Nursing Opportunities

1. 1 Nursing Opportunities The Sky is the Limit! Class # 152 -Welcome to Class # 152, Nursing Opportunities, the Sky’s the Limit. During the next hour or so, we hope to share ideas with you regarding the ever-expanding role of nurses, and will highlight the ways in which Information Technology has impacted nursing practice. -Welcome to Class # 152, Nursing Opportunities, the Sky’s the Limit. During the next hour or so, we hope to share ideas with you regarding the ever-expanding role of nurses, and will highlight the ways in which Information Technology has impacted nursing practice.

2. 2 HOUSE KEEPING Welcome This is a 1.5 hour class Please silence your cell phones and pagers. If you must answer a call, please leave the room. Thank you. Before we get started we need to take care of some Housekeeping issues. This is a 90 minute class. Please take time to turn off your cell phones, or set them to vibrate. If you must take a call, please leave the room to answer. Before we get started we need to take care of some Housekeeping issues. This is a 90 minute class. Please take time to turn off your cell phones, or set them to vibrate. If you must take a call, please leave the room to answer.

3. 3 Please, Hold your questions during the presentation. Questions written on the 3X5 cards provided will be answered at the conclusion of the presentation. For all questions, the question and the answer will be available on the web. If you have any questions please write them on the 3X5 card provided. Answers to your questions will be posted on the VEHU website. So please check the website when you return home.If you have any questions please write them on the 3X5 card provided. Answers to your questions will be posted on the VEHU website. So please check the website when you return home.

4. Nursing OpportunitiesThe Sky is the Limit! Course # 152 Now, let’s move on. Now, let’s move on.

5. 5 Objectives -To explore what the future can hold within the nursing profession. -To chronicle the shift occurring in nursing that is linked to the explosion of the computerized patient record system. -To examine nursing practice, education, and new executive leadership roles against the backdrop of a massive infusion of information technology.

6. 6 Introductions Nancy H. Prewitt, B.S.N., R.N.C., C.N.A. Nurse Manager, Primary Care Lexington, Kentucky VAMC Cynthia L. Andrus, MSN, RN BCMA / Nursing ADPAC Houston, Texas VAMC Jawel Lemons, RN, MS, FNP-C Associate Director, Patient Care Services Augusta, Georgia VAMC Presenting today are…Presenting today are…

7. 7 Have you seen any changes in the Nursing Profession lately? -What changes in process or practice have you observed during the last 10 years? -What new roles have emerged which have ties to Informatics? -What are the pros and cons? -In the next 20 minutes or so we will take a look at the impact of computerization upon the nursing profession, and the expanded roles that are constantly emerging which are related to informatics. -What changes in process or practice have you observed in the past few years? (Give example of shaking down glass thermometers and cleaning them with disinfectant solutions between patients versus fast and accurate electronic temperature measurement with disposable systems. Just one small example.) -What new roles have emerged which have ties to informatics? -What are the pros and cons of computerization? -When we think back on our careers, we recognize many changes in the way our work is performed, and many of those changes are related to the electronic age. -Some of these changes are very positive, others may not seem quite as positive. -Long story, short, some of us have been pulled kicking and screaming into the computer age, but we’re here, and we wear many hats, as nurses have always performed multiple jobs and fulfilled many varied roles. -Computerization of processes has led to additional opportunities for nurses as they are intricately involved in nearly every patient care process, and their roles often mesh very nicely. -It has also led to automated mechanisms for data gathering, thereby improving efforts to increase productivity, efficiency and outcomes. Unfortunately, we sometimes get lost in the massive volumes of data that are easily retrievable, and can’t see the forest for the trees.-In the next 20 minutes or so we will take a look at the impact of computerization upon the nursing profession, and the expanded roles that are constantly emerging which are related to informatics. -What changes in process or practice have you observed in the past few years? (Give example of shaking down glass thermometers and cleaning them with disinfectant solutions between patients versus fast and accurate electronic temperature measurement with disposable systems. Just one small example.) -What new roles have emerged which have ties to informatics? -What are the pros and cons of computerization? -When we think back on our careers, we recognize many changes in the way our work is performed, and many of those changes are related to the electronic age. -Some of these changes are very positive, others may not seem quite as positive. -Long story, short, some of us have been pulled kicking and screaming into the computer age, but we’re here, and we wear many hats, as nurses have always performed multiple jobs and fulfilled many varied roles. -Computerization of processes has led to additional opportunities for nurses as they are intricately involved in nearly every patient care process, and their roles often mesh very nicely. -It has also led to automated mechanisms for data gathering, thereby improving efforts to increase productivity, efficiency and outcomes. Unfortunately, we sometimes get lost in the massive volumes of data that are easily retrievable, and can’t see the forest for the trees.

