Exemplary Professional Practice
Exemplifying the true essence of the Magnet model, UT Southwestern provides nurses with an environment that fosters excellence through continual learning and the development of transformational leaders. As an organization that values, recognizes, and encourages continuing education and professional certifications, we believe these are vital components to building the professional development and practice of our nurses. As a leading academic medical center, we support our nurses to push past the status quo to create a new level of excellence. Through interdisciplinary relationships, professional autonomy, nurses as teachers, establishing professional models of care, and maintaining resource-rich facilities, we continue to shine within our community, state, and nation.
Nursing Professional Practice Model at UTSW
Nurses at UT Southwestern provide the highest-quality patient care through the application of relationship-based care, which focuses on what matters most: caring and healing relationships at the point of care. Compassion, knowledge, and evidence-based care formulate the foundation for excellence and make a profound difference in the patient’s ability to recover and heal. The UT Southwestern Nursing Professional Practice Model is based on the belief that patients and families are at the center of everything we do and are our partners in care. Patients and families are honored as individuals and cared for with dignity and respect.
Our model provides a framework for achieving excellent clinical outcomes by allowing nurses to practice professionally. Through this framework, we put our vision into action. The model guides our decisions, supports the delivery of professional nursing care and quality outcomes, ensures consistency in nursing practice, and promotes a healthy environment for the delivery of care. The nurse-patient relationship is strengthened through a focus on continuity of care and interdisciplinary collaboration. Nurses at UT Southwestern are empowered through a shared governance structure to make decisions while building professional accountability. Nurses have a strong voice on issues impacting nurses. Our practice environment values, encourages, recognizes, and rewards innovation, creativity, and scholarly pursuit to improve patient care.
Nurse Satisfaction Survey
In 2021, for the first time ever, a single, standardized nurse satisfaction survey was sent to all nurses at UT Southwestern Medical Center. Literature shows that when nurses enjoy their jobs and intend to stay in their positions long term, it translates to improved patient outcomes. As a Magnet organization, UTSW strives to be above the benchmark in all areas of performance, including nurse satisfaction. The results of the 2021 nurse satisfaction survey showed outperformance in all categories based on the national benchmark, with the exception of Autonomy, the only category in which UTSW tied the national score.
Exemplary Professional Practice in Action
Working Toward a Level 4 Designation for Texas Moms and Babies
In the U.S., and in Texas in particular, maternal outcomes are in need of improvement. After large-scale initiatives through the Texas Alliance for Innovation on Maternal Health (AIM) and the Texas Collaborative for Healthy Mothers and Babies (TCHMB) helped improve outcomes in hospitals, a state requirement followed, mandating that all maternal units were to be surveyed and designated by the fall of 2021. Staff in the maternal units at UTSW’s William P. Clements Jr. University Hospital decided in 2018 to apply for a Level 4 designation, the highest level designated, and worked for more than three years toward achieving that goal.
A secondary goal was to meet or exceed requirements that would warrant a designation of Level 4 Maternal Care for our Labor and Delivery and Postpartum units. Actions included membership and participation in Texas AIM and TCHMB as well as in the Perinatal Regional Advisory Council (RAC). This was a group project involving providers, staff, and leadership from all service lines and total commitment to the best practice standards of care. The accreditation department was also integral to success.
Best practices related to managing or decreasing postpartum hemorrhage, hypertension, sepsis, opioid dependence, depression, and surgical site infections were introduced to staff and providers and rolled out methodically. Intensive care units, psychiatric units, rehabilitation units, and the emergency department were also included and equipped with processes and tools in place to address these issues because they could arise with any pregnant or postpartum patient. All participating units and their medical and nursing leadership were included in the education of the best practice processes, and ultimately all also participated in a survey course that took place in February of 2021.
The course, done virtually, took place over two days. It involved an extensive review of patient charts fitting into the related diagnoses and appropriate interventions with provider and nursing navigators. Virtual tours were conducted to ancillary units, intensive care units, emergency departments, neonatal intensive care, and the maternal units. The survey resulted in three issues requiring correction, a few recommendations, and a list of exemplary best practices from the surveyors.
