On January 25, IV Nurse Day celebrates the infusion nurses who complete the high-tech and exceedingly patient-sensitive process of infusion care.
The 2017 theme, “IV Nurses: Outstanding Skills. Outstanding Care.” gives acknowledgment to the specific skills IV nurses bring to a care team. Sponsored by the Infusion Nurses Society, this day has been an annual international event since 1980, says Mary Alexander, MA, RN, CRNI, CAE, FAAN, and chief executive officer of the society and of the Infusion Nurses Certification Corporation.
The IV Nurses Society has 7,000 members across the globe in more than 40 countries and territories outside the US. Approximately 3,500 of the members are certified as well. And they work in many settings—about half of infusion nurses work in hospitals and the other half work in alternate sites like infusion centers, physicians’ offices, or in home care settings.
“The care we provide is something all patients can relate to,” says Alexander. “Patients go into a hospital and almost everyone gets an IV.”
While IV certified nurses are not the only ones who can place an IV, the additional training gives the nurse the skills and the experience to do it well, she says. To place an IV properly, nurses must asses the patient, determine the appropriate device, and the proper management of care once the IV is in place.
As some patients can have an IV for a few short hours or in extraordinary circumstances for the rest of their lives, proper placement and care is paramount to patient comfort and safety, says Alexander. Infusion nurses are also then responsible for patient or caregiver education upon discharge. They need to convey accurate information about how to care for an IV and why it’s important for the patient to have it.
“It’s vitally important that clinicians are experienced and know what they are doing,” says Alexander. Because the lines bring solutions directly into a patient’s bloodstream, any complications can be life or death.
Patient safety is every nurse’s top concern, but infusion nurses also have a direct impact on patient satisfaction. Alexander says when patients are asked about their hospital stays, some surveys indicate the quality of food and the experience a patient had with an IV as the top influences of their overall satisfaction with the hospital.
IV Nurse Day recognizes all the work infusion nurses do, says Alexander. “We are all over the place,” she says, “You won’t find us in one specific place. We are an important part of the health care team when we are looking at the overall care of the patient.”
As part of the team, IV nurses can educate others on the team as well. Having an IV nurse on the team means the other team members are able to focus on their own tasks. Because of their experience, IV nurses save costs and labor because they generally get an IV placed correctly on the first attempt. That improves cost, reduces the risk of complications, and makes for a much happier patient.
If newer nurses are interested in this certification, Alexander strongly suggests getting some overall clinical experience prior to fulfilling the IV nurse certification process. And for nurses who are not yet certified, but interested, the Infusion Therapy Standards of Practice outlines some of the common guidelines for this specialty.
“The more you do it, the better at it you get,” says Alexander. “It’s good to recognize infusion nurses do a fabulous job and patients appreciate what we have to offer.”
Alexander notes that while some might expect IVs to eventually be replaced by a different process, she doesn’t see that happening in the very near future. And IV nurses also bring an extra component that’s hard to quantify. “To me, it’s high-touch, hands-on caring as well as high tech,” she says. “That’s extremely important.”
With nearly 30 million people nationwide living with diabetes nationwide, it’s no wonder that the disease is a national issue. But diabetes hits racial and ethnic minority populations especially hard, so it’s helpful to take the time to help your patients who might be more vulnerable to diabetes.
November is designated as National Diabetes Month – a great opportunity to remind patients with diabetes of the importance of self-care and consistent medical care. But it’s also an opportunity to speak with patients who don’t have the disease but are at a higher risk for it about prevention and being alert to any trouble.
Because it’s silent, many people don’t take the potential complications from diabetes seriously enough until it’s too late. Urging all patients to keep their blood sugar in check is essential, but according to the FDA, minority populations also need to know that their heritage can put them at an even greater risk of not only having diabetes, but also experiencing more severe complications and having worse outcomes.
According to CDC survey results, Hispanic or Latino adults and non-Hispanic or Latino black adults have a 13.9 and 13.8 percent of the population with diabetes compared to 6.6 percent for non-Hispanic or Latino white populations. With such a disparity, it’s clear that education and care are crucial to keeping diabetes symptoms in control.
As usual, discussions about healthy habits like eating well, exercising, getting enough sleep, stress management, and being monitored for any problems or complications can’t be neglected.