8. 8 Traditional Roles Changing -Home Health / Extended Care -Improved Referral Process -Improved Processing of Physicians’ Orders -Reduced Processing Time -There are many traditional roles within nursing which now have incorporated information technology to improve efficiency, productivity and ultimately patient outcomes. -Here are a few examples. Our Community Health staff perceived a great need to improve the referral process for home health services. Referrals were already being submitted by electronic consult, but the processing time remained outside of expected timeframes. The consult templates were re-organized and streamlined for ease of use by the sender, while making it simpler for the community staff as well. Significant improvements were made in the reduction of processing time from receipt of the referral to initial assessment within the veteran’s home. Additionally, more useful information was documented on the revised consult templates, which led to the implementation of more appropriate referrals and use of resources. -A second benefit of the electronic record for the home health staff has been their processing of Physicians’ orders. Previously, hard copy home health orders were hand-carried to each Provider within the Medical Center for concurrence and signature. Once the Provider uncovered the orders in piles of paperwork, they sign them, and place them back in a central location or pick up by the Community Nursing Staff and mail out to the particular Home Health Agencies. -A process improvement team developed a new process for handling these orders electronically, within CPRS, and implemented it with great success. The electronic process reduced the average number of days required to complete home health order verification from nearly 3 weeks to about 3 work days. -There are many traditional roles within nursing which now have incorporated information technology to improve efficiency, productivity and ultimately patient outcomes. -Here are a few examples. Our Community Health staff perceived a great need to improve the referral process for home health services. Referrals were already being submitted by electronic consult, but the processing time remained outside of expected timeframes. The consult templates were re-organized and streamlined for ease of use by the sender, while making it simpler for the community staff as well. Significant improvements were made in the reduction of processing time from receipt of the referral to initial assessment within the veteran’s home. Additionally, more useful information was documented on the revised consult templates, which led to the implementation of more appropriate referrals and use of resources. -A second benefit of the electronic record for the home health staff has been their processing of Physicians’ orders. Previously, hard copy home health orders were hand-carried to each Provider within the Medical Center for concurrence and signature. Once the Provider uncovered the orders in piles of paperwork, they sign them, and place them back in a central location or pick up by the Community Nursing Staff and mail out to the particular Home Health Agencies. -A process improvement team developed a new process for handling these orders electronically, within CPRS, and implemented it with great success. The electronic process reduced the average number of days required to complete home health order verification from nearly 3 weeks to about 3 work days.

9. 9 Home Based Primary Care (HBPC) -Dialogue Box Templates -Improved Documentation -Improved Efficiency -Another example of changes related to information technology relates to our HBPC Program. Prior to full implementation of the electronic medical record, HBPC Staff traveled to care for patients in their homes, then returned to the hospital at the end of the day to document the care delivered. -As improvements in both hardware and software became available, the HBPC Staff began experimenting with remote methods of documentation as well as improved electronic templates to reduce their time spent away from direct patient care. -As as result, they have been able to reduce their average documentation time by 30 minutes per patient per day. They have accomplished this through the use of laptops with remote access in the home, and have worked with Information Technology Department to implement point and click, dialogue box templates for repetitive processes such as Initial Nursing Assessments. -The reduction in the time required for documentation has further led to their ability to manage a larger panel of patients. -Another example of changes related to information technology relates to our HBPC Program. Prior to full implementation of the electronic medical record, HBPC Staff traveled to care for patients in their homes, then returned to the hospital at the end of the day to document the care delivered. -As improvements in both hardware and software became available, the HBPC Staff began experimenting with remote methods of documentation as well as improved electronic templates to reduce their time spent away from direct patient care. -As as result, they have been able to reduce their average documentation time by 30 minutes per patient per day. They have accomplished this through the use of laptops with remote access in the home, and have worked with Information Technology Department to implement point and click, dialogue box templates for repetitive processes such as Initial Nursing Assessments. -The reduction in the time required for documentation has further led to their ability to manage a larger panel of patients.