Changing the Language Used in Care for Patients Declining Bed Alarms
Encouraging words to patients declining bed and chair alarms made the difference for Med-Surg care team members on 10 Orange at UTSW’s Clements University Hospital. Ambulation with assistance after a procedure is important for the patient’s recovery. Often patients believe they don’t need help getting from the bed to a chair or from a chair to the bathroom, so they decline the assistance that’s available with the push of a button. Previously, staff members were unsure what to say to ensure patients would consistently and confidently use the alarms. Nurse managers used staff meetings to explain the importance of family teaching and re-educating each patient and family on the importance of the alarms every shift. In addition, managers suggested using language that would not be intimidating to patients and implemented use of the phrases daily for about a month during quick hits. For example, when nurses responded to an alarm, they entered the patient’s room, asking, “What can we do for you?” – a simple query of friendly assistance. If the patient declined the alarm, nurses explained that the alarm is not a restraint and that the patient can get up anytime but also that staff would respond quickly to assist them if/when the alarm goes off. An escalation flow chart was created, and all staff were instructed in its use in the event a patient continued to decline the alarm. The goal of this initiative was for our unit’s fall rate to be less than 2.1. Prior to implementation, our fall rate average was 3.32. After our implementation of the escalation tree and everyone utilizing the same, less-intimidating language with patients, our average is now 2.1.
Communicating Through N95s, PAPRs, and Epic
As COVID-19 care ramped up in the fall of 2021 and ancillary staff was brought back into the mix of caring for COVID patients, communication with nursing staff became more complex. Because of the necessary use of N95s, PAPRs, and other PPE, nurses were unable to use WL3 phones in COVID rooms, and the Vocera wireless voice communication tool was still relatively new technology. Feedback from nurses indicated that communication through transitions was their biggest challenge. It became a team goal to improve communication and response time to staff needs while inside a COVID patient room.
One suggestion for meeting that goal was to use the chat function available in Epic, UTSW’s electronic medical record application. Initially, different group chats were created in Epic for each shift to include groups of buddy nurses, their PCT, their RN runner (when present), the charge nurse, and the HUC. This allowed primary nurses in COVID rooms to ask for help to a group of people outside the room and get assistance from whoever was readily available. When COVID numbers declined as 2021 progressed, the process was updated to have one Epic chat for the whole unit, with all RNs, PCTs, the charge nurse, and HUC in the COVID area included together rather than separately. Using this chat function made communication more efficient and decreased the need for RNs and PCTs to leave the room for requested items, saving doffing and donning of PPE and overall time. Feedback from leadership rounding with staff indicated increased satisfaction with communication and teamwork from using the Epic chat function.
Improving Morale in the Time of COVID
The Aston Infusion Clinic staff were beginning to feel the strain of battling the ebbs and flows of the COVID-19 pandemic. With new protocols implemented and sometimes changing weekly, with a revolving door of daily coaching sessions for the management team, and with the daily grind of an ever-growing patient population, new workarounds, and sometimes unexpected, pandemic-related roadblocks, burnout among the AIC staff was beginning to become a potential issue.
After a year of working conditions overshadowed by COVID, it felt like there was no end in sight, and it seemed we needed to make a proactive move before a general lack of zeal could carry over to one another, our referring departments, or patients. It was time to make a change and fix the things we had control over and not continue to let the things we couldn’t control dictate our daily attitudes. So we formed an employee-led recognition committee.
The new committee’s goal was to increase workplace wellness and satisfaction by recognizing achievements, accolades, and hard work.
The committee recognized birthdays every month, employment anniversaries, education and professional advancements, and other important milestones. Along with management led recognition efforts, the employee-led recognition team provided an increase in workplace satisfaction across the clinic.
The impact made by the committee was evident in the quarterly Press Ganey Reports. The clinic received the Service Excellence Award for the first three FY quarters of 2021. One staff member was awarded the Meritorious Award and another the Spirit of Caring Award.
Collaboration among the employee-led recognition team consisted of nurses, billing specialists, financial counselors, and CSAs.
