCUHS’s nursing services is designated as Magnet by the American Nurses Credentialing Center (ANCC). 779 Licensed Beds, Level One Trauma Center 2100 RNs, 94 LPNs, 261 Care Partners

Academic-Service Partnerships

Academic-Service Partnerships are not simply Hospital-School Affiliations

Academic-Service Partnerships There are as many possible ways to formulate academic-service partnerships as there are potential partners Partnerships are about trusting, open relationships and ongoing communication, joint planning and day to day operations Recognize what your individual strengths are and what you can do better as partners Beware of “Power Struggles”

Academic-Service Partnerships Many Models Academic Medical Center Models Hospital-Community Partners Models Blended Models

Work in Progress

Living Next Door to one another or within the same university does not a partnership make!

Story of One Partnership Model Early meetings and Discussions Start with a small very committed group of people Must include the Dean and CNO Must include people who will work through the details and day to day operations

Vision For The Partnership As formal structural partnership will create a synergy for continuous quality improvement in both the education and practice of nursing. Furthermore, it will advance an organizational model consistent with the underlying philosophy of operation of an academic Health Sciences Center as a component of a university.

Board Approved Positions Titles For The Partnership Nursing Services Primary – School of Nursing VP Patient Care services & CNO of VCU Health System (VCUHS) AND Associate Dean for Clinical Programs, SON Director of Medical and Geriatric Nursing AND Assistant Dean for Clinical Operations, SON Director of Education and Professional Development AND Assistant Dean of Continuing Education, SON Dean of VCU School of Nursing AND Executive Director for Academic Nursing, VCUHS Associate Dean for Academic Programs AND Director of Academic Nursing, VCUHS Associate Dean for Doctoral Program and Research AND Director of Clinical Research and Evidence based Practice, VCUHS

Create Preferred Futures

Nursing is: Knowledge Work

Nurses are not DOERS who happen to think But are THINKERS who also do

Outcomes of our Partnership The outcomes of our partnership have been many to include: Increase in number of staff serving as preceptors for students >350/yr Increase in number of VCU SON students hired by the VCUHS. 60% of all new grad hires are from VCU SON Joint Council Membership Development of Nursing Administration and Leadership Graduate Track Work Study Program Hospital Funded Faculty Positions Improved student, faculty and staff satisfaction

Outcomes of our Partnership The outcomes of our partnership have been many to include: State supported faculty salary increases Faculty, student and staff recruitment Creation of faculty practice affiliations Increase commitment of staff to student development AACN/UHC New Graduate Nurse Residency Program Joint Simulation Development Evidence Based Practice Internship and Scholars Program Nursing Camps

Outcomes of our Partnership The outcomes of our partnership have been many to include: Joint Capital Campaign for new School of Nursing Building Increase in the number of hospital staff enrolled in RN- BS, MS and PhD programs Creation of multiple internship programs Increase in the number of hospital staff serving in adjunct faculty positions Successful Magnet accreditation Successful NLNAC accreditation Joint Research

Outcomes of our Partnership STUDENTS

Summer Camps

OR Internship Program

Enrollment Data

Staff

Partnered Courses Undergrad Leadership and Management Practicum Course Nursing Admin and Leadership Graduate Track Senior Synthesis Curriculum Development EBP Course

Nursing Students as VCUHS Care Partners Spring, 2010 Of the 261 care partners 120 were VCU Nursing Students

Number of VCUHS Staff Enrolled in School at VCU SON

AACN/UHC Nurse Residents

Number of new Nurse UHC/AACN Residents 2006-2010 and Number who were VCU Graduates VCU SON Graduates 2006 60 43 2007 51 32 2008 77 69 2009 86 65 2010 94 75 Total 368 284

Hospital Staff in Adjunct Faculty Positions

VCUHS Staff Serving in Adjunct Faculty Positions at VCU SON Year Total Number of Adjunct Faculty VCUHS Staff Percent 2006 67 33 49% 2007 55 22 40% 2008 31 56% 2009 93 56 62%

Our Research and Evidence Based Practice Partnership Journey

Research and EBP Builds The Professional Practice Environment Fosters autonomy Promotes control over practice Promotes nurse/physician teamwork Reduces conflicts Appreciates diversity Values knowledge Acknowledges disciplinary knowledge Addresses effective communication Creates an environment that focuses on high quality, safe, effective, efficient, timely care Is concerned about patient and provider satisfaction Operationally links professional knowledge and improved quality care

Shared Beliefs - Nursing Research Builds Knowledge Tests and refines Knowledge Improves patient care Advances nursing science Provides evidence for nursing’s contribution to care outcomes Fosters opportunities for collaborative work with other disciplines

Creating a Joint Culture of Inquiry Integrating Research into goals, mission and strategic initiatives. Establishing performance expectations and evaluation of practice that include levels of evidence. Integrating concepts and models related to EBC in governance structures. Developing a research Infrastructure. Recognizing and rewarding the development and use of all evidence.

