nurse led rounds

2

Nurse Led Rounds

Nurse Led Rounds by Frank Molloy RN, MSc ANP is licensed under a Creative Commons Attribution-NonCommercial 4.0 International

License.

11th Global Forum of Humanitarian Assistance in Cardiology and Cardiac Surgery

International Quality Improvement Collaborative

(IQIC) Learning Sessions

Geneva June 24-27 2015

Frank Molloy RN, MSC ANP (UK) Clinical Nurse Specialist, Educator & Co-Founder

The William Novick Global Cardiac Alliance

http://www.creativecommons.org/licenses/by-nc/4.0/

https://iqic.chboston.org/default.aspx









http://www.gfhm.ch

3

Disclosures

• Personal and professional observations from over 15 years of international assistance work

• Covers two large NGO’s

• (current - NCA and former ICHF)

• No work is proprietary

4

Core Messages

5

Core messages

• Rounds - define

• Other communication agendas

• Nurse led rounds - how to

• Experience from sites

• Visiting teams

• Pro and con nurse led rounds

6

Rounds



7

Rounds

“Bedside visits by a physician—or other health professional—to evaluate treatment, assess current course and document the patient’s progress or recuperation”

http://www.thefreedictionary.com/round


8

Rounds

“In a teaching conference … which the clinical problems encountered in the practice of medicine, dentistry, nursing, or other service are discussed.”



9

Rounds

9

Rounds

• Rounds - treatment planning, as a bedside event

• Information - sequence

• Discussion and decision

• Almost always includes teaching

• Discussion and decision - plan

9

Rounds

• Rounds - treatment planning, as a bedside event

• Information - sequence

• Discussion and decision

• Almost always includes teaching

• Discussion and decision - plan

clinical “communication agenda”

10

Communication Agendas



11

Communicaton Agenda

• Defined Speaker(s)

• Specific information

• Defined time

• Listeners and Participants

• Relevant to the information presented

12

Communicaton Agendas

12


• Examples

• Airline Safety briefing

• Preoperative time out

12


• Examples



• Reading the rights

12


• Examples




• Information relevant to listener… and within the scope of responsibility of the speaker

13

Golden Rules - Communication Agenda

13


• Everybody listen

13



• No background conversations

13




• No taking calls or looking at phones

13





• Don’t interrupt

13






• Speaker - be concise - and correct

13






• Speaker - be concise - and correct

• Listeners - be patient and attentive

14


• Examples




• Information should be relevant to listener… and the resposibiitoes of the listener

15


16

Rounds - Structure

16

Rounds - Structure

• Someone is speaking

16

Rounds - Structure


• Team is listening

16

Rounds - Structure



• Sequence of information

16

Rounds - Structure




• Added information other team members

16

Rounds - Structure





• Insights, conclusions,

16

Rounds - Structure






• Questions and Plan

16

Rounds - Structure






• Questions and Plan

• move on….

17

Making it work

17

Making it work

• Presenting structure

17

Making it work


• Primary presenter - who ?

17

Making it work



• Additional information

17

Making it work




• Listening structure

17

Making it work





• Know the sequence

17

Making it work






• Dont interrupt

17

Making it work






• Dont interrupt

• Part of the routine

18

Rounds, Handover, OR signout

18

Rounds, Handover, OR signout

• Common features

• Schedule of who should speak and when

• Every one else should be listening - or not present

• The information IS IMPORTANT

• Transferable team based skills

19

Nurse led rounds



20

Nurse led rounds?

20

Nurse led rounds?

• Nurse introduced rounds - nurse is the first speaker on a communication agenda

20

Nurse led rounds?


• Common issues with other clinical Communication Agendas…. e.g.

20

Nurse led rounds?



- OR-ICU (anaesthesiologist or surgeon first),

20

Nurse led rounds?




- end of shift (end of shift person starts),

20

Nurse led rounds?