10. 10 Discharge Planner -Interdisciplinary Notes -Collaborative Care Note -Day of Discharge Note -Reduced Discharge Errors / Omissions -With the rapid turn over of inpatients in hospitals, it has become necessary to implement Discharge Planners in many settings. The computerized medical record system (CPRS) has made it possible for the Interdisciplinary Team Members to communicate appropriately via the medical record. -Examples of some of the templates utilized for this purpose are: Interdisciplinary Note Collaborative Care Notes Day of Discharge Note -The improved communication amongst staff along with the built in checks and balances of an electronic medical record have led to a reduction in discharge errors and omissions. -With the rapid turn over of inpatients in hospitals, it has become necessary to implement Discharge Planners in many settings. The computerized medical record system (CPRS) has made it possible for the Interdisciplinary Team Members to communicate appropriately via the medical record. -Examples of some of the templates utilized for this purpose are: Interdisciplinary Note Collaborative Care Notes Day of Discharge Note -The improved communication amongst staff along with the built in checks and balances of an electronic medical record have led to a reduction in discharge errors and omissions.

11. 11 Diverse / Expanded Roles -Clinical Applications Coordinator -BCMA Coordinator -Informatics Nurse -Computer ADPAC -Here are some examples of fairly common roles which nurses have participated in developing and implementing. Nurses are flexible and highly adaptable, not to mention intelligent and creative. Their knowledge base can be applied to almost any problem, setting or situation. -Our next presenter, Cynthia, will delve further into these opportunities. -Here are some examples of fairly common roles which nurses have participated in developing and implementing. Nurses are flexible and highly adaptable, not to mention intelligent and creative. Their knowledge base can be applied to almost any problem, setting or situation. -Our next presenter, Cynthia, will delve further into these opportunities.

12. 12 More Expanded Roles -Decision Support System (DSS) -Safety Officer -NSQIP surgical data and trending -Med-model Consultant -Performance Monitor / Measure Expert -Home Tele Health (Health Buddy) -Nurses have also successfully moved into roles which are not traditionally nurse roles, but are enhanced by the clinical knowledge and decision making skills that nurses possess. -Expand on the examples above. -Nurses have also successfully moved into roles which are not traditionally nurse roles, but are enhanced by the clinical knowledge and decision making skills that nurses possess. -Expand on the examples above.

13. 13 Even More Expanded Roles -Patient Advocate -Admissions Coordinator -Utilization Management -Process Improvement Coordinator -Expand on these roles as well. -Expand on these roles as well.

14. 14 And Even More Expanded Roles -Case Management Manage smaller numbers of patient intensively -Care Management Manage, large number of patients across the continuum -Telephone Care / Triage Automatic Call Distributor Triage Software -Discuss these roles moving into the forefront of patient care particularly in the Outpatient Setting. -We are becoming more skilled at caring for patients at a distance rather than as traditionally, face to face. -Many services can be provided by way of telephone, computer, telemedicine, etc. -Expand on these roles. -Discuss these roles moving into the forefront of patient care particularly in the Outpatient Setting. -We are becoming more skilled at caring for patients at a distance rather than as traditionally, face to face. -Many services can be provided by way of telephone, computer, telemedicine, etc. -Expand on these roles.

