Exemplary Professional Practice
Compassionate, Evidence-Based Nursing 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
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.
In 2022, UT Southwestern Medical Center utilized the Values in Practice (V.I.P.) engagement survey in both the spring and fall to get the pulse of all health system employees including nurses. The survey was administered by a third-party vendor, Glint, to ensure feedback was completely confidential. The results were also analyzed by Human Resources and key leaders to identify growth and areas for improvement from both previous engagement surveys and Academic Medical Center (AMC) benchmarks. The October results of the engagement index – a summary measure of employee commitment and satisfaction from across the entire health system – came in at 80. That rating was one point higher than the February 2022 survey and four points above the AMC benchmark, consistent with pre-pandemic levels.
The survey results netted positive satisfaction comments across the entire health system for nurses in two areas overall in both pulse surveys: Leadership Support and Professional Development. Our nurses feel supported by management and confident in their pursuit of the most noble career, nursing.
The survey recognized top strengths in the nursing organization in the areas of communication, growth paths for professional development, and belief in their ability to achieve those career goals at UT Southwestern.
Making a Difference in Staff Well-Being
NOMAD (Navigating Our Multifaceted Acute Distress) was born and incubated in the UTSW Ethics Committee as a collaboration between Michael Rubin, M.D., M.A., Associate Professor in the Departments of Neurology and Neurological Surgery, and two nursing directors, Lori Hodge, D.N.P., RN, and Shelley Brown-Cleere, M.S.N., RN. Ethics committees nationwide have recognized for years the impact of moral distress when they were unable to resolve challenging situations, and they realized that a different mechanism was needed to support staff in these circumstances. Additionally, requests came in to support staff with issues outside of moral distress. With a structure already in place, the same peer support model was expanded to include distress within the health care setting. These developments launched on the groundswell of the wellness movement, which recognized that job dissatisfaction and burnout could contribute to substandard patient care and staff turnover. With the support of the Office of Faculty Wellness and Nurse Excellence, NOMAD received financial backing from the health system and has now expanded from its original group of volunteers to an established peer support system with hopes for continued expansion throughout our health care community.
In light of its Operational Goals Moving People to the Top, one of the initiatives NOMAD launched in the first fiscal quarter of 2023 was Joy Cart. In addition to offering support sessions, NOMAD began its Joy Cart mission to visit units and improve morale.
Joy Cart partnerships forged:
- Music Therapy
- Pet Therapy
- Spiritual Care
Witnessing the positivity amongst staff as they dance with their peers or amongst patients as they find comfort through the touch of a four-legged friend while sharing treats is at the heart of how and why the program is growing.
The NOMAD facilitator team hit its target growth to double in 2023, ahead of schedule, by the end of January. This allowed the NOMAD team to accommodate a wider range of times and locations for sessions. As awareness for the program has grown, so has the number of sessions held each month. More than half of NOMAD sessions for 2022 occurred in the final quarter. Session requests began to be tracked in REDCap beginning in 2023.
- 16 facilitators (at time of publication)
- 39 sessions in 2022
- 20 sessions held in the final FY2022 quarter
The value of attending a session was recently highlighted by a staff member who shared, “I just feel 50% better after being heard – I feel lighter.” The NOMAD team is grateful for the unilateral support from UT Southwestern leadership.
Nursing Peer Review
The UT Southwestern Nursing Peer Review Committee (NPRC) marked 2022 with growth and innovation. In January 2022, when Omicron variant cases began to spike, NPR (Nursing Peer Review) leadership quickly pivoted to keep all staff members safe during proceedings. The committee implemented a virtual resource binder for members to use during proceedings conducted via Microsoft Teams. All pen and paper resources were digitalized in OneNote, and other portions of the determination process transitioned to REDCap links for ease of use and accessibility. Moving to a fully online platform for proceedings also made it easier to navigate the chart for questions posed by the committee and to hear all responses and discussion. This new format also improved accessibility for ambulatory staff and removed barriers to getting involved because staff did not need to leave their clinic site to get to meetings at the hospital. As 2022 closed, the NPRC reimplemented in-person hybrid meetings for hospital-based reviews but maintained use of virtual OneNote binders by using tablets for necessary resource materials.