Nursing Research: Multiple Paths Performance Improvement Evidence –based Practice Research

Performance Improvement - Definition PI, or performance improvement, is a problem-solving system for achieving improvements in specific local problems based on local data and interventions developed for the specific clinical situation; “systematic, data-guided activities designed to bring about immediate improvement in healthcare delivery in particular settings.”

Performance/Quality Improvement At the Unit Level People working together to improve practice. Focus on improving practice performance, including changes in care delivery modalities ( team vs. primary nursing), systems supports (electronic record. Usually clinical projects that use research findings to improve care. Address a clinical problems (e.g. Pain management; use of catheters.

Evidence Based Practice Definition Evidence-based practice (EBP) is a problem-solving approach for applying relevant evidence to local problems, with interventions based on comprehensive review and synthesis of credible best evidence. The conscientious use/integration of the best research evidence with clinical expertise and patient preferences in nursing practice.

Levels of Evidence (Melynk and Fineout-Overholt, 2005) Level 1 : evidence from systematic review – meta analysis of all relevant control trials or evidence based practice guidelines based upon RCT’s. Level 2: evidence obtained from at least one well designed randomized clinical trial (RCT). Level 3 : Evidence obtained from well controlled clinical trials without randomization ( quasi experimental). Level 4: evidence from non experimental studies e.g. case control or cohort studies.

EBP Levels continued Level 5: Evidence from systematic reviews of descriptive /qualitative studies. Level 6: Evidence from single descriptive/ qualitative studies. Level 7: Evidence from opinion of authority or experts.

Research - Definition Research is a system for generating new knowledge based on systematic investigation that may extend beyond the local setting; outcomes may or may not be applied to the local setting. A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to general knowledge.

Nursing Research will … provide new opportunities for discovery and innovation which in the end will enhance the work environment, build new knowledge to improve care, increase the visibility of nursing's contributions to care and enhance high quality, safe, cost effective, timely outcomes for patients and their families.

Informative Process…Can Not have one without the other

VCUHS Nursing Inquiry Process Box E1 Finalize team membership and schedule conferences Box E2 Assess translation of evidence into practice setting Box E3 Create action plan and implement change Box E4 Evaluate outcome and/or impact Box E5 Report results to decision- makers Box E6 Adopt change and identify next steps If answer is yes, proceed to EBP Project. Box 5 Appraisal of literature Box 6 Adequate evidence? Box 2 Unit or department resource Box 1 Initial question Box 3 Assemble initial project team Box 4 Focus the question Box 7 Disseminate If answer is no, proceed to research project Box R1 Contact NRAC or NRF Box R2 Assign mentor Box R3 IRB proposal Box R4 Data collection Box R5 Data analysis Box R6 Impact and/or outcome

New Knowledge Facilitation Model Professional Development Programs IRB Nursing Research Advisory Council Nurse Clinicians Center for Clinical & Translational Research Advancement Program CNO/ Director/Nurse Manager Support VCU School of Nursing Partnership General Clinical Research Center Information Systems Support Library Systems Support Mentors Budget Director, Nursing Research/ Facilitator New Knowledge & Innovation

Evidence Based Practice Choose a Model: Johns Hopkins Model Puts some structure to your processes Provides guidance tools Allows for common language

EBP Facilitation Model EBP Education And Resources Nursing Research Advisory Council Clinical Guidance Documents EBP Internship & Scholars Program UHC Nurse Residency Program EBP Subcommittee of ELC Nurse Clinicians Professional Advancement CNO/ Director/Nurse Manager Support VCU School of Nursing Partnership Nursing Services & Divisional Practice Councils Information Systems Support Library Systems Support EBP Mentors EBP Budget Director, Facilitator Evidence Based Practice