Easy enough, but every nurse knows that patients often hear what they want to hear. Or maybe they hear it, but their cultural expectations or beliefs, living situations, or other barriers interfere with what they need to do.
This month, take the extra time to dig deeper and find out what your patients might have getting in the way of good diabetes management or self care in general. Do they have access to fresh foods? Transportation to doctor’s appointments? A comfortable, quiet place to sleep? Are they experiencing any pain that’s keeping them from exercising?
By asking a few more questions, you might be able to uncover important information that can give you insight into your patients’ lives and can help you find solutions for them. You might not be able to fix everything, but if you can fix something, it can be an enormous help. And when a patient feels listened to, the trust you build is especially valuable.
In the medical community, the subject of mental health care services in the United States is one that appears to be receiving more and more attention with questions surrounding the appropriateness and level of care that is being provided to patients. More and more individuals are seeking out therapeutic interventions for mental health related issues, but disparities still exist with regards to effective treatment interventions.
For many patients, it may take years before a diagnosis is given, and after which there may be trials of pharmaceutical interventions before one is found that adequately manages their symptoms. Receiving immediate mental health care services not only has an impact on the individual but also on the families, caregivers, and guardians that are involved in their ongoing—and often times lifelong—care. Among the various health care professionals who can play a role in this mission to achieve a desirable therapeutic outcome, nurses continuously play a pivotal role in the proper identification and reduction in the time it takes for patients to receive proper treatment.
The impact of receiving optimal mental health care services can be observed in the functionality and quality of life of the individual. Furthermore, it demonstrates how nurses can be viewed as patient advocates working towards the promotion of mental health services. The outcome of mental health care services that is provided to any given patient is largely dependent on the actions that are taken by the health care professionals who should be aware of the hallmark signs and symptoms that may be associated with a specific psychiatric episode. For example, an individual may present to an emergency room complaining of difficulty sleeping, visual as well as auditory disturbances, and possible mood fluctuations. The presence of both a trained physician along with a psychiatric trained nurse can lead to the immediate identification of these symptoms, diagnosis of what these cluster of symptoms might indicate, and the initiation of an appropriate therapeutic intervention.
Given the time sensitive nature of the event, it is of the utmost importance for the physician as well as the nurse to be mindful of possible diagnoses, but also rule out those that would not be applicable to the patient case. Nurses are becoming trained in the area of psychiatry as a result of the increasing rates of diagnoses as well as the expansion of their scope of practice. This growth in nursing serves to improve the level of care that individuals who present with mental health related issues can receive at any given location.
Nursing students anticipate going into a nursing clinical where they can finally begin to take all their book knowledge and apply it in real situations. Sounds exciting and empowering, right?
Sure, but the thought of starting a first nursing clinical also terrifies a lot of nursing students.
So, what spikes anxiety about clinicals? Lots of students are afraid they don’t know enough to go into a nursing clinical and are afraid they will make a mistake. Truthfully, this is a wholly valid concern. You will now be treating people and that is vastly different from anything else you have ever done.
Acknowledge that fear, but work with it as well. Don’t let your fear and your anxiety fluster you, let it focus you. Prepare as best you can for your clinicals and identify your own weaknesses and your own strengths. Try to find ways (and ask for them as well) to make use of your strong points and to stabilize and improve any areas where you don’t feel as competent as you’d like to be.
When you start your clinicals, ask more experienced nurses for advice. You will likely hear them say constant reassessment and reflection is a big part of any nurse’s job. After each day, think about what went right and what went wrong. Figure out ways you can make anything you did a little better.
Get the lay of the land early and memorize it. Know who is in charge, where different patients go, what the general routine is, where the supplies are, and who to go to with questions.
Be the student who asks thoughtful questions. If you don’t know how to use a piece of equipment or you don’t know what to record, ask. And then listen to the answers and take notes so you don’t become the student who asks the same questions over and over. Ask and learn from it.
When you are in such a new situation, you are going to have to work harder to become better. Do some learning on the side – away from clinical and away from the classroom. Spend a few nights familiarizing yourself with the conditions you might see the most, the patient population that is prevalent in your clinical, or even medications and procedures you have seen. The more knowledge you have, the better you will be in your clinicals.