15. 15 Changes in Delivery of Care -Continued Shift from Inpatient to Outpatient -Community Based Outreach Clinics (CBOC) -Staff Education and Training -Group Clinics -Access, Access, Access -As hospitals moved toward improving utilization of their resources and reducing hospital bed days, the flood-gates opened for Outpatient Services. Traditional nursing roles quickly adapted to the change, and led the way. Nurses are flexible and adaptable, you know! -Later, the focus within our system moved closer to the patient through Community Based Outreach Clinics. Computerization has made this transition possible by creating clinics which operate exactly like those within the home facility. When working in a CBOC, it’s just like being in the “mother ship”. -Additionally, education and training for staff can be accomplished through the use of computerized independent study programs. Staff meetings, committee meetings and other conferencing is done via video teleconference. Even better, patients can receive specialty consults via telemedicine. -Computerization of the medical record has also paved the way for the increased utilization of group clinics. By the creation of templates for documentation of repetitive data, groups of patients can be assessed, evaluated, educated within a group setting. -This practice then improves provider productivity and creates improved access for patients. As we all know, access has been a very hot topic within our system of late. -As hospitals moved toward improving utilization of their resources and reducing hospital bed days, the flood-gates opened for Outpatient Services. Traditional nursing roles quickly adapted to the change, and led the way. Nurses are flexible and adaptable, you know! -Later, the focus within our system moved closer to the patient through Community Based Outreach Clinics. Computerization has made this transition possible by creating clinics which operate exactly like those within the home facility. When working in a CBOC, it’s just like being in the “mother ship”. -Additionally, education and training for staff can be accomplished through the use of computerized independent study programs. Staff meetings, committee meetings and other conferencing is done via video teleconference. Even better, patients can receive specialty consults via telemedicine. -Computerization of the medical record has also paved the way for the increased utilization of group clinics. By the creation of templates for documentation of repetitive data, groups of patients can be assessed, evaluated, educated within a group setting. -This practice then improves provider productivity and creates improved access for patients. As we all know, access has been a very hot topic within our system of late.

16. 16 For Those Who Served My Health e Vet For Staff and Patients Disease Management Diaries and Logs Prescriptions Lab Results Health Information -Yet another electronic avenue for both patients and staff is My Health e Vet. The possibilities for patients and staff are many. -Expand on key points above, and also mention possibility of patients e-mailing questions to Providers and Nurses via this avenue. -Yet another electronic avenue for both patients and staff is My Health e Vet. The possibilities for patients and staff are many. -Expand on key points above, and also mention possibility of patients e-mailing questions to Providers and Nurses via this avenue.

17. 17 One VA -Standardization / Expectations -No Veteran Left Behind -Remote Data -Cross-country Committees / Task Forces -Networking / Knowledge Sharing -Computer technology has assisted us in providing improved and more consistent care throughout the VA System, and helps us to meet our Mission and to serve our veterans as One VA. -Expand on key points above. -Computer technology has assisted us in providing improved and more consistent care throughout the VA System, and helps us to meet our Mission and to serve our veterans as One VA. -Expand on key points above.

18. 18 Summary The sky really is the limit. See what needs to be done, what processes need improvement, and create a niche. Have fun, and be careful out there. -So we’ve talked about a number of expanded roles for nurses, and have seen how they have evolved over time along with improved computerization. -As you can see, the sky really is the limit. When nurses see a need, they often just step in, problem-solve, go to work, and fix it! -There are many opportunities to advance and expand your practice, whether you wish to move into Leadership or stay at the bedside. You do not need to go into Leadership to advance. There are opportunities open to staff at all levels and in all fields of practice. -I am a Year 2000 graduate of the VISN 9 Leadership Development Institute. I choose to continue to deliver direct patient care while managing a work unit. It’s the best of both worlds, I get to dabble in the two fields that I love. -If you are a nurse in these days and times, you deal with informatics on a daily basis. Another example of the influence and impact of informatics is VANOD. Through this database, trends and practices are tracked in regard to skin, falls, hours per patient day, nurse injuries, patient satisfaction and nurse satisfaction. -So let’s get out there and see what needs to be done, and create a niche for yourself. -Now let’s move on. Cynthia Andrus is going to give us a different perspective of the expanding roles of nurses as well as their relationship to Information Technology. -So we’ve talked about a number of expanded roles for nurses, and have seen how they have evolved over time along with improved computerization. -As you can see, the sky really is the limit. When nurses see a need, they often just step in, problem-solve, go to work, and fix it! -There are many opportunities to advance and expand your practice, whether you wish to move into Leadership or stay at the bedside. You do not need to go into Leadership to advance. There are opportunities open to staff at all levels and in all fields of practice. -I am a Year 2000 graduate of the VISN 9 Leadership Development Institute. I choose to continue to deliver direct patient care while managing a work unit. It’s the best of both worlds, I get to dabble in the two fields that I love. -If you are a nurse in these days and times, you deal with informatics on a daily basis. Another example of the influence and impact of informatics is VANOD. Through this database, trends and practices are tracked in regard to skin, falls, hours per patient day, nurse injuries, patient satisfaction and nurse satisfaction. -So let’s get out there and see what needs to be done, and create a niche for yourself. -Now let’s move on. Cynthia Andrus is going to give us a different perspective of the expanding roles of nurses as well as their relationship to Information Technology.