- end of shift (end of shift person starts),

“Handovers” (Sign-outs, Sign-offs, Hand-offs)

21

Clinical Communication Agendas

21

Clinical Communication Agendas

• Quality of information spoken is important

• Quality of listening is equally important

22

Handovers and Rounds - Differences

22


• Handover objective is pure information transfer

22



- Go home and don’t get called with a question

22




• May be less listeners (less pressure)

22




• May be less listeners (less pressure)

• Single responsible individual

23

Handover or Rounds - Similarities

23


• Rounds - Basic information sequence is same

23



• Rounds usually closely follows a shift change

- Nurse handovers can be a rehearsal for nurse led rounds

23



• Rounds usually closely follows a shift change

- Nurse handovers can be a rehearsal for nurse led rounds

• Same information structure can be used in both

24

Information Structure - nurses

24

Information Structure - nurses

• With a good Information Structure presenting the information…

- Can be done by nurses at all levels

25

Information Structure

25

Information Structure

• Who is the patient

• Demographics and diagnosis

• What operation - and when

• What were the perioperative issues and early post course, recent events

• What is status and progress in last 12 hours - and now

26

Junior Nurses - Information presentation

26

Junior Nurses - Information presentation

• Fact based presentation

• May miss some rich detail

• e.g. breath sounds, heart sounds, complexity of operative details

• Will stick to the script

• Information may be incomplete - but it is rarely “wrong”

• Listener needs to work …

• DO NOT INTERRUPT

27

Junior Nurses

27

Junior Nurses

• Generally will not create linkages between systems

• Story will not have a bias based on an opinion

28

More experienced Nurses

28



28



• Add skills based observations

28




• Strays from the script - appropriately links cardiac and respiratory and renal issues in a narrative

28





• May be repetitive, and longer

28





• May be repetitive, and longer

• Forms an opinion,

29

Expert / Advanced

29

Expert / Advanced

• Rich observational information throughout


• Summarises based on context

30

Depth of Presentation

30


Basic - Short and Factual

30



Interemediate - combines some opinions, linkeages and suggests diagnosis

from issues

30



Interemediate - combines some opinions, linkeages and suggests diagnosis

from issues

Advanced - Integrated thinking, informed recommendations,

can outline majority of the plan

31

Examples - sites



32

Sites

• AFIC - Rawalpindi

• STAR hospitals Hyderabad

• Beijing Childrens Hospital

• Skopje Paediatrc Surgical Clinic

• Kharkiv Centre for Urgent and General Surgery

• Tobruk Medical Centre

• Guayaquil - Hosp Fco y Casa Bustamante

33

AFIC - Rawalpindi

33

AFIC - Rawalpindi

• Collaboration June 2005-Dec 2009 (19 trips)

33

AFIC - Rawalpindi


• Nurse Led Rounds - introduced at beginning of our collaboration - nurse educator resident in country in first phase

33

AFIC - Rawalpindi



• Simultaneous creation of new paediatric team within CICU

33

AFIC - Rawalpindi




• Nurse (8-12) v Doctor (1) ratio favourable to nurse led rounds structure

33

AFIC - Rawalpindi




• Nurse (8-12) v Doctor (1) ratio favourable to nurse led rounds structure

• Minimal written structure - mentored and taught sequence

35

AFIC - Rawalpindi

35

AFIC - Rawalpindi

• Sustained outcome

• Nurses respected in team - clinical judgements

• Key drivers….

• leadership from Chief anaesthesiologist - and

• respected visiting educator,

• appointment of clinically expert head ICU nurse

• Handover is to all nurse team - and prepares for round

37

STAR - Hyderabad

37

STAR - Hyderabad

• Collaboration Dec 2009-Dec 2011 (7 trips)

• Anesthesia led ICU - doctors busy in OR much of the day

• Nurse led rounds - structure introduced on 2nd or 3rd trip

• Cultural hierarchy initially different to Pakistan team

41

Beijing Childrens Hospital

41


• Collaboration 5/2004- 9/2010

41



• Nursing team increased in numbers - year 3 - 2007 - new larger ICU

41




• Single intensivist (plus 1 trainee) - 20 nurses

41





• Simple sequence - minimal detail in structure

41






• NO hierarchical issues (personality of intensivist)

41






• NO hierarchical issues (personality of intensivist)

• Presented in Chinese initially.. then over the space of 2 years almost all nurses learned english.

44

Kharkiv - Ukraine

44

Kharkiv - Ukraine

• Collaboration 5/2008- continuing (32 trips)

44

Kharkiv - Ukraine


• Night nurse led handover / rounds at 8am - all teams start at same time

44

Kharkiv - Ukraine



• One nurse (night senior) presents every patent - about 10-15 people listening (or not) - night duty doctor minimal input unless exceptions (critical)

44

Kharkiv - Ukraine




• Many nurses are 4th year medical students

44

Kharkiv - Ukraine





• Core plan made at this round

44

Kharkiv - Ukraine





• Core plan made at this round

• Weaknesses - no individual responsibility, too much background conversation & too much for one person