Develop a thick skin when you are in clinicals. Nursing is a fast-moving, stressful profession and if a nurse seems rude to you, she might not mean it personally, so don’t take it personally. Throughout your career, you’ll find not everyone is going to be helpful or nice. That just means you have to find a different way of getting your questions answered so your patient receives the best care possible. Don’t dwell on abruptness.
Remember the end goal is that you want to learn, but also remember it’s your patient who needs to be treated with the best care possible. With that focus in mind, you can stay on the right track to making the most of this first experience.
When a new kind of health care model burst onto the scene more than two decades ago promising techniques that gave better patient care, created less work for nurses and physicians, and saved organizations money, the reaction was decidedly lukewarm. The promises sounded great, but the origins of what we now know as lean production principles were based on factory work with cars, not the decidedly different work of caring for human beings.
Based on Toyota Motor Corporation’s streamlined production approach (coined the Toyota Production System), hospital workers found the idea of implementing manufacturing principles into a hospital setting jarring.
Building cars isn’t the same as caring for a complex human being, but the end goal is the same—a customer-driven, high-quality end result with as little waste of money and resources as possible. Lean proponents say each organization has to run efficiently and precisely because the satisfaction and safety of customers is the priority.
“One of the biggest hurdles is the recognition that lean isn’t a method for building cars, but for building a better management system and process improvement methodology,” says lean expert Mark Graban, author of The Executive Guide to Healthcare Kaizen: Leadership for a Continuously Learning and Improving Organization and author of LeanBlog.org.
“It’s an improvement of quality, better workplaces, reducing wait time and cost,” says Graban. “It seems like common sense, but health care organizations are complex.” Lean is not a Band-Aid fix for a larger problem. “Lean gets people engaged in fixing the end-to-end patient flow,” says Graban of the hospital-based lean practices. “For an emergency department visit, that is from the time someone calls 911 to the time they are sent home.”
How Does Lean Go from Cars to People?
Also known as “kaizen,” the process of lean is a customer-focused production process centered on constantly improving the start-to-finish (or end-to-end) flow of production. Whether it’s a patient or someone buying a car, consumer satisfaction with the end product is the goal.
“There’s lots of pressure on health care to reduce costs,” says Graban. But there’s always the worry that reducing costs results in substandard patient care and lost health care jobs.
Although lean has been around in health care since the Virginia Mason Medical Center in Seattle officially implemented lean programs in 2002, it is not industry-wide because, quite simply, it’s a lot of work.
Charleen Tachibana, RN, is senior vice president, chief nursing officer, and hospital administrator for Virginia Mason Medical Center, the first health care facility in the country to adopt lean practices and now one the leaders in training professionals in the lean process. In 2001, the organization began compiling a new strategic plan and investigating other effective management systems. When they could find nothing satisfactory in a health care setting, they turned to a totally different industry, car manufacturing, which had made news for its revolutionary process, to see if any of their industry practices could be applied to hospitals, says Tachibana.
After a year of investigation, Virginia Mason announced the changes to the staff’s uncertain reception. “The vast majority were in the middle,” Tachibana recalls. Wanting to take a wait-and-see approach, the staff was willing, but hesitant. “Part of the work wasn’t the tools and production methods, it was how do you handle change,” says Tachibana.
What Is Lean?
Sometimes, it’s just hard to understand something when you know nothing about it. Lean is simply an improvement method that aims to minimize waste and maximize value. Health care organizations like Virginia Mason and Beth Israel Deaconess Medical Center in Boston (where they implemented a “House of Lean” model) quickly realized the methods could transfer easily to a health care setting.
But lean isn’t about making everything faster with fewer people to do more work. Lean is about efficiency and quality, say proponents. For a health care consumer, that means a better health care experience in less time and with less waste. For nurses, lean means a more efficient work process, so they can get more done in less time so they have more time to spend with patients. And that’s where most nurses are happy with lean—they reconnect with patients and remember the very reason most of them got into health care in the first place.
Why Turn to Lean?
Alice Lee, vice president of business transformation at Beth Israel Deaconess Medical Center, first learned about lean principles when she was approached to look at the organization’s business processes with fresh eyes. While researching practices in other industries, Lee discovered lean principles appealed to her business sense. “Back then, lean got little to no attention,” says Lee. “People in health care were not thinking in the same ways as those in industry.”