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21. 21 My Journey 1981- 1989 Enter the VA System Student Nurse/Health Tech Staff Nurse Clinic Nurse Entered Graduate School 1989 -1993 Private Sector Clinical Coordinator Nursing Supervisor Associate Director 1993 - Re-entered the VA System

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23. 23 I Returned Home! Nurse Manager for the Social Learning Program Nurse Manager for the Social Learning Program and Day Treatment Nurse Manager for the Psychosocial Rehabilitation Program with a Collaborative Role as the Acting Associate Nurse Executive for Mental Health Care Line Nurse Manager with a Collaborative Role as the Senior Nurse Consultant for Mental Health Care Line

24. 24 While at Home 2002 Adjunct Clinical Instructor, Adult Mental Health, The University of Texas- Houston School of Nursing Role of the Nurse Manager for the Psychosocial Rehabilitation Program expanded to 5 other Mental Health Outpatient Programs: Substance Dependency Program Post Traumatic Stress Disorder Program Comprehensive Mental Health Program Homeless Veterans Program Gero-Psychiatry Program Psychosocial Rehabilitation Program

25. 25 Opportunity Knocks 2004 Leadership Development Institute (LDI) Graduate Co-Chair Goal Share Project 2004 128 Teams and 1022 Employees Participated Co-Chair Combined Federal Campaign (CFC) 2006 At the End of the Campaign ( October 2006 to January 2007) Total Collection $294,196.11

26. 26 A Shift In Practice Bar Code Medication Administration (BCMA) Coordinator

27. 27 Nursing Practice Nurse Manager’s Computer Skills are developing at rapid speed and becoming Proficient Graduate Nurses are Computer Competent Staff Nurses embracing Computer Tools to monitor and Deliver Patient Care

28. 28 Bedside Technology…..How Do We Use It In Nursing? Patient Safety Medication Administration Clinical Documentation Patient Information Clinical Templates Patient Education Online Educational Material

29. 29 Embarking on New Territory Learning a different culture Learning to speak the Lingo Learning the BCMA Software Learning The Team Players and their Roles

30. 30 Blending Roles Become A Member of the BCMA Multidisciplinary Committee Become Visible to Staff and Senior Leadership Become an active Listener

31. 31 Leadership Remains The Same BCMA Coordinator function as a Middle Manager Cohesive Multidisciplinary Team Developing Working Relationship with Staff (End-Users)

32. 32 AN Opportunity To Advance My Practice Technology and Patient Care Technology and Nursing Practice Technology and Senior Leadership

33. 33 Nursing Informatics A Collaborative Role Advance Practice Supporting Mainframe Applications Developing Databases Maintaining Desktops Applications

34. 34 Technology and Patient Care Hand-Off Communication Interdisciplinary Treatment Planning Electronic Medical Records

35. 35 Technology and Nursing Practice Bar Code Medication Administration (BCMA) Patient Safety (5 Rights) Point-Of-Care Data Driven PRN Effectiveness 4. Improving Performance

36. 36 Technology And Senior Leadership Staff Performance Early/Late Product Evaluation Equipment Purchases

37. 37 Opportunities, Opportunities, Opportunities!