These innovations helped us grow the committee’s membership. The NPRC is responsible for reviewing the individual practice for nurses at every level of licensure. To accomplish this, we have worked to grow our membership by partnering with our ambulatory clinics, as well as advanced practice provider and ambulatory clinic leaders. To date, our membership has grown to eight APRNs (advanced practice registered nurses), 33 RNs (registered nurses), and five LVNs (licensed vocational nurses). We work to ensure that a nurse’s specialty is represented in his or her peer group and that his or her approximate years of experience are also represented by a voting member for their review.
Involving NICU Parents in Innovative Initiatives
Parental involvement in infant care is an essential component of parental satisfaction in the Neonatal Intensive Care Unit (NICU) at UT Southwestern. In spring 2022, a new committee was developed to address a need to involve parents more in the care of these tiny and vulnerable patients. The NICU Family Support and Satisfaction Committee, led by Jamie Del Valle, RN (Chair), and Roxann Davis, RN (Co-Chair), was formed to identify ways to involve parents, elicit parental feedback, and support parents in their journey through the first part of their infant’s life.
Through the collaborative work of the committee, initiatives were developed to include parents as partners in care in their infant’s early stages of development. A literature search located several articles that provided valuable information for guiding interventions. The activities implemented included an infant library with books for parents to read, footprint and milestone cards for the baby book, and enhancing communication through whiteboards and multidisciplinary rounding. One innovative measure, funded by a set of parents, was called Beads of Courage. This program offered a bead to parents whose infants were experiencing something that could represent an act of courage to overcome, such as a day in the NICU, a needlestick, a therapy, or any event that could be painful or uncomfortable. Parents were able to string their infant’s beads together into a memento of hope that they could take with them upon discharge.
Many fun initiatives were also included, such as holiday celebrations that allowed parents to dress their babies in costumes for Halloween or Super Bowl jerseys for the big game, or giving holiday ornaments to families at discharge as a souvenir of their infant’s holiday in the hospital.
The NICU Family Support and Satisfaction Committee has been an important part of improving parents' experience and satisfaction during their infant’s care. The work of this committee has also increased the satisfaction of NICU staff members, who have enjoyed coordinating activities for the infants and providing memorabilia for the parents to take home and share with their children as they grow up. To continue with this great work, the committee is now preparing to implement a parent panel as a means of growing and receiving feedback on parents’ perception of the care their infant received while in the NICU.
ERAS Collaboration Creates Patient-Centered Post-Op Checklist
Seven Orange is a 32-bed medical-surgical unit at UT Southwestern Medical Center that provides care to patients after surgery. Patient immobility after surgery can contribute to postoperative complications such as pneumonia, deep vein thrombosis, and ileus. Enhanced recovery after surgery (ERAS) encourages early mobility of eligible patients to promote improved rehabilitation and facilitate recovery.
In 2022, the 7 Orange leadership team collaborated with the ERAS team to optimize postoperative documentation of daily ERAS goals. A multidisciplinary team was formed that included nursing, advanced practice providers, anesthesiologists, clinical educators, and members of the quality and operational excellence departments. This team’s efforts were focused on developing a patient-centered post-op paper checklist to document daily goals in real time.
The team endeavored to improve both out of bed to chair (OOBTC) and ambulation of postoperative colorectal patients from baseline (OOBTC: 47% and ambulation X3: 35%) from August 30 to November 31, 2021. Each week, department leadership communicated data trends and findings to frontline staff by reviewing charts of patients with completed paper checklists. The ERAS team shared results weekly with the nursing leadership team and presented updates at 7 Orange staff meetings to collect feedback from frontline staff.
Documentation of OOBTC and ambulation of postoperative colorectal patients improved during the pilot period (significant at p = .0017). Seven Orange staff feedback suggested the use of the post-op checklist improved nurse-to-patient communication by providing a useful roadmap for the patient to anticipate their plan of care by post-op day. One of the major benefits of the checklist was the involvement in the healing process. It helped patients know they had a specific plan designed for them and that they were collaborating with the physician and nurses in the process of recovery and healing.
Expanding Lactation Services to Improve Prenatal Care
Several factors have contributed to more mothers choosing breastfeeding rather than using formula. Many mothers consider the overall benefits of infant health, having milk readily available, and not having to manage shortages of formula caused by supply chain limits as important reasons to breastfeed their babies. Even with known benefits, barriers to breastfeeding remain. For many, the costs associated with paying for lactation services and consultation are significant barriers. The Women’s Resource Center at UT Southwestern believes the responsibility to promote, protect, support, and improve breastfeeding rates encompasses prenatal care through the postpartum period. So, in spring 2022, several initiatives were planned to address patient needs and to offer expanded lactation services.