VCUHS Nursing Inquiry Process: Fecal Management Practice In ICU Patients Future Steps Box 4 Focus the question: FMS primarily used to prevent skin breakdown. Need to determine if policy & procedure for FMS EBP and approp. to meet primary goal. Box 6 Adequate evidence? Box 7 Disseminate Box 1 Initial question: Analysis of patient experience with adverse outcome lead to question “What patient monitoring is required when a FMS is in place for a prolonged period of time?” Box 2 Unit/Department Resource: Staff involved in caring for the index patient brought the question forward to the Critical Care Professional Practice Council (CCPPC). Box E2 Assess translation of evidence into practice setting: Policy/procedure change process initiated. Three devices identified and trial recommended. Recommended creation of Skin Bundle for all ICU patients. Box E3 Create action plan and implement change: Changes to policy/procedure submitted and approved at hospital level. Device trial completed, product selection completed, staff training in process. Skin Bundle for ICU patients developed, approved by CCPPC, and implementation planned for April 2010. Box E4 Evaluate outcome and/or impact Will monitor patient outcomes once implementation complete. Box E1 Finalize team membership and schedule conferences: Representative from Materials Management department joined project team so that appropriate products could be reviewed. Box E5 Report results to decision makers. Box E6 Adopt change and identify next steps Box 5 Appraisal of literature: Reviewed existing policy, Manufacturer’s instructions for current devices, national standards, and literature search using PubMed Box 3 Assemble Initial Project Team: Representative from the Wound Care Team and a subgroup of CCPPC members formed initial project team. Manufacturer’s recommend that a digital rectal exam be performed prior to inserting the FMS. Digital rectal exam not part of current procedure. Literature supported need for EBP project.

Differentiate PI, EBP and Research for Your Organization

Differentiate PI, EBP and Research for Your Organization Local Examples at VCUMC ICUs: UTIs L&D: Foley Catheter Insertion Procedure MRICU: Evaluation of pain scales in the critically ill patient Problem solving system Focus- incidence of UTIs Analyze- Quarterly Patient Assessment & Chart data extraction Develop- standard of care Execute- rollout recommendations Comprehensive literature review including review of manufacturer’s guidelines regarding testing of foley balloon prior to insertion Comparison of validity and reliability of 6 different pain assessment scales in the adult sedated and ventilated population Required for regulatory standards? CMS standard- hospital acquired conditions are not billable Not a regulatory issue IRB review? Not required to go through IRB IRB review is not required for literature review Yes. IRB approval required for human subject research Data Generated from Data generated locally Data generated from critical appraisal of all literature reviewed (Lippincott, research articles, manufacturer’s guidelines) Ongoing data collection through conduct of original research Outcomes applied locally? Standardization of documentation, products & treatment resulted in a decreased incidence of hospital acquired UTIs Recommendations disseminated through Professional Practice Council and revision of hospital policy May be applied locally to MRICU and other VCUHS adult ICUs; may be disseminated internationally through publication

Integrate PI, EBP, Research Into Your Organizational Process, Practices and Evaluation Clinical Ladders Internships Student Experiences Evaluations Residency Programs Joint Staff/Faculty Research Support Staff in Doctoral Programs

Contributed to Clinical Ladder Advancement Domain 2: Assuring Quality Care (Evidence Based Practice and Research) Clin I Demonstrates an awareness of current unit based practice goals and nursing care guidelines/policies and procedures and incorporates these into practice. Identify that current best evidence is the basis for nursing care guidelines/policies and procedures. Seeks out and utilizes resources to help identify nursing practice issues, including those that require evidence-based evaluation/research. Clin II Validates nursing practice based on current best evidence. Asks clinical questions related to nursing care of patients and demonstrates ability to locate and obtain evidence to answer clinical questions. Shares the synthesis of current best evidence with peers and others. May participate in research activities.

Contributed to Clinical Ladder Advancement Domain 2: Assuring Quality Care (Evidence Based Practice and Research) Clin III Questions clinical practice at the unit and/or department level and incorporates the use of current best evidence, clinical judgment and patient values/preferences. Initiates steps towards problem resolution based on current best evidence; seeks collaborative relationships that can lead to effective research partnerships. Contributes to the revision and development of unit and/or department nursing care guidelines and/or policies and procedures based on current best practice. Consistently shares the synthesis of current best evidence at the unit and/or department level. Clin IV Acts as resource for and role models the use of evidence-based nursing practice. Contributes to or may facilitate other in revising and developing clinical practice and/or nursing care guidelines for specific patient populations using current best evidence. Evaluates unit or department-based clinical or administrative outcomes following implementation of evidence-based policies and procedures; disseminates findings as appropriate. May participate as a member of a research team involved in design and implementation of clinical studies.