Infusing Hope: Implementing a Monoclonal Antibody Infusion Therapy Pathway for COVID-19 Patients
In November of 2020, some nine months after COVID-19 was first detected in the United States, monoclonal antibody infusions such as bamlanivimab were identified as an effective treatment for more severe cases of SARS-CoV-2 and were given Emergency Use Authorization (EUA) by the U.S. Food and Drug Administration (FDA). At UTSW, ambulatory nursing leadership was tasked with collaborating with Pharmacy Services, Infection Prevention, Supply Chain Management, Information Resources (IR), Facilities, and the Epic training team to create an infusion area that could provide biologic infusion services for actively symptomatic COVID-19 patients meeting the medical criteria for treatment. Thus, the COVID Infusion Clinic was opened within a space originally created for COVID-19 testing with the help of our COVID Readiness team, which included staff from Ambulatory Nursing Operations.
The goal of the initiative was to provide biologic infusion therapy to patients who were high risk for progressing to severe COVID-19. We aimed to do so in a safe environment that reduced the risks of endangering staff or other healthy patients on campus and to decrease the risk of positive COVID-19 patient admissions via the Emergency Department.
One challenge to accomplishing these goals was the need to identify a clinical area isolated from common patient and staff access, while also meeting the logistical and engineering specifications of needing a negative-pressure space within the existing building. Additional challenges included identifying available support staff for patient scheduling and check-in, as well as to identifying available infusion-trained and certified RNs to administer the infusions to patients. Coordination of additional tasks included identifying necessary supplies, determining the clinical workflow, creating a scheduling template, and creating a staff schedule template based on seven day-a-week, eight-hour-a-day operations. Collaboration continued as education and training needs were identified, including PAPR training for all clinical staff. Additionally, Pharmacy and Logistics leadership were tasked with ensuring the workflow for drug mixing and delivery coincided with the infusion clinic workflows. As a result of this initiative, over the past 12 months more than 750 SARS-CoV-2-positive patients have received, and continue to receive, treatment with monoclonal antibody infusions.
New Building, New Plans for 8 Orange Epilepsy Monitoring Unit
Prior to the move from Zale Lipshy Pavilion to William P. Clements Jr. University Hospital, the Epilepsy Monitoring Unit team was informed that due to the distance between the pharmacy and the new location there might be a delay in getting some of the IV anti-seizure medication to the bedside if a patient went into status epilepticus, a seizure lasting more than five minutes. This was disheartening news for the EMU APPs because they had recently completed a QI project with the Zale pharmacy on improving delivery time of these medications; nevertheless, they knew they’d need to identify a solution in order to provide their patients with the best possible care.
The EMU APPs conducted a literature review and compiled a list of evidence-based rescue medications for patients in status epilepticus. They then reviewed the list with the EMU Medical Director and a pharmacist to determine which medications could be kept in the unit’s Pyxis station and used as first-line rescue for patients in status epilepticus while the pharmacy was mixing and delivering the second- and third-line medications. It was determined that levetiracetam (Keppra) could be stocked in the Pyxis and used in instances when a patient’s seizures were refractory to lorazepam. This request was then taken to the hospital pharmacy committee for review and approved. By Feb. 1, 2021, all stakeholders and committees had approved the request. The APPs then collaborated with the new EMU Nurse Manager to ensure all bedside nurses received notification of the change and education on administering the levetiracetam IV push. The EMU seizure rescue order set was also updated in Epic.
As a result of the team’s efforts, there has not been a single instance of a delay in medication administration in a patient with status epilepticus. The nurses are able to retrieve both lorazepam and levetiracetam from the Pyxis and administer them while the pharmacy is mixing and delivering second- and third-line rescue medications. Alleviating seizures as quickly as possible is imperative in patients with status epilepticus. Because of this team’s diligent efforts, patients have received high-quality, evidence-based care that has kept them from being intubated and transferred to the ICU and improved their overall outcomes.
After-Hours Telephone Triage Nursing
Telephone triage nurses have been helping guide patients to the appropriate disposition and providing standardized care advice as a best practice for several years. However, this support has not been available to patients after regular business hours. Previously, nonclinical call center staff would take patient calls after clinic operations ceased and would page on-call providers for medical advice. Unfortunately, this did not provide immediate access for patients to talk to a licensed health care provider about their symptoms, which often delayed patient care. Using the Iowa Evidence-Based Practice (EBP) as a framework, UTSW identified a root cause analysis (RCA) as a trigger issue and opportunity to improve patient care. Thus, the After-Hours Triage Program (AHTP) was born.
