How do you make big changes when you lack major resources? It may be as simple as looking to your long-term ED nurses. At Mecosta County General Hospital, a 78-bed hospital in Big Rapids, MI, 10 nurses, each with five years of continuous experience in the ED, were invited to be part of a core group and attend a brainstorming meeting to solve chronic problems in the ED.
The goal was to boost morale by including the most experienced ED nurses in developing policies and standards, providing staff education, setting minimum practice standards, and decision making, says Kathleen M. Walter, RN, BSN, the ED’s clinical support nurse. All ED nurses were asked for suggestions to be addressed at monthly meetings. (See memorandum, below.)
"There is a new energy in the department with the core nurses assuming a greater leadership role," says Virginia R. Keusch, RN, clinical manager of the ED. "It’s amazing how creative and talented nurses are when given the chance to shine."
You have the potential to realize these significant benefits with a core team:
• There are zero vacancy rates. Before the core team was started, the ED had a 30% vacancy rate, says Keusch. "Currently, we have no open positions and no need for agency staff nurses," she says. Several ED nurses from other area hospitals have started working on a per-diem basis in hopes they will obtain a staff position, she reports. "Since nurses see that they can make a difference, we anticipate continued success with retention and recruitment," says Keusch. "Less-experienced nurses anticipate joining the core team."
• Staff members receive frequent inservices. "Our nurses were hungry for more inservices because our education budget was cut, and it’s difficult to send them for training," says Walter. To meet this need, the core nurses now give numerous inservices. They are held in two sessions so that all nurses can attend, including per diems, and an evaluation form completed afterward. (See Evaluation Form.) Topics include shock, thoracic trauma, thrombolytics, pediatric intravenous lines, and abuse, says Walter.
• ED managers have a resource to solve chronic problems. When a problem surfaces, ED nurse managers can take it to the core group, says Walter. "This gives a forum of people to help us share the responsibility for problem solving," she says. Recently, there was a problem with charting done by LPNs who were assigned to the ED. "The core group helped us come up with a decision," says Walter. "They are now being used pretty much the same way as health care technicians and won’t be assigned patients."
• Many ED processes have been improved. As a small rural ED, making major changes seemed impossible due to lack of resources, but the core group proved that assumption wrong, says Walter. "Simple and cheap solutions were found," she says. The core group found many quick fixes for chronic ED problems. Here are several:
— A dedicated triage nurse role was created. Previously, whichever nurse was free would do triage, but this system was problematic, says Walter. "After a while, nurses didn’t want to do triage because they were so busy taking care of patients," she says. "It got to be a real problem." A dedicated triage nurse is now utilized for four-hour blocks of time, she says. This nurse also keeps patients informed about delays, offers them ice or blankets, and performs tasks such as starting IVs, says Walter.
— The patient tracking board is used to assign tasks to health care technicians. Previously, nurses instructed the technicians continually, which was frustrating for all concerned, says Walter. Now, nurses write the jobs in blue marker on the patient assignment board, she explains. "They techs just look at the board, and it gives them direction without a nurse having to tell them what to do next," she explains. "This also gives the techs some more autonomy so they don’t feel bombarded."
—A call system was put in the charting area. A counter area was put in the utility room for nurse to do charting, but the charge nurse constantly had to come ask nurses to perform certain tasks, says Walter. "She was feeling pretty stressed," says Walter. A doorbell system was installed to alert nurses to come find out what is needed, she says. "It cost us about $20, and it solved our problem."
— The triage record sheet is placed on top of the patient’s chart. When Walter was doing quality improvement checks on charts, she noticed that there were abnormal findings noted at triage that weren’t being addressed. "Nurses weren’t looking at the triage form, which was buried underneath everything else," she says. The sheet was simply put right on top so nurses can’t miss it, she says. "I see it reflected on the charting that they are addressing abnormal vital signs that they were missing before," she says.
— A "communication book" is used. This is a notebook kept at the nurses’ station for staff to leave messages for each other, says Walter. "For example, somebody may write, We rearranged our trauma cart; go look at it,’" she explains. "Notes can be left by anybody who has anything to pass on. We are all responsible for reading it and initialing afterward."
For more information on the core team of ED nurses, contact:
• Virginia R. Keusch, RN, Critical Care Services Clinical Manager, Emergency and Cardiopulmonary Departments, Mecosta County General Hospital, 405 Winter Ave., Big Rapids, MI 49307. Telephone: (231) 796-8691, ext. 4381. Fax: (231) 592-4421. E-mail: email@example.com.
• Kathleen M. Walter, RN, BSN, Clinical Support Nurse, Emergency and Cardiopulmonary Departments, Mecosta County General Hospital, 405 Winter Ave., Big Rapids, MI 49307. Telephone: (231) 796-8691, ext. 4131. Fax: (231) 592-4421. E-mail: firstname.lastname@example.org.