After visiting manufacturing facilities, Lee says it soon became clear to her how the end-to-end flow approach suited a hospital. Applying the tactics to Beth Israel would lead to an environment that was less burdensome for nurses especially and that would understand and remedy those existing burdens.
“Lean is very, very, very customer-focused, “ says Graban. “But it also helps people in health care rediscover their sense of purpose. Lean as an approach is very respectful of people doing work.”
Tachibana says Virginia Mason had direct goals in mind. “Our goal was to get nurses in with patients and to increase patient time,” says Tachibana. “What is adding value in what we do and what is not adding value?” At Virginia Mason, the changes were incremental, so they were both easier to adopt and easier to adjust to. “We started on one floor or with one shift until we had it where we wanted it,” explains Tachibana. “Then you can think of ‘how do you spread this.’ There was a series of changes that fed to a higher goal.”
What Is Lean Like in Real Use?
What does a lean process look like? At Virginia Mason, lean means a Patient Safety Alert System allows any employee to “stop the line,” or make a report and cease any activity, if they ever see something that is likely to harm a patient. In another organization, IV trays were cluttered with several tools that were never used. By redesigning and streamlining the trays, staff found them easier and faster to use.
At Virginia Mason, Tachibana says staff-designed changes made for a better process and invested the staff in the outcomes. They were given a week at what’s called a Rapid Process Improvement Workshop, to redesign a process. Once implemented, improvements were measured at regular intervals. Moving some essential supplies to patient rooms gave nurses more time with patients. Changing a sign-off procedure to be in the patient’s room with the patient’s input not only reduced hand-off times by two-thirds, but also engaged the patient and the family in a way that was immensely more satisfying to them.
When an organization adapts to lean models, innovation is encouraged, but it’s also standardized. So while another organization might welcome innovation and suggestions, staff don’t always have the resources or authority to implement the suggestions or track follow-up with measurements.
“The production system provides structure and methods,” says Tachibana. “It has an interesting impact in that it liberates the culture. People can get more innovative.”
So while some improvement processes might focus on one problem, lean principles discover how to provide the right support and resources every step of the way. And while some might say lean only aims to treat more patients in the same amount of time and thereby creates more work and more pressure, Graban says the opposite is true. Instead of working harder, he says, lean principles encourage working smarter.
Alexandra Zaremba, RN, manager of the short-stay surgical unit at Virginia Mason, and Rowena Ponischil, RN, MSN, director of the cardiac telemetry unit at Virginia Mason, have both seen the transition to lean over the past decade.
“This took a lot of growing pains, and it didn’t happen overnight,” says Ponischil.
But the changes made the nurses feel supported by the leadership, says Zaremba. “It gave a voice to the nursing staff,” she says. “And then they felt empowered and supported.”
Eventually, Zaremba noticed something different when new charting procedures required her to do the chart in the patient’s room, not at the end of her shift. “I was interacting more with patients,” she says. “I was talking to them and meeting them on an emotional level.”
Chikodiri Gibson, RN, MSN, MBA, DNPs, APN, CNS (Adult Acute Care), and senior associate director of behavioral health at HHC Kings County Hospital in New York, says even the most minor change can reap huge benefits. Having never experienced lean models before coming to Kings County Hospital, Gibson says the ideas were new to her, but the process of identifying a problem and understanding the real root causes made sense to her.
Gibson recalls one change that involved rearranging the nurses’ stations. Nurses couldn’t find what they needed and patients were being delayed when they were ready to leave the hospital because it took so much time to find anything, she says. “We started one unit at a time, and everything is labeled and nice and clean and neat,” she explains. “Nurses are happier, patients are happier, and now nurses have more time to spend with patients,” says Gibson. “We moved it to every unit now, and no matter what nurses’ station you go to in the hospital, it all looks the same and you can find what you need.”
Involving More than Managers
No matter how great a project is, the magic of implementing lean is creating a culture where everyone in the organization makes a change. Engaging everybody, even patients, to fix the smaller problems not only highlights problems that might have been overlooked, but also makes everyone involved and invested in its outcome.
“Whenever we do design work of process, space, or roles, we bring patients in to participate on the design team, and they always teach us something,” says Lee. “This has really been a wonderful way to convey to patients that we are trying to make this better.”
