Institute of Medicine

Caitlin Buren, Carrie Cutler,Pat Gallagher, Michelle Smith

Ferris State University4/28/2013

Nursing Practice Standards

Started in 1970, The Institute of Medicine is an independent, nonprofit organization that provides honest and definitive advice to decision makers and the public.

The aim of the IOM is to help people in the government and the private sector make informed health decisions by providing evidence which they can rely on. Each year more than 2000,distinguished professionals, volunteer their time, knowledge, and expertise to advance the nation's health through the work of the IOM.

The IOM appointed the Committee on the RWJF Initiative on the Future of Nursing, with the purpose of producing a report that would make recommendations for an action-oriented blueprint for the future of nursing. Through its deliberations, the committee developed four key messages:

•Nurses should practice to the full extent of their education and training.

•Nurses should achieve higher levels of education and training through an improved education system.

•Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

•Effective workforce planning and policy making require better data collection.

Key Message #1

Regulations on scope of practice vary state to state. The Federal government is best suited to address this issue, by encouraging best practice standards and giving incentives in the form of better reimbursement rates to health care systems that adopt these standards.

Development of nurse residency programs, especially in acute care settings, are designed to give new nurses time to gain the knowledge and skills needed to deliver safe, quality care that meets professional practice standards.

Key Message #2

To be prepared for the demands of an evolving healthcare system, and to meet the needs of our patients, nurses need to achieve higher levels of education and training. More nurses are needed at the BSN level, and many hospitals are requiring ADNs to go back to school.

Nursing education needs to be a smooth transition from LPN-ADN, from ADN- BSN, from BSN-MSN, and from MSN-DNP. One way this is being done is by the formation of online classes. The formal nursing education should serve as a platform for continued life long learning.

• Key Messages #3

Strong Leadership is crucial if we are to play a part in the vision of a transformed healthcare system. We must be leaders, from bedside nursing through our nursing CEO’s, while working with physicians and other healthcare professionals, to deliver the highest quality care.

Strong leadership skills are needed if nurses are to play a part in devising and implementing the changes needed to increase quality, access, and value while delivering patient centered care. Leadership competencies need to be imbedded throughout nursing education. Leadership development and mentoring programs need to be made available to nurses at all levels. All nurses at all levels must take responsibility for developing their leadership competencies.

Key Message #3

There needs to be data collected on who is working in healthcare, where are they working, what are their roles, what types of duties do they perform, and how many there are. Once this data collection is up and going, an assessment and projection of nurse requirements by role, skill mix, region, and demographics will be used to determine regional healthcare workforce needs and to form a plan to increase the healthcare workforce. This data is also used in the planning for fundamental, wide-ranging changes in the education and deployment of the nursing workforce.

Pat

How I have seen IOM influence in my practice.• Critical Care internships for new nurses, to give them time to develop the skills

and knowledge needed to work in critical care areas.• Mandatory for new RN’s to achieve a BSN within 10 years.• Encouragement for existing ADN’s to obtain a BSN, through use of a clinical

ladder, where as you climb the ladder in your education you make more money.• Implementation of Unit Action Committees, made up of nurses and other

healthcare providers, which help form policies, work to increase efficiency within the unit, and work to improve patient safety.

• Munson is a Magnet hospital and encourages it’s nurses to further their education through use of a clinical ladder system. This applies to becoming certified in their field of expertise, as well as attaining a BSN.

• Munson has increased the education requirement across the board. Clinical specialists now need a MSN, nurse managers now require a MSN, and clinical coordinators now require a BSN. This is being done to maintain Magnet status and to increase the quality of care we give our patients.

ld

In June 2006, the Institute of Medicine (IOM) concurrently released three reports on the Future of Emergency Care in the United States Health System. The reports focused on hospital-based emergency care, pre-hospital emergency care, and pediatric emergency care.

