Resident Orientation to the NICU: Improving Nurse and resident communication

1. Resident Orientation to the NICU: Improving Nurse and resident communication Heidi Thompson, MSN, RN Monique Landor, MSN, RNC-NIC, IBCLC

2. Objectives • Discuss the effectiveness of communication between interdisciplinary team members related to patient safety. • Acknowledge the impact nurses make on the training of resident physicians. • Utilize techniques to empower nurses to impart change promoting optimal patient care.

3. Conflict of Interest/Disclosure Heidi Thompson and Monique Landor have nothing to disclose and do not have any conflicts of interest

4. TEXAS CHILDREN’S HOSPITAL - nicu • Newborn Center: Average Daily Census 135 max capacity is 173 • Level 4-76 beds located in West Tower (pod) • Level 2-55 beds located in West Tower (pod) • PFW NICU (II/III) – 42 beds located in Pavilion for Women (private room) • All inborn patients located in this unit • All Residents located in this unit

5. Background • October 2017 – Residents and Bedside RNs had multiple confrontations throughout the month • Residents unaware of Nursing Chain of Command • Dislike and fear of NICU rotation • NICU Education • First opportunity in NICU or Critical Care setting • Lack of experience with NICU population and culture

6. Evidence from Research • 2014 study related to bullying of residents by nurses (based on survey of surgical residents regarding 22 negative acts deemed as workplace bullying by nurses) • Concluded that bullying in the work environment occurred up to 82% of the time • Surgical residents experienced nurses ignoring medical orders with 30.2% frequency • Person-related bullying (17-18%) was reported as ignoring or excluding the resident and treatment in a hostile manner • Study on communication and patient safety • Patient outcomes are directly effected by the effectiveness communication between healthcare providers regarding patient medication • Healthcare providers should maintain open lines of communication which challenge practice decisions Schlitzkus, L. L., Vogt, K. N., Sullivan, M. E., & Schenarts, K. D. (2014). Workplace bullying of general surgery residents by nurses. Journal of Surgical Education, 71(6), e149-e154. doi:10.1016/j.jsurg.2014.08.003

7. Needs assessment

8. General Theme: Communication Gaps IMPACT Patient Safety

9. Closing gap in communication • Gap identification • Delayed communication • Delays in care • Perceived bullying • Unfamiliarity with unit routines • Addressing the gap • Displaying photo pictures of team in unit • Team signs in patient rooms • Resident names in VOALTE • Individual communication style • Standardized resident orientation

10. Closing the Gap:Who are the Providers

11. Closing the GAP – care Provider • Placed in each room at the head of the bed • Denotes patient’s name, given name and medical provider • Updated weekly by Unit Secretaries

12. Closing the Gap – Resident’s Preferred Name & RN Assignment Monique – 812 & 815 Loving – Here to Help!

13. Resident Orientation

14. Residents first day in NICU • Leadership attends morning safety huddle with nursing staff • Posting of photos of incoming residents by unit secretaries • Selection of nurses to provide NICU bedside orientation for residents • Afternoon didactic for residents

15. Orientation with Nursing Leaders

16. Morning orientation with Nurse

17. Morning Orientation Checklist

18. Afternoon Orientation Didactic

19. Resident orientation Presentation • Orientation content includes: • NICU environment and culture • Hand hygiene • Nest concept • Developmental care • Quality improvement initiatives • Nursing Chain of Command • Small Baby Program • Unit tour by Fellow

20. NICU Environment and Culture The single biggest problem is the illusion that it has taken place. - George Bernard Shaw • SBAR communication style • What is your communication preference? • RNs are assertive • Culture of questioning • We rely on your help • Chain of command

21. Hygiene…More than Handwashing • Please remove these items before entering patient nest: • Jackets • Watches • Rings especially with stones • Only short, natural nails are allowed • No shellac • No acrylic TCH Procedure: #1959, #1956TCH Video: Hand Hygiene Video – NICU

22. Most Everything inside the private room is considered inside the “Nest” except computers! • Hand Hygiene can be performed once upon entering the nest (private room). • Then Again: • If performing invasive procedures • If contact with bodily fluids • Before placing gloves • After removing gloves