Despite the Affordable Care Act requiring payment for lactation services to be covered by medical insurance, the law limited coverage to services provided by physicians and midlevel providers. Training limitations and time constraints prohibited these providers from offering counseling and assistance comparable to an internationally board-certified lactation consultant (IBCLC). To address this gap in care, the Women’s Resource Center established several objectives to guide its work and overcome obstacles to affordable, accessible lactation support. These objectives included:
- Offering lactation consults to postpartum women at no charge to increase accessibility
- Offering lactation consults to postpartum women returning to their UTSW faculty clinic obstetrician for a follow-up appointment
- Acquiring an accurate list of UTSW patients who are in their 32nd week of a viable pregnancy and providing educational lactation information to them
- Scheduling lactation education classes
- Creating a process to have telehealth visits with clients for lactation consults
Interprofessional collaboration between faculty clinic staff and departments such as Compliance, Financial Services, Informatics, and Information Technology resulted in the planning, development, and implementation of these initiatives by November 2022. Major accomplishments from these initiatives included having an expanded presence at the faculty clinic for lactation consults, and patient financial services authorizing not charging for lactation services as an extension of peripartum and neonatal care. The Women’s Resource Center continues to work on these processes with its staff and interprofessional partners.
Lowering Patient Wait Times at Simmons Cancer Center
In 2022, Simmons Cancer Center (SCC) provided more than 21,000 infusions to oncology patients. The infusion clinic is staffed by oncology-certified registered nurses who communicate regularly with patients’ primary oncology providers to address infusion-related issues. Communications include questions regarding chemotherapy, biotherapy, or immunotherapy parameters; clarification of orders; symptom management or adverse reactions; and lab abnormalities. If a provider is unavailable, the communication is escalated to the provider in attendance (PIA). Monday through Friday, providers serving as PIAs are also committed to fulfilling clinical responsibilities, both inpatient and outpatient, which may lead to additional contact delays. The communication flow outside of infusion might impact care by creating delays both with patients' infusions and by interrupting clinic/unit workflows. The workflow also relies on the SCC infusion RN assessment and may result in additional patient appointments for further evaluation by the primary clinical team.
In 2022, SCC infusion patients waited an average of 45 minutes from the time they checked in to the time their infusion was started. Increased wait times are known to negatively impact patient experience, and ultimately, they likewise negatively impact the nursing experience. In 2022, increased wait times required approximately 70% of infusion RNs to stay 1-1.5 hours beyond closing hours. Barriers experienced by infusion RNs in coordinating treatment for patients have frequently been identified as a reason for burnout. These combined factors led to the development of a new role for an oncology infusion-designated advanced practice provider to be present in Infusion and readily available to respond to urgent issues and serve as the PIA. With all of this in mind, the SCC established goals to improve patient access, decrease wait times, and facilitate quality patient care by serving as a direct resource for patient and nursing education.
To achieve the goals set forth by SCC, the oncology infusion APPs deployed several evidence-based interventions and process improvements. First, a work group consisting of nursing and APP leadership was created to define the responsibilities of the oncology infusion APP role and to obtain buy-in from SCC stakeholders and leadership. Next, a pre-intervention survey was created and distributed via REDCap to assess provider and nursing satisfaction with the current infusion workflow.
Based on SCC infusion hours of operation and patient volumes, three full-time oncology infusion APP positions were approved and recruited to start providing the service January 2, 2023. A data collection plan with a list of metrics was created by a multidisciplinary team to measure the success of the oncology infusion APP role. A request for assistance (RFA) form was submitted through UT Southwestern Health System Quality and Operational Excellence to garner the help of a quality analyst to build the outcome measures and make them visible for review. Communication of the role has been discussed at service line/disease-oriented team meetings to solicit feedback on the role description and operational processes.
Due to the work group’s efforts, three infusion-dedicated APP positions were approved, and two APPs were hired in November 2022. After the implementation of the Dallas Infusion APP role in January 2023, the team anticipates seeing a decrease in wait time for infusion services and an increase in both patient and nurse satisfaction due to multiple factors, including length of time between diagnosis and first treatment, APP patient education, and improvement in the oncology clinic workflow. The infusion-dedicated APPs will improve patient access to care and facilitate quality patient care.