46

Skopje - FYR Macedonia

46


• Collaboration March 2013-continuing (12 trips)

46



• Nursing team only 4 - no interim trip experience as yet, early focus year 1 on tasks and safety

46




• Nurse led handover all trips - from visiting team— but did not place responsibly on local nurse too early

46





• Newest nurse - age 18, first to present - using guide structure - in Macedonian

46





• Newest nurse - age 18, first to present - using guide structure - in Macedonian

• Now - patient allocations in SKP, one patent local nurse one visiting team nurse

52

Tobruk - Libya

.. nurse rounds here is a very structured handover of facts to the next shift and as yet they have not moved on to critical analysis or even patient comparison. ….. feel more responsible for the patient if they know they have to hand over .. next trip … will start asking for their input in planning care…

52

Tobruk - Libya

• Collaboration - Feb 2015

• Small Nursing team from closed benghazi centre

• Very early - nurse led handovers..

.. nurse rounds here is a very structured handover of facts to the next shift and as yet they have not moved on to critical analysis or even patient comparison. ….. feel more responsible for the patient if they know they have to hand over .. next trip … will start asking for their input in planning care…

55

Guayaquil - Ecuador

55

Guayaquil - Ecuador

• Collaboration - 2010-2014

55

Guayaquil - Ecuador


• No nurse led rounds attempted in these first 4 years

55

Guayaquil - Ecuador



• Small number of nurses - not consistently allocated to the “cardiac side”

55

Guayaquil - Ecuador



• Small number of nurses - not consistently allocated to the “cardiac side”

• Large number of paediatric residents - 2 per shift

56

Visiting teams (or individuals)



57

Can visitors mentor good practice?

57


• May be first appearance of truly collaborative interdisciplinary working

57


• May be first appearance of truly collaborative interdisciplinary working

• Visiting team itself needs a structure

58

My Briefing to visitors - Handover

• Shift Handover - is not the treatment planning round

58



• Information exchange, get people home with clarity

58




• Presented by the person who is leaving - to ALL ICU TEAM

58






58






• Save teaching for later

58







• No side conversations

58







• No side conversations

• Ensure all have had a chance to clarify before moving on

58


59

Language

• Local language preferred

59

Language


• American English is not same as UK engish or Indian English

59

Language


• American English is not same as UK engish or Indian English

• English as a second language team members - who apparently speak good english still need consideration….

59

Language

• CBC, FBC, TBC,

• BMP, U&E,

• RBG, BM,

• O’s, I’s and O’s

• DC, IDC, ICD,

• FG & E

• CVS

• RS60

Language - Avoid Abbreviations

61

Improving the presentation

61


• Don’t interrupt Junior staff

• … unless completely wrong

• Presentation should not be from memory -

• Team responsible for accurate bedside written information

• Visual or graphical teaching aids -

62

Summary

63


64

Pro and cons and -conclusions



65

Why not?

65

Why not?

• Might impose on medical teaching curriculum

65

Why not?


• Junior nurse may not correctly report the operation

65

Why not?



• Some units more doctors than nurses, - residents need the practice

65

Why not?



• Some units more doctors than nurses, - residents need the practice

• Different model for morning rounds as evening rounds

66

Why? Cardiac Surgery VERY suitable

66


• Operation report should be easily available

66



• Nurse present at Operation Signout - hears same information

66




• Majority of patients should follow predictable course

66





• Sequence of events - predictable

66






• Morbidity exceptions - recognised - can trigger plan changes

66






• Morbidity exceptions - recognised - can trigger plan changes

• The nurses should know the expected plan

67

Features of easy implementation sites

67


• AFIC - Rawalpindi, Beijing Childrens Hospital

67



• Nurses outnumber doctors

67




• Regular cardiac surgical practice in large numbers (including adults?)

67




• Regular cardiac surgical practice in large numbers (including adults?)

• ICU medical and nursing lead

68

My experience - 40 PICU’s 24 countries

68


• Probably not typical - but is broad

68



• If Rounds happen - always in the presence of the nurse

68




• Mostly open plan units

68





• A few sites do partial rounds in office first (x-rays etc..)

68






• Nurse led rounds is possible - almost everywhere - without structural change

68






• Nurse led rounds is possible - almost everywhere - without structural change

• But we are only visitors - can show example - but may not exactly fit the local situation

69

final advice…



70

try to look interested…

72

or..

73

LISTEN attentively

75

www.cardiac-alliance.org

http://www.cardiac-alliance.org

nurse led rounds

Documents