Considerable progress has been made to strengthen emergency care, but here are some challenges that still remain:

• Widespread emergency department crowding • Frequent boarding of admitted patients in emergency department hallways • Diversion of inbound ambulances due to lack of capacity • Persistent financial compromises

ld

The IOM report helps with addressing patient flow problems. CEO’s need to be in direct contact with the hospital’s emergency department management team to decrease the length of stay for patients and the increased admitted patients to the ER. ED crowding and admitted patients in the emergency room needs to be addressed.

The issues of a National epidemic of overcrowding of the Emergency Department:•Uncompensated emergency and trauma care•Availability of specialists•Management of patient flow•Hospital disaster preparedness

Another challenge that the IOM is working on for better results in the Emergency department is ambulance diversion. An

ambulance diversion occurs when a hospital ED cannot care for

additional emergency patients. When a hospital is “on diversion” it redirects ambulances from their ED to another hospital or medical facility.

Michelle

How I witnessed IOM in the Emergency Department I work in a Trauma one center and we are a very busy emergency

room. There will be days I come in at 7pm and we are 30 patients deep in the waiting room waiting to be sent back to their room. The problem is as the patients are waiting for a room, we are still taking ambulances. Ambulances come first, but if we get too busy, we have to put our ambulances on diversion. When we have busy days and our Doctors are not fast enough, our specialist are not seeing our patients in a timely manner, or the hospital is too full to admit patients, we get extremely overcrowding. This is a huge problem, especially in the flu season in Michigan. I hope IOM will be able to help correct these problems, but I feel it will be extremely difficult since our population is increasing

data

Idyllic Application of IOM in the Surgical Suite – Nurse and Patient Safety

• OR Nurses are at great risk for developing health impairments associated with increased fatigue.

• Health impairments could include increased injuries, cases of depression, and stress.

• Further, experts note that cognitively demanding tasks should not be performed by individuals who are sleep deprived.

• A lack of focus and compromised cognition skills could have disastrous results for the patient, whose advocate in the OR is the nurse.

• Experts have written that after a 9 hour shift, employees will note an increase in errors.

• For shifts greater than 12 hours, errors may potentially double.

• IOM has made recommendations that surgical nursing shifts not exceed eight hours. Polling indicates that up to 75% of nurses are still faced with shifts greater than 12 hours though.

• An OR nurse could currently potentially work more than 90 hours in any given week, especially with call-ins, mandates, case over-runs, etc.

u

• From this information, it is easy to see the potential detriment to nurse and patient safety.

• Mistakes in health care may affect up to 98,000 patients a year.

• Sleep deprived (or overcommitted) nurses may be a party to or responsible for some of these due to increased medication issues, failure–to-rescue events, or neglected nursing duties.

E

Equipment Training and IOM

• New equipment in the OR is becoming more commonplace (e.g. DaVinci robotic surgery, etc.).

• Positive patient outcomes can only be reasonably guaranteed in the OR when the staff making use of the equipment knows how it functions completely.

• IOM recommends developing and conducting proper training programs that span the experience level of the users.

• Initial training seminars followed by on-going refreshers for the entire perioperative staff on complex equipment with initial education sessions would be positive.

CarrieHow I Have Witnessed IOM in the OR

• While my hospital does require sign-ups for on-call periods, it does not specify how these shifts must be allocated. As such, I normally spread a call over multiple days in order to reduce workload and avoid fatigue. This ought to be policy, although it is not, as some nurses will combine these calls consecutive to normal shifts in order to ensure longer rest periods.

• The hospital does have specific policies in place for extraordinary situations, whereby someone having been called in (on an overnight) but scheduled for a shift the next day may be excused for up to eight hours (without penalty) in order to rest.

• The hospital does maintain a resource room within the OR and has identified those individuals who are “experts” on given procedures or equipment who may be consulted, and is also setting up seminars and sessions for new capital equipment purchases.

April of 2008 IOM created a report on building the health care workforce in efforts to prepare America for its aging population. The number of older adults will nearly double between 2005 and 2030. In 2011 the baby boomer generation will begin turning 65. Although many of these older adults are healthy and able to manage their own care, more than three-quarters suffer from a chronic medical condition that requires ongoing care and management. The baby boomer generation is the most diverse group the nation has ever seen. The group is more racially and ethnically diverse, with higher education, and increased longevity. With the diversity of the group their needs become much different from previous generations.