Creation of Clinical Nurse V Level on The Clinical Ladder Keeping MS Prepared Nurses At The Bedside

Clinical Nurse V Criteria Years of practice – 5+ Certification status – Must be certified Education level: MS in Nursing Involvement in professional organization Focus on EBP Strong “leadership” roles Submit for publication of article/poster/podium presentation Affiliate faculty for VCU SON Add other things from our 1st meeting: not set in stone, need focus groups to determine….. MS in Nursing!!!!!! Adjunct faculty 63 63

EBP Internship and Fellows Program

EBP Internship and Fellows Program

Joint Faculty/Staff Research

Joint Faculty/Staff Research

VCU School of Nursing NIH funding and Ranking Year Funding Amount Ranking 1999 $25,305 84th 2000 $554,000 43rd 2001 $1,02,538 35th 2002 $1,573,511 26th 2003 $1,640,058 25th 2004 $2,701,993 14th 2005 $1,785,390 27st 2006 $2,006,125 21st 2007 $1,846,075 23rd 2008 $2,224,669 21st 2009 $2,506,742 Not yet available

Partnership Role in Accreditations for both the Hospital and SON

VCU School of Nursing and VCUHS Nursing Services The relationship between the School and Nursing Services was cited by the site visitors as the most significant strength of the application for Magnet status in 2006. The partnership is highlighted throughout the VCUHS 2010 Magnet Redesignation document.

Nursing Research Highlighted in VCUHS Magnet Document 2006 Submission – 10 Research Study Abstracts and 0 EBP projects Included in the document 2010 – Submission – 45 Research Study Abstracts and 50 EBP projects Included in the document

NLNAC 2009 Accreditation Partnership was sited as a significant strength of the VCU SON. Visitors met with the entire nursing leadership of the hospital. Dr. Goodloe assigned to the clinical site visitor.

Joint Capital Campaign for New School of Nursing Building

Nursing Education Building

West Hospital Potential “New Home”

School of Nursing Building Photo: Alain Jaramillo

Second Floor Lounge Photo: Alain Jaramillo

Virtual IV Room Given by MCV Hospital Auxiliary

State of the Science Classroom Photo: Alain Jaramillo

Simulation Development

Meti Man and Maggie

Recommendations – IOM Future of Nursing Report Academia and Service must partner if we are to be successful creating this preferred future.

IOM Future of Nursing Report Key Topic Areas 1)Improve nursing education. 2)Remove scope of practice barriers. 3)Foster interprofessional health care teams. 4)Make workforce planning more effective by developing better data collection and a more effective information infrastructure.

Key Topic #1: Improve Nursing Education To ensure the delivery of safe, patient-centered care across settings, an improved nursing education system is critical. To respond to these increasing demands, nurses must achieve higher levels of education and training. Education should include opportunities for seamless transition into higher degree programs

Key Topic #2: Scope of Practice The variability of scope-of-practice regulations across states may hinder nurse practitioners from giving care they were trained to provide and contributing to innovative health care delivery solutions. Although some states have regulations that allow nurse practitioners to see patients and prescribe medications without a physician’s supervision, for example, a majority of states do not. The federal government is well suited to promote reform of states’ scope-of-practice laws by sharing and incentivizing the adoption of best practices.

Key Topic #3: Foster Interprofessional Health Care Teams As leaders, nurses must: Act as full partners with other health care professionals Be accountable for their responsibility to deliver high-quality care Work collaboratively with leaders from other health professions Identify and propose solutions to problems Devise and implement plans for improvement Participate in health policy decision-making

Key Topic #4: Workforce Planning Nurses must plan for fundamental, wide-ranging changes in the education and deployment of the nursing workforce will require comprehensive data on the numbers and types of nurses currently available and required to meet future needs. Once an infrastructure for collecting and analyzing workforce data is in place, systematic assessment and projection of nursing workforce requirements will be needed to inform necessary changes in nursing practice and education. These programs should prioritize systematic monitoring of the supply of health care workers across profession, review of the data and methods needed to develop accurate predictions of future workforce needs

Summary Nurses are committed to delivering high-quality care under current regulatory, business, and organizational conditions. The power to change those conditions to deliver better care does not rest primarily with nurses. Responsibility also lies with governments, businesses, health care institutions, professional organizations and other health professionals, and the insurance industry.