Ponischil agrees. “We want to create a product that is good for the patient, not what we think is good for the patient,” she says.
John Toussaint, CEO of ThedaCare Center for Healthcare Value and author of On the Mend: Revolutionizing Healthcare to Save Lives and Transform the Industry and Potent Medicine: The Collaborative Cure for Healthcare, recalls the overhaul brought about by one patient’s letter. An obstetric patent wrote Toussaint a critical letter about her bad experience giving birth at the facility. Toussaint, who agreed that a poor information flow was at the root of the problem, invited the woman to a week-long improvement event to see what changes a team of staff, physicians, patients, and nurses could make to the process that encompasses the time from a baby’s birth to the time he or she visits the doctor for the first visit.
“Our process involved 140 steps, and we reduced it to 70 steps,” says Toussaint. “We ran experiments to see if the doctor would get all the information needed, and we were 100% reliable every time. We started at 40% reliable. It was a dramatic improvement.” The diverse group, some of whom were cynical about lean methods, were focused around one thing and that created a better experience for the patient, says Toussaint.
Giving the reasons for change also helps. “You have to get that down to an individual person who asks, ‘Why should I change,’” says Tachibana. “The greatest gift of this is that people are engaged in improving their own work. They know what works and what doesn’t.”
“It’s not uncommon for a department to provide 25% more care without adding equipment or people,” Graban says. “You can take care of more patients in a shorter time without shortchanging the care. Patients are happier, but they are safer, too.”
That could mean redesigned space that allows fewer steps or fewer trips to get equipment or even paperwork that is designed to reduce duplication and enhance accuracy.
Convincing People to Go Lean Is Tough
Why do people resist lean? In busy hospitals and health care organizations, learning something new eats up time that no one has to give. Even nurses in the thick of the lean process say the work can seem counter-intuitive. When you have done something one way for so long, it is a struggle to change.
Talk of being more efficient inevitably leads to concerns of reducing staff. “People do get nervous,” says Graban. “Sadly, the traditional way hospitals cut costs is by laying off people. Lean is one of the best alternatives to layoffs.”
How Do You Keep Lean Going?
Lean doesn’t work without commitment and dedication to a long-reaching goal. Because hospital staff changes frequently, organizations are constantly acclimating new people to the lean culture. “When CEOs and managers behave in this style, it reinforces that ‘this is the way we do things here,’” says Graban. “It has to be reinforced in a lot of ways that this is the new normal.”
Beth Israel’s hiring approach begins right from the first encounter, such as an online assessment, and Lee says that is what makes lean challenging. “How do we hire people with the mindset of those who are able to work in a lean environment?” she asks. “We have 2,000 new people come in every year. That means we have 2,000 opportunities to get it right or get it wrong.”
A Lean Future?
What is the future of lean? Graban points out that with any manufacturing process, change happens in fits and starts over the course of decades, not months.
An initial wave of interest spurs others to dabble in the process, says Graban, and of that group, some will embrace it and others will give up on it. When an organization has success, other groups will take a fresh look at the process and learn from the deeper understanding the other organizations gained from experience.
Lee doesn’t pretend that lean is simplistic or quick.
“We are 10 years in,” says Lee. “This work is hard, and initially there is a lot of resistance. It’s uncommon to find a hospital not doing something with lean now. Who is going to stay the course? And who will stay the course when the course gets tough? It takes daily perseverance.”
Lee says keeping an eye to the future and on the end goal helps staff persevere as the health care climate evolves and changes with time. “This takes a constancy of purpose,” says Lee. “You have to believe there is no option but to improve the current condition. If you don’t, you resort back to chaos.”
When lean practices become part of the new culture, Graban says the results are tangible and intangible. “I think the most exciting things are the moments when you see pride on the people in the health care field,” says Graban. “To see them get re-energized about the work they are doing and why they got into health care.”
Zaremba says the changes have made her unit tight. “It’s the teamwork approach,” she says. “We are responsible for each other, and we have the spirit of one team.”
And Toussaint says the measurable results are inevitable if you follow lean principles correctly. “If you do it right, three things will happen,” he explains. “Staff morale improves, quality of care process improves, and costs go down. People recognize that this is a way to fix the system.”
Julia Quinn-Szcesuil is a freelance writer based in Bolton, Massachusetts.