The goal of the program is for RNs to triage patient calls after clinic hours, ensuring the use of evidence-based decision support tools (DST). Because these nurses come from varying backgrounds, some without ambulatory telephone triage experience, they also have providers as a resource if they are uncertain on a disposition or if questions arise outside their scope of practice. Before program implementation, there was six months of prep work. The telephone triage educator initially met with the hospital admissions team to discuss launching the AHTP. The teams collaborated with local and national content experts to help with program development – including defining hours, staffing, workflows, and staff education – and determining departmental priority for the initial launch. Training for the AHTP staff included the new nurses shadowing other experienced ambulatory nurses performing telephone triage in different specialty areas. The outcome of this initiative is still ongoing. Since its launch date in October 2021, the AHTP has received 248 symptom based calls from the General Internal Medicine (GIM) Clinic. Of those calls, 39 required guidance from a provider, whereas previously all calls required a provider to address the symptoms. The decrease in provider involvement supports the idea of a “top of license” practice. When nurses have the ability to work independently, they have increased job satisfaction, which leads to improved retention.
Spreading ‘Sunshine’ in the GIM Clinic
Because COVID-19 pandemic restrictions resulted in limited ability for in-person meetings and staff celebrations, leaders in the General Internal Medicine (GIM) Clinic wished to enhance opportunities for team-building and promotion of employee satisfaction and wellness. To accomplish this, they created what has been dubbed the “Sunshine Committee.” The specific goal was to bring together the clinic’s “work family” by hosting encouraging team-building activities (one example: a Halloween holiday decorating contest that accommodated COVID-19 meeting restrictions), recognizing employee birthdays, and celebrating staff members’ “wows and wins.”
Development of the GIM Sunshine Committee has increased opportunities for staff recognition. As COVID-related in-person meeting restrictions move toward less restriction, the committee plans to continue with future team-building and recognition events to keep up positive morale.
Community Involvement and Outreach
One of the most rewarding ways UT Southwestern nurses share their experience with the community is by lending their skills, knowledge, and time as volunteers. From formal volunteer programs to impromptu acts of service, our nurses make a difference in the health and well-being of their local communities while also bettering themselves as nurses by offering their services and lending a hand. UT Southwestern encourages nurses to participate in many ways and through many local entities, putting their expertise into action and developing professionally through community involvement.
Encouraging Volunteers, Making a Difference
Continuing the Legacy of Filipino Nurses Serving on the Critical Care Front Lines
Many of the nurses at UTSW dedicate their free time to various community organizations in the Dallas-Fort Worth Metroplex. Neuro ICU nurse Melissa Cunanan, B.S.N., RN, CCRN, is a tireless, visible advocate for nursing and an active member of the Philippine Nurses Association of America (PNAA), a professional nursing organization with 55 chapters across the United States. She has served as North Texas-Dallas Chapter President and now holds an executive board role in the national organization as Membership Chairman/Assistant Treasurer for 2020-2022.
“Being part of the organization has really helped me to grow a lot as a person,” Mrs. Cunanan says. “I really found where my passion is.” That passion is palpable as she speaks about working to uphold and showcase the positive image of Filipino American nurses. “All of my days off are spent on this,” she says.
According to Ms. Cunanan, only 4% of the U.S. nursing workforce is of Filipino descent, but they accounted for about 30% of registered nurses who died of COVID-19 per the National Nurses United data. This disparity may be related to a concentrated number of Filipino nurses working at the bedside, especially in critical care units, which created vulnerabilities to COVID-19 exposure. The North Texas-Dallas Chapter of PNA, which has 75 members (the majority from UTSW) worked tirelessly to share education during the pandemic. The chapter organized a virtual Zoom webinar, "COVID-19: Boosting and Rejuvenating the Immune system Through Food and Nutrients.” The chapter also donated face shields, masks, and hand sanitizers to local elementary schools and nursing homes. Ms. Cunanan says the chapter stayed with its mission despite the pandemic by volunteering and donating to several foodbanks, volunteering at vaccination sites, collaborating with other local organizations through Kidney Care bundles, and participating in the "Mask Is a Must" campaign and in virtual health walks. The local chapter's initiatives were highlighted at an exhibit dedicated to the PNAA front-liners in the newly opened Archives Gallery at the organization’s National Legacy headquarters in New Jersey.