23. Shared private rooms are treated like the open Pod Smith, 1Janesgirl • Anything that is shared cannot be included in the nest! • Multiples are no exception • Not Included: • Med Drawer • Linen Cabinets • Computers inside of the room

24. PFW Chain of Command -Monday-Friday

25. PFW NICU Chain of Command– Weekends/Holidays

26. Small baby Program • All infants born at 28 0/7 wks OR less than 1000 gms • Cohorted in PFW NICU rooms 822-833 • All care providers (RNs, RTs, Fellows, and Attendings) received specialized training to provide care for this population • Only the nurses that have received this specialized training are assigned to this area

27. Resident and bedside Nurse partnerships

28. Survey results

29. Post rotation survey to residents

30. Feedback from the Residents – What went well

31. Resident Feedback – What went well • “The RN was nice and waited for me to come to give me the orientation. However, she didn't seem to know what I was supposed to gleam from it, and I honestly wasn't sure either. It would be good to have a checklist to go through or something short and brief to describe the exercise for both of us.”

32. Resident feedback – Any Impact of overall experience from first day orientation

33. Resident feedback – Any Impact of overall experience from first day orientation

34. Resident Feedback from overall NICU experience • One resident said the NICU rotation should be the “model rotation.” • Another resident said they had heard not so favorable things about the NICU rotation, especially in regards to interactions with nursing staff. However, this resident thought it was one of the best rotations in regards to interactions with the nursing staff.

35. Beside Nurse Feedback – What went well • “Able to navigate being calm when getting push back while trying to advocate because they understand that we want what's best for the baby.” • “Better job looking for RNs before assessing and before rounding.” • “No issues with communication.” • “I like doing the bedside orientation to show them how to use the isolette.”

36. Beside Nurse Feedback – What went well

37. Bedside Nurse Feedback – Impact on unit

38. Beside Nurse Feedback – Impact on unit

39. Bedside Nurses – Additional considerations

40. Bedside Nurses – Additional considerations • “The first day the fellow and attending should round without residents so the residents can focus getting acclimated to the unit. When they round on the first day it causes a delay in care because orders are not written in a timely manner.”

41. Overall Impact on the unit – Bedside RN

42. Sustaining Program • Leadership team partnership • Supportive of bedside RN to aid in orientation • Twice yearly meeting with Chief Residents, RN Leadership, Bedside RN, NICU Attendings over resident program

43. References • Benike, L. A., & Clark, J. E. (2015). Enhancing nurse-resident physician partnerships. Creative Nursing, 21(3), 150-155. doi:10.1891/1078-4535.21.3.150 • Lancaster, G., Kolakowsky-Haynner, S., Kovacich, J., & Greer-Williams, N. (2015). Interdisciplinary communication and collaboration among physicians, nurses, and unlicensed assistive personnel. Journal of Nursing Scholarship, 47(3), 275-284. doi: 10.1111/jnu.12130 • Liu, W., Gerdtz, M., & Manias, E. (2016). Creating opportunities for interdisciplinary collaboration and patient‐centered care: How nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting. Journal of Clinical Nursing, 25(19-20), 2943-2957. doi: 10.1111/jocn.13360 • Schlitzkus, L. L., Vogt, K. N., Sullivan, M. E., & Schenarts, K. D. (2014). Workplace bullying of general surgery residents by nurses. Journal of Surgical Education, 71(6), e149-e154. doi:10.1016/j.jsurg.2014.08.003 • Smith, H., Greenberg, J., Yeh, S., Williams, L., & Moloo, H. (2018). Improving communication between nurses and resident physicians: A 3-year quality improvement project. Quality Management in Health Care, 27(4), 229-233. doi:10.1097/QMH.0000000000000192 • Muller-Juge, V., Cullati, S., Blondon, K. S., Hudelson, P., Maître, F., Vu, N. V., Savoldelli, G. L., Nendaz, M. R. (2014). Interprofessional collaboration between residents and nurses in general internal medicine: A qualitative study on behaviours enhancing teamwork quality. PloS One, 9(4), e96160. doi:10.1371/journal.pone.0096160