Retooling for an Aging America: Building the Health Care Workforce addresses the problem of having a health care workforce that is too small and critically unprepared to meet the health care needs of the aging population. IOM acknowledges that initiatives need to be designed to:•Boost recruitment and retention of geriatric specialist and health care aides•Explore ways to widen the duties and responsibilities of workers at various levels of training•Better prepare informal caregivers to tend to the needs of aging family members and friends•Develop new models of health care delivery and payment as old ways sponsored by federal programs such as Medicare prove too ineffective and inefficient

Ways in which health care providers can meet these initiatives are:•Provide training to health care providers in the basics of geriatric care so there are more capable of caring for older patients•To attract and retain health care providers in the geriatric setting we need to pay higher salary and wages•Require new payment mechanisms in order for providers to deliver care to older adults more effectively, such as through interdisciplinary care teams•Educate patients their friends and family how to retain their independence by learning how to manage their health. Training programs should be designed to deliver the necessary knowledge of managing their care as well as the stress they may incur from providing care.

CaitlinHow I Have Witnessed IOM in Long Term Care

•In efforts to boost recruitment the facility I work at conducts a certified nurse aide training course. In this individuals interview for the opportunity to participate in our training that is a couple weeks long, while learning in a classroom and clinical environment they also receive pay. Once they have completed so many hours of clinical experience the facility pays for their CNA exam and upon passing offers them a position. Another example of how my facility attempts to boost recruitment is by allowing local colleges to have their nursing students assigned to the facility for a portion of their clinical hours. This allows student who may have limited to no LTC experience and allows them to gain knowledge in things such as end of life and patients that are receiving long term assistance. A final effort the LTC facility works at that makes it different from the rest is their generous hourly compensation, health benefits, and pension.

•The LTC facility I work at has multiple mandatory in-services for all disciplines that occur on a monthly, quarterly, and annually basis. This enables us to provide the best possible care to our elderly patients and keeps our skills above the minimum level of competency. By setting higher facility standards we are able to score highly in our annual state survey. The on-going training and review also allows us to provide excellent care and allows us to help patient’s loved ones in learning how they can participate in the health and well being of the patient.

References

About the IOM. (2012). Retrieved from http://www.iom.edu/About-IOM.aspx

Clancy, C. J (June 2012). From our readers: Overtime is only fun in baseball: A somber look at mandatory

overtime and nursing care. American Nurse Today, 7. Retrieved from

http://www.americannursetoday.com/article.aspx?id=9184&fid=9138.

Committee on the Robert Wood Johnson Foundation on the Future of Nursing. (2011) The future of

nursing: leading change advancing health. Retrieved from

http://www.nap.edu/openbook.php?record_id=12956&page=2

Francis, P. (January 2008). New technology and patient safety go hand in hand. Nursing Center, 2. Retrieved

from http://www.nursingcenter.com/lnc/journalarticleprint?Article_ID=762274.

Institute of Medicine. (April 2008). Retooling for an aging america: building the health care workforce. Retrieved from: http://www.iom.edu/~/media/Files/Report%20Files/2008/Retooling-for-an-Aging-America-Building-the-Health-Care-Workforce/RetoolingforanAgingAmericaBuildingtheHealthCareWorkforce.pdf

IOM. (2006). Hospital based emergency care at the breaking point. Retrieved from www.ed-qual.com/emergency_medicine_news/ED_news_IOM_report_on_emergency_medicine.htm. Washington, DC: National Academy of Science.

References

Wheatley, B. (2013). Regionalizing emergency care. The National Academies Press. (pp. 7-10). Retrieved from www.nap.edu/openbook.php?record_id=12872&page=R10

Wood, D. (2013). IOM Calls for Changes to Nurses' Working Environments. Retrieved from

http://www.nursezone.com/nursing-news-events/more-news/IOM-Calls-for-Changes-to-Nurses’-Working-

Environments_27578.asp

x