Nurse Leader Q&A: Overcoming Barriers to Excellence in the ED
Learn from the experts. Kate Cronin, MS, RN CNO at Cheshire Medical Center/Dartmouth-Hitchcock Keene in Keene, NH and Donna Sparks, MSN, RN Director, Emergency Services at Baptist Miami Hospital, Miami FL tell you what it takes to excel in the ED.
HR: What barriers did you have to remove to create a culture of excellence in the ED?
KC: Like in other EDs, our culture was a major barrier. We felt it was our job to save lives…not to do these "other" things. We also believed our patients were different from those in other EDs (e.g., more psych patients, sicker patients, less willing to complete patient satisfaction surveys). Plus we thought, "Hey, we're already pretty good compared to the other EDs in town. Patients don't usually have to wait more than four to five hours to be seen, so what's the problem?"
DS: I didn't see the challenge so much as "barriers", but the need to find ways to demonstrate "what's in it for me" to staff. When we started hourly rounding in the ED, we shared evidence from the literature that showed why this was an evidence-based nursing practice to provide better patient care and how it would reduce call lights by anticipating patient needs better.
I did have one nurse who thought that completing the rounding log was a waste of time. I said, "But when you give medication, you document it, right?" I explained that we used information from the logs at our twice-a day shift briefings to recognize staff and identify opportunities for improvement. Then he got on board.
HR: Did you find that staff resistance to change was primarily an issue of "will" or "skill?"
KC: In the beginning, it was will. The team didn't feel it was valuable or needed. This shifted once leaders in the ED owned it. Once leaders understood the data measured us against other EDs, they were determined to be better. We appealed to their competitive natures.
Later, it became a question of skill. Nurses used to avoid angry patients who had been waiting awhile. ("Don't go into cubicle 7 because they're angry!" they'd say.) But once they learned how to use AIDET, they felt comfortable defusing a patient's anger and anxiety with detailed information and genuine caring. Also, fewer complaints fueled more willingness to use the tools.
DS: Back when we started, I saw it as an issue of "will." But now that I look back, it seems like "skill". Staff didn't have the knowledge or insight about what patients were experiencing. They didn't have the training and education for rounding and AIDET. Now, we constantly re-train when we have tech turnover to ensure these behaviors remain hardwired.
HR: How did you find the time to use new tools and behaviors without adding staff?
DS: At first, triage nurses were fearful about rounding in the reception area on patients who had waited awhile. Our old ED was small and cramped then, so we'd bring blankets and pillows. But when nurses saw their managers and directors stepping up to round too, they were comforted and more confident. Patients were so receptive and complaints went down…fewer interruptions meant we got time back! Soon, it just became a better way to work that we incorporated into our routines and reinforced at shift briefings. We didn't need more staff.
HR: Do you have any advice for other nurse leaders trying to change the culture in the ED?
KC: You really need true leader buy-in—through role modeling, competency assessment, feedback, training, and holding people accountable— to succeed. If leaders do this, I think an organization can get significant results in six months. Also, provide data—share it widely and celebrate results frequently!
DS: Introduce just one or two tactics at a time to ensure they are hardwired before you layer more on. It took us a long time and a lot of effort to really hardwire hourly rounding to ensure it happened with every patient every time. At first, we used wind chimes on the loudspeaker as an audio cue. It takes time to practice a new behavior before it becomes a habit.
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