MADIGAN ARMY MEDICAL CENTER, Joint Base Lewis-McChord, Wash. – Excellence Conference served to reinforce these strengths in the nursing community at Madigan Army Medical Center on Joint Base Lewis-McChord, Wash., on March 25.
Nurses of all specialties and levels participated virtually to see presentations and interact with a slate of subject matter experts on topics of concern to the field.
Interspersed were drawings for raffles and polls of what attendees would like to see in future conferences with subjects like, “Should the conference be in-person, virtual or hybrid?” and “What topics would you like to see addressed in future conference presentations?”
In its in-person iterations in the past, the conference has included large and small group activities as well as a luncheon. The virtual platform pared it down to its presentations but was able to retain a good degree of interaction between presenters and participants.
Bringing the conference together offers a learning opportunity for nurses who are newer to the field, like 1st Lt. Lauren Dexter, who is a clinical staff nurse and one of the organizers of this year’s event.
“This experience taught me the importance of creating deadlines, backwards planning, and communication. From the planning, to fundraising, to coordinating with all of our presenters, and trying to find the best way to provide an interesting and engaging virtual learning opportunity, it was absolutely a learning experience,” said Dexter. “I am very grateful we had mentors in the CNSCI office to help us out, Jessica Rea and CPT [Danielle] Garcia. This experience taught me the importance of creating deadlines, backwards planning, and communication.”
Rea, a member of the Center for Nursing Science and Clinical Inquiry or CNSCI team, and Garcia, a clinical nurse specialist, also helped plan the conference, as did 1st Lt. Briana Inestroza.
The role of bias in healthcare inequities
It was Inestroza who recruited one of the speakers who joined the conference remotely – Dr. Susan Swayze, and associate professor at The George Washington University in Washington, D.C.
For example, “Stating that there is no history – that difference, even though subtle, can change the way a patient is viewed,” said Swayze.
Dexter gleaned exactly that point from Swayze’s presentation – that the understated and subconscious can impact care.
“We all have our own implicit bias and sometimes unknowingly, these biases can affect how we interact with our patients. The most important thing is try to identify these biases and work to implement strategies to reduce them so that we can provide the best possible care for our patients,” Dexter noted. “No one is immune to bias, even those in healthcare.
“Nurse turnover rates can average about 20%, costing hospitals an average of 6.5 million dollars every year. Now, 20% may not seem like a lot, but 6.5 million certainly is a large chunk of the budget,” said Lt. Col. Tanekkia Taylor-Clark, Ph.D. “The consequences of nurse turnover are not just monetary. But also have been associated with adverse patient outcomes like increased fall and staff outcomes such as burnout.”
Taylor-Clark offered information from a study that has looked at this issue. It framed its analysis around three aspects: the structure of an organization, with heavy focus on military hospitals; the process, which highlights the nursing work environment; and the outcome, including the intent to leave the current position.
In this study, 40 percent of respondents indicated they intended to leave their jobs in the next 3 to 12 months.
The top two preventable reasons – one that management could potentially resolve with their action – were dissatisfied with management and dissatisfied with nursing work environment. The top two non-preventable reasons were permanent change of station (military move) and pursuit of further education.
Within her presentation, Taylor-Clark queried the conference participants using the polling function of the virtual platform. The first asked what they thought was the most commonly reported reason for nurses to leave their job, of three options – workload, management or time and scheduling. A healthy majority – 59 percent – said management.
This answer was in line with one of the major takeaways from the study as it found that nurse managers play a significant role in the job satisfaction of the nursing staff. It also offered some solutions.
“Actions recommended for leaders to take in an attempt to avert turnover include improving nurse manager competency and performance through formal training, mentorship and coaching,” noted Taylor-Clark.
She also pointed out that Madigan’s research team is looking into current leadership and manager training options for nurses to better prepare them for these roles.
“Are we ensuring that our staff nurses are properly trained, or formally, for management and leadership before we put them into these positions? I bet a lot of you would say no,” commented Taylor-Clark.
She became impassioned when she spoke of the need for intervention to address the reasons nurses are leaving.
“We need to re-engage our nurses. The military has a saying – check your battle buddy. It’s time to check our battle buddy and be intentional about it,” she stated.
From her office at Womack Army Medical Center on Fort Bragg, N.C., she engaged in additional interaction with the attendees as they discussed barriers and their potential solutions for enacting interventions.
As the lead sexual assault medical forensic examiner at Madigan, Christine Picart, R.N., B.S.N., has years of experience with trauma-informed care.
Through experience performing forensic exams on individuals on base looking for treatment and care following a sexual assault and specialized training and study in this work, she has become a subject matter expert in the ways trauma affects both mind and body. She completes her exams by implementing a keen awareness of these impacts and ways to respond to them.
Picart’s presentation defined trauma and some of its impacts, then delved into the neurobiology involved to include the hormonal response, effect on memory and the visible responses seen from a patient such as irrational thought, emotional flatness or freezing or immobility.
Effective trauma-informed care rests on four R’s because it: realizes the impact of trauma; recognizes the signs and symptoms; responds by integrating this care into both policy and procedures; and it resists re-traumatizing the patient.
