This is the fourth installment of our series chronicling the experiences of two nurses in University of Colorado Hospital’s Graduate Nurse Residency Program (GNRP). Maggie O’Connor, RN, with the Transplant Unit, and Sarah Doble, RN, with the Surgical/Trauma ICU. are part of a cohort of 50 resident nurses who began in February 2015.
O’Connor and Doble are now in the homestretch of their one-year residencies, and that means getting down to work on their evidence-based projects, which they and their colleagues will present at their completion ceremonies in March. The projects give the new grads experience in researching medical literature, but the goal is to relate the information they glean to the real world of clinical practice, said Mandy Moorer, RN, coordinator for the GNRP.
“The goal is to create a project that is related to the patient populations that staff nurses would find of interest,” Moorer said.
We caught up with O’Connor and Doble in early December during a break in a four-hour research session for new grads.
Ten months into their residency programs, new-grad nurses Maggie O’Connor and Sarah Doble continue to hone their bedside skills. There is still plenty to learn there – O’Connor admits there are days she’s frustrated by discovering new gaps in her nursing knowledge – and now they have a fresh challenge: developing and completing required evidence-based projects that they will present to their colleagues and nursing leadership at their completion ceremonies March 10.
The work is demanding. It requires selecting a topic that applies to patient care on their units, conducting research on it, analyzing the results of the work, and finally developing a poster presentation or leading a journal club that outlines and explains the research process and summarizes the importance of their findings. All the while, O’Connor, Doble, and the more than 40 other nurses in their cohort hold down their regular nursing shifts.
It’s a challenge, but the program puts no nurse on an island. They work in teams – O’Connor has one partner; Doble has three – and are free to consult with nurse managers and educators, research nurse scientists, and others who can provide insight and guidance.
Filling a blank page
One of the big questions is familiar to anyone who has written a term paper: What’s my topic?
“It was hard to come up with ideas,” said O’Connor. “The unit is always changing and improving, and other nurses have more experience.”
She and her colleague got input from the Unit-Based Council for Transplant and from Clinical Nurse Educator Heather Kunselman, RN. They decided to address the effectiveness of a tool used to assess the acuity of patients admitted to the unit.
The tool, an 8-by-10 piece of paper with “tiny writing,” O’Connor said, helps charge nurses assign staff. The acuity of each patient is ranked from 3 (least) to 6 (most severe), based on measures such as pain, medications, mobility, presence of drains, need for special equipment, and so on. The findings help guide decisions on allocating resources. A nurse assigned a very sick patient might care for three patients instead of the usual four, for example.
In theory, if the assessments are accurate, the unit works more efficiently, with better workflow. That, in turn, reduces the risk of nurse frustration and burnout, and allows managers to produce a more accurate budget, O’Connor said. Her project will look at how consistently nurses actually use the tool and if they aren’t using it, the reasons why. She and her colleague plan on gathering that information with a staff survey.
“Depending on the answers, we might redo the tool or re-educate staff,” O’Connor said.
Delving into delirium
Doble and her team are taking on the subject of delirium, a condition characterized by sudden and severe confusion and disorientation that results from rapid changes in the brain. It is measured using the Confusion Assessment Method (CAM), which includes specific criteria, such as acute memory impairment and sleep disruptions.
“It lets us know if patients are speaking logically and are oriented to themselves and the situation,” Doble said.
But sometimes providers report they are unable to assess patients with the CAM, and Doble and her team will focus on finding out why. They will retrieve the information from medical chart audits and look for reasons – if any – for the notation “unable to assess.”
“We were casting around for a topic,” Doble said. “It was something I’ve noticed, and others mentioned it.”
She sees it as a complicated and important question. Sometimes it’s not possible to assess patients for delirium – they might be heavily sedated, for example. But if they can be assessed, it’s vital to do so, Doble said. Left untreated, delirium can cause cognitive changes in patients and lead to dangerous behaviors, such as pulling out IVs or becoming verbally and physically combative.
“It’s difficult to rationalize with a person who is not capable of rational thought,” Doble said. “It’s a situation that is rough for everybody, especially family members, because they can’t actively participate in the patient getting better.”
Providers can help mitigate delirium by opening blinds during the day and closing them at night to encourage a natural circadian rhythm, Doble said. Getting patients moving also can help. But taking those measures depends on a quick assessment.
“It boils down to cutting it off at the pass with the CAM and steering patients away from that path,” she said.
The project work that Doble, O’Connor and their fellow grads complete is an important stepping-stone in their professional development, said Mandy Moorer, RN, coordinator of the GNRP.
“The work could channel later to quality improvement,” Moorer said. “They are learning what it’s like to apply something they have learned to develop a change in patient care. They’re getting a taste of taking a project and making it a reality in nursing practice.”
O’Connor admits the project heaps another helping of work and responsibility on an already crowded plate that includes not only regular nursing duties but also a steady flow of new things to learn, from reconfigured Alaris pumps to the recently launched Beaker laboratory electronic record system. But she appreciates the practical goals of the research.
“I like learning something new, but especially because it ties back to helping to make the day on the unit flow better,” she said. “It’s an added bonus that the evidence we find could prove helpful and implement changes on the unit.”
Doble said she finds research satisfying as an end in itself – “I’m one of those people who wants to know things” – and as a way to test her own beliefs and those of others.
“The project is a nice way to look at multiple studies and compare population sizes, why the studies were done, and what was the true focus,” she said. “Even in a landmark study, you have to remember that the findings are guidelines; they are not saying what will actually happen. There are still external circumstances, like bias. It’s not like baking.”