Wound Care Patient Support Using Comprehensive Therapy Plans
Oftentimes, nurses create innovative solutions when they consider their patients’ needs from a perspective of compassion and empathy. When patients have an ostomy surgically placed, many aspects of their lives change drastically – their eating habits, elimination processes, and body image are all permanently affected. Team members in the UT Southwestern Wound Care Clinic care for patients who are susceptible to feeling overwhelmed, stressed, or isolated because of these changes in their bodies post-procedure. Patient education is often a way for staff to reduce the emotional, mental, and spiritual distress patients experience associated with ostomy placement.
To address patient needs, nurses in the University Hospital Wound Care Clinic (WOC), Colorectal and Urology clinics, and Clinical Informatics Center collaborated to identify more effective ways to support this population. To begin, wound ostomy nurse Liēla Taylor, B.S.N., RN, CWON, sent a survey to patients who recently had ostomy placement surgery. The survey was designed to collect feedback from a patient perspective on how to provide the best support. Survey results determined that education needs extended beyond the inpatient setting and confirmed an opportunity for outpatient and inpatient surgical and ostomy nurses to work together. This information helped the team decide to focus their combined efforts by creating a comprehensive, standardized approach to ostomy education across the health care continuum.
From the larger group, a task force including Ms. Taylor, Michele Houghton, M.S.N., RN, AGPCNP-BC, Rachel Shearon, B.S.N., RN, and RoviElle Brisco, M.S.N., RN, was formed. Regina Lowe, LVN, Tammy Rodriguez, B.S.N., RN, and Samantha Aguilar, B.S.N., RN, joined thereafter to have full representation and expertise from each setting that provides care for ostomy patients. The goal of the task force was to focus the work of the team more fully on best practices, patient satisfaction, educational needs, and efficiency.
Over the course of approximately a year, the team developed a comprehensive and innovative educational program that met all the requirements of the Ostomy and Continent Diversion Patient Bill of Rights (PBOR) as defined by the United Ostomy Associations of America (UOAA). The program officially started in July 2022, ensuring UTSW was meeting the best practice standards in providing comprehensive education for patients with a new ostomy.
The team worked together to review and revise the process and content of patient education for those who were expected to have an ostomy placed. The newly designed patient education not only involved two detailed classes but also one-to-one guidance offered by nurses who connected with the patient after the surgery. For the new education process, Ostomy Class I, primarily taught by Ms. Lowe for the Urology Clinic and Ms. Shearon for the Colorectal Surgery Clinic, was designed to review the surgical procedure to place the ostomy, offering patients a high-level overview of what to expect, possible complications, and planning for the surgery.
Ostomy Class II, led by Ms. Houghton, became a weekly two-hour ostomy class assisting up to five patients and their families with new ostomies. Class content has been redesigned to review pre- and post-surgical considerations in depth, with topics such as bathing, dressing, and expectations on stoma appearance through the healing process. During this class, patients receive hands-on experience manipulating a simulated stoma and ostomy bag, providing a realistic understanding of day-to-day pouch maintenance and emptying. In addition to increasing patient education and familiarity with ostomy care, the class provides an opportunity for patients undergoing the procedure to obtain peer support.
Personalized, hands-on training was also implemented by the team. Updates to the program include changes to pre- and postoperative meetings with patients and families regarding the care and maintenance of their new ostomy. Now, immediately after ostomy surgery, the WOC nurse determines goals, milestones, and teaching points for each day post-surgery. A WOC nurse visits the patient for 3-4 days while they are still in the hospital and provides teaching that meets all of the requirements of the PBOR. In addition, patients participate in two sessions with the WOC nurse that offer hands-on training and support. After discharge, the patient meets with the wound care clinic provider and board-certified WOC nurse at two weeks and then again at three months post-discharge to discuss topics such as resources, information on support groups, and reinforcement of prior teaching. Patients then follow up annually and can use the clinic nurse as an ongoing resource who they can visit in person or contact via MyChart for additional long-term support.
Early feedback on the program has been encouraging. Another positive effect has been relationship building between patients who attend the class together. Participants have reported to the facilitators that the class helped them realize that they are not alone and they are no longer afraid to ask questions on this sensitive topic. A post-class survey is in development for more targeted feedback on the education process.