Picart stressed that a trauma-informed care approach relies on a strong foundation of safety. Both the patient and the provider rendering care must feel that they are safe and have a voice in the treatment that will be heard.
It is important to understand two aspects of an exam that occurs after an assault.
One is that the term forensic means that it is conducted in such a manner as to gain viable evidence to potentially prosecute a crime. While a nurse performing any sort of procedure on a patient would normally don personal protective equipment, a nurse doing this type of exam must use a kit that is approved by the state for this type of crime. Most people call it a rape kit. It has multiple sets of equipment such as gloves and extensive and specific requirements for its use that must be followed precisely in order to obtain evidence that is not contaminated and that is accurately documented.
The second is that the same nurse may well perform this exam on both victim and assailant. While a person accused of sexual assault may refuse to submit to such an exam much of the time, when they do allow it, it is vital that the examiner be well-trained in many of the same principles, especially those regarding the proper collection of potential evidence.
Part of the work of those providing this care is to work with multiple people who may be involved. As Picart offers medical services to someone following an assault, she must collaborate and coordinate with law enforcement, legal representatives and advocacy and support services. Despite the interests of all these elements, the focus should always be centered on the patient.
Picart described aspects of the exam, covering sample collection, consent, chain of custody, the tools involved and some of the process.
An exam is a lengthy, thorough and physically and emotionally taxing experience for both patient and provider. Understanding some of the impacts of trauma makes this care more approachable and effective.
Tools to drive change
Col. Pauline Swiger, Ph.D., the chief of Center for Nursing Science & Clinical Inquiry, offered insights into understanding the microsystem analysis and the use of run charts.
“What we’re looking at when we talk about the microsystem is that really acute area that is one of the lowest denominators that you can split up the hospital and say, this is one intact system that I can take to look at and then consider how it interacts with the rest of the system altogether,” she said.
Swiger’s presentation saw some good interactivity from the attendees as she asked the audience a lot of questions about their own microsystems, which are small functional pieces of the larger organization, and expounded on the replies.
For example, she asked if the information/data they need is readily available or if they have to go find it. Many responded they are doing chart reviews, which means they have to find it.
She led them through the five P’s that a microsystem analysis should address – purpose, patients, processes, professionals and performance patterns.
This type of analysis gives an overview of these elements and identifies both areas to improve and best practices to continue. It fosters innovation and can conserve effort as a team may be attempting to fix a problem that is assumed to be wider spread than it is, for example.
An analysis involves digging into all sorts of data collected to show how a system is functioning. For instance, when looking at patients, evaluating the top three diagnoses can give an idea of where the challenges are for them specifically and how the system is addressing those over time.
Collecting and looking at the actual numbers can clarify things. A run chart is a good way to visualize data over time.
The discussion at the end of Swiger’s presentation included what support there is at Madigan for data collection and analysis, like Clinical Informatics.
Wellness and resilience
Mary McCarthy, Ph.D., a senior nurse scientist in the CNSCI, shared current information on simple strategies to support personal wellness and resilience.
“Consider physical activity as a vital sign,” encouraged McCarthy, summing up some of the research that indicates that the capability of physical activity to reduce mortality risk is profound.
She queried the audience as to what they thought the number of steps per day an individual must get to cross the threshold into significant impact on health.
She revealed that a 10-year study to see the mortality and incidence of disease in relation to physical activity found that individual achieving greater than 7000 steps per day had a 50 to 70 percent lower mortality than those doing less.
“You nurses out on the floor, you are probably easily getting 7000 steps per day. But, do you know that? Are you tracking your own activity? Your awareness of your own activity will help maintain your consistency,” encouraged McCarthy.
She also pointed to a tool at Madigan that may not be widely known for tracking steps – a trails map that shows how many steps our own pathways provide.
In addressing some of the symptoms of possible chronic conditions and the power of movement to improve them, she stated, “In every case of elevated blood pressure, my first recommendation would be to get more physical activity. Get a few more steps or moderate to vigorous activity and that right there will likely help decrease those levels.”
McCarthy also spoke about vitamin D, which she has studied extensively for a number of years, saying it is crucial and the majority of Americans do not get enough of it. The vitamin has impacts on many aspects of health and wellness, including immune system support.
Concluding that no one element would single-handedly sustain health or help manage weight, she said, “It’s going to take this combination of appropriate diet, physical activity and sleep to have a significant impact on wellness and resilience.”
Impact in any setting
With over 100 virtual participants, the conference was well attended. Though it is a general hope that the conference can return to its typical in-person delivery next year, organizers and attendees alike found it a worthy endeavor this year too.
“I would say most people enjoyed the conference and still got to engage with our presenters and ask questions even though it was done virtually. I think this year by including topics like bias in healthcare, identifying potentially preventable reasons nurses intend to leave a job, and strategies to support personal wellness and resilience we focused slightly less on the clinical aspect of nursing and more on the potential obstacles we face as nurses and how we can better ourselves so that our patients receive the best care that we can provide,” Dexter confirmed.
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