38. 38 References Sensmeier, Joyce, RN, BC, CPHIMS, FHIMSS, Survey Says: Care, communication Enhance by IT, www.nursingmanagement.com., October 2006. Troester, Sandra, RN,MS, Drive Nursing Activities to the Bedside with a Closed-Loop System, www.nursingmanagement.com., December 2006 Wilholt, Kathryn, RN,CNAA, FACHE, How Does Technology Drive Safety? Travel To A Patient-Centered Culture, www.nursingmanagement.com., October 2006 Wimms, Teresa, RN, and Oblak, Marlene, Nursing Informatics http://cms.clevelandclinic.org

39. 39 Leadership in Nursing Jawel Lemons, RN, MS, FNP-C Associate Director, Patient Care Services Augusta, Georgia VAMC

40. 40 HISTORY Started my medical career in the US Army as a medic Selected to attend a 1-year LVN program while in the Army Upon discharge enrolled in RN Diploma Program Obtained BSN Obtained MS, FNP-C

41. 41 HISTORY Staff Nurse in ICU Visiting Nurse IV Team with certification Nurse Manager of Telemetry Specialized in Cardiology as APN Developed and Coordinated Heart Failure Clinic Associate Chief Nurse Medicine/Surgery ECF participant (Executive Career Field)

42. 42 LEADERSHIP OPPORTUNITIES IN NURSING! ECF (PROGRAM) – Executive Career Field a. A national program to prepare health care leaders. b. A very competitive program. c. A 2-year commitment. b. Entry is based on how well one can articulate written and orally the 8 Core Competencies.

43. 43 LEADERSHIP OPPORTUNITIES IN NURSING! Eight Core Competencies Interpersonal Effectiveness Customer Service Systems Thinking Flexibility/Adaptability Creative Thinking Organizational Stewardship Personal Mastery Technical

44. 44 LEADERSHIP OPPORTUNITIES IN NURSING! Performance based interview questions for each category and there are 4 levels of questions. Level I – staff nurse Level II – Nurse Manager Level III – Associate Chief Nurse Level IV – Executive Level (Medical Center Director etc.) Website www.pbi.com

45. 45 LEADERSHIP OPPORTUNITIES IN NURSING! Each core competency is defined with a listing of sample questions under each Level. SAMPLE COMPETENCY A. Systems Thinking – The ability to understand the pieces as a whole and appreciate the consequences of actions on other parts of the system.

46. 46 LEADERSHIP OPPORTUNITIES IN NURSING! Interviewing Tips Be prepared Practice your answers prior to the interview. Use a process that clearly identifies the problem or issue, describe the plan and interventions and state the outcome in measurable terms. Be concise but thorough.

47. 47 LEADERSHIP OPPORTUNITIES IN NURSING! SAMPLE QUESTION: Describe a change you are responsible for that improved the performance of your work area or organization. 1. How did: 1) you come up with the idea for the change, 2) you go about implementing the change, 3) staff respond to the change, and 4) you measure the outcome of the change?

48. 48 LEADERSHIP OPPORTUNITIES IN NURSING! ANSWER: 1. Performance measure CHF 2. Required by the VA to comply and measure. 3. Pulled all disciplines that impacted the completion of this measure, nurses, physicians, pharmacist, clerks etc. 4. Weekly kudos and posting of increase in compliance.

49. 49 NURSING OPPORTUNITIES & CPRS Nurses create templates to facilitate documentation. Nurses create templates to capture performance measure information Nurses create templates to document patient education.

50. 50 NURSING OPPORTUNITIES! Create Patient Education Materials using Computer Technology Find a Topic – Example: Low-literacy!

51. 51 CREATING PATIENT EDUCATION MATERIALS! What time is this medication supposed to be taken?

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53. 53 CREATING PATIENT EDUCATION MATERIALS!

54. 54 PUBLICATIONS Utilize the VA library to get started publishing your article. The library has excellent resources. Published an article on low-literacy, the symbols just shared with you. Magazines are constantly looking for articles on various subjects. Take a chance, take a risk, try it.

55. 55 SUMMARY There are multiple opportunities to expand one’s career in the VA system. Every nurse has the opportunity to be creative and successful. Utilize the computer resources in the VA system for your growth and development of patient care initiatives.

56. 56 Questions -Now it’s time for your Questions -Ask away!