Summary (continued) The committee’s recommendations are directed to policy makers; national, state, and local government leaders; payers; researchers; executives; and professionals, including nurses; licensing bodies; educational institutions, and philanthropic and advocacy organizations. Together, these groups have the power to transform the health care system to provide seamless, affordable, quality care that is accessible to all, patient centered, evidence based and leads to improved health outcomes

National Summit on Advancing Health through Nursing On November 30 and December 1, 2010, IOM and RWJF will begin the next important phase of this project, and begin to tackle the challenges of translating the report’s recommendations into action. The goal is to create a robust plan that will become a Foundation priority for 2011 and beyond. The summit will bring together diverse leaders from every sector to discuss the implications of the recommendations from the report. Participants at the Summit will be asked to work with appointed stakeholders to chart a course for successful implementation of these recommendations

Value of Partnership In Our Own Words

Partnership Quotes “My partnership with VCUHS and in particular, the critical care units has been crucial to the success of my program of research. From the beginning more than 20 years ago when we began asking specific clinical questions with unit clinicians about routine endotracheal suctioning practices to today when we are evaluating practices to improve outcomes for mechanically ventilated patients, our research-clinical partnership has been essential. This partnership allows us to stay grounded in important clinical questions, provides an unparalleled clinical environment and access to subjects, as well as nursing staff that is overwhelmingly supportive and enthusiastic about our research projects. The combination of research and clinical expertise supported by this partnership has resulted in significant changes in practice and improvements in patient outcomes.” – Mary Jo Grap, PhD, RN, ANP, FAAN, Nursing Alumni Endowed Professor, VCU School of Nursing

Partnership Quotes “Quite simply, I could not do the complex critical care research I have been federally funded for without the collaboration of the nurses and other providers at VCUHS. Over the years I have been at VCU, I have been astonished at the level of interaction between School of Nursing faculty and practicing nurses. I think the relationship is truly one of mutual respect, admiration and support of each other’s work and research interests (both academic and at the bedside).” – Cindy Munro, PhD, RN, FNP, FAAN, Nursing Alumni Endowed Professor, VCU School of Nursing

Partnership Quotes “The quality of our School of Nursing and the relationship that it has developed with the health system has changed my life and has allowed me to take advantage of opportunities in a way that I never thought possible. Doctoral education and research for me has always been a dream. The School of Nursing and the health system have worked together to offer scheduling and financial support to make my dream a reality. I have received a high-quality doctoral education, which has changed my ability to think, process information and work with data. I am working on my dissertation with a focus on nurse decision-making and patient safety. I hope in some small way my work will help give back to the school and the health system for all the things they have given me.” – Kathy Baker, PhD(c), RN, director of resource management, VCUHS, and adjunct faculty member, VCU School of Nursing

Partnership Quotes “The partnership allows me to develop staff professionally and help them see how far they have come. By involving them in the education of students, we are able to teach them how to mentor new professionals. in an environment that does not have the same risks associated with a new hire. The involvement of the VCU School of Nursing faculty members and students in our clinical environment helps to push clinical practice to the next level. They bring forward the current evidence and ask the questions that help us look at our practice and update it as needed. They also help keep staff from falling into the pattern of doing the same thing all the time, even if it is not working. By having to explain what they are doing and why to students, staff are kept grounded in research and evidence-based practice.” – Heather Craven, MS, RN, CMSN, nurse clinician, VCUHS, adjunct faculty member, VCU School of Nursing, and doctoral student, Medical University of South Carolina

Partnership Quotes “The School of Nursing faculty and students are direct beneficiaries of this partnership. Our faculty gain from the partnership as we work jointly to develop clinical expectations and learning experiences for our students from undergraduate through doctoral level. The participation of direct care nurses, nurse managers, nurse clinicians, nursing directors and advance practice nurses as classroom and clinical faculty members creates a dynamic exchange with full-time faculty that results in cutting-edge educational experiences for students while simultaneously grounding them for current practice. Furthermore, our doctoral program is enhanced by the presence of current clinicians as they engage as students in formal education to become scientists engaged in biobehavioral clinical research. Additionally, the partnership that creates the presence of students and faculty in the clinical setting, from the pre-licensure through the experienced nurse becoming a scientist, creates a dynamic that is a magnet for nurses to continue their formal education because it is simply a visible part of the culture of the organization rather than simply an administrative mandate. “One.” – Nancy Langston, PhD, RN, FAAN, dean and professor, VCU School of Nursing

All our dreams can come true – if we have the courage to pursue them – Walt Disney Contact Information: Lauren R. Goodloe, PhD, RN, NEA-BC, VCU Health System/VCU SON (804) 628-0027 lgoodloe@mcvh-vcu.edu