VA Hines

1. VA Hines / Loyola UniversityNursing CENTER for Integrated Mental Health Care�Innovation, Integration, and Investigation� 1st Annual VA Nursing Academy National Conference Chicago, Illinois August 4,2010 1

2. Hines/Loyola VA Nursing Academy Leadership Co-Directors Sharon Zandell, PhD, RN Margaret Kraft, PhD, RN Edward Hines, Jr. VA Hospital Marcella Niehoff School of Nursing Loyola University Chicago Executive Team Carol Gouty, PhD, RN Vicki Keough, PhD, RN Associate Director/Patient Dean, School of Nursing Care Services 2

3. CENTER Mission Statement To support and foster nursing education, nursing practice, and nursing research. The CENTER stresses the importance of integrating mental health concepts into the primary, acute, and long-term nursing care of veterans and their families. 3

4. CENTER Faculty Co-Directors Nancy Harris, PhD, RN (Hines) Shirley Butler, PhD, RN (Loyola) Anne Fitzgerald, MS, RN (Hines) Edwin Kopytko, PMHCNS-BC (Hines) Constance Ritzman, MS, RN (Loyola) Eugene Ryan, PMHCNS-BC (Hines) Susan Smalheiser, MS, RN (Hines) Anna Stachyra, PMHCNS-BC (Hines) 4

5. CENTER Projects Clinical Self-Injury Precaution [SIP] Monitoring Clinical Indicator of Withdrawal of Alcohol-Alcohol revised [CIWA-Ar] Implementation 5

6. CENTER Projects Innovative Pedagogy In-House Service-Learning Learning from Veteran Art Alternative learning sites Mental Health Clinical Simulation 6

7. CENTER Projects Staff Education Psychosocial Nursing content in Nursing Orientation SIP Training for Sitters/RNs CIWA-Ar Training for inpatient psychiatry RNs Workshops Conflict management content for Charge Nurse Development, Nurse Preceptors Development and Nurse Resident programs Veteran-Centered communication skills �Needs of Returning Veterans� Conference Fall 2010 7

8. Self-Injury Precaution Monitoring Identified need Root cause analyses of patient self-harm incidents on inpatient units conducted January 2009 Inconsistent standard of care for 1:1 self-injury precaution monitoring discovered No protocol, procedure, or training for 1:1 self-injury monitoring 8

9. Self-Injury Precaution Monitoring Interdisciplinary Team Formed to revise policy October 2009 CENTER faculty Inpatient nurse managers Patient safety officer Suicide prevention coordinators Medical staff Hines Chief of Police 9

10. Self-Injury Precaution Monitoring Protocol Development Facility-wide clinical nurse managers consulted Standardized �Keep It SAFE� 1:1 self-injury precaution guidelines developed Sitter responsibilities RN responsibilities Hand-off communication guidelines 10

11. Self-Injury Precaution Monitoring Training Program Facility-wide training program initiated December 2009 Didactic, handouts, Q&A Competency quiz administered Over 350 nursing staff received SIP training Part of monthly Nursing Orientation training 11

12. Self-Injury Precaution Monitoring Compliance Audit Performance improvement opportunity implemented in response to new incidents Ensure that new policy is being properly followed by staff Plan Collect data on 30 observations; at least 3 cases on each inpatient unit Findings will be used to identify additional education needed and/or workflow issues 12

13. Self-Injury Precaution Monitoring Outcomes Consistency in monitoring whole procedure will result in fewer self-injury incidents SIP policy to be integrated into a newly developed facility-wide Sitter Project SIP policy used by VISN 12 Suicide Risk Assessment workgroup to standardize 1:1 protocol 13

14. CIWA-Ar Implementation Evidence-Based Practice Literature supports that CIWA-Ar is a valid, reliable tool for measuring degree of withdrawal symptoms objectively (Addiction Medicine, 2001; Reoux, & Oreskovich, 2006; Sullivan, et al., 1989) Studies reveal link between benzodiazepine use and falls (Hartikainen, & Lonnroos, 2010) Use of CIWA-Ar may reduce amount of benzodiazepines used and therefore reduce fall rate Clinical Informatics created CIWA-Ar template for use in CPRS- August 2009 Use of CIWA-Ar piloted in Inpatient Psychiatry, January 2009 14

15. CIWA-Ar Implementation Interdisciplinary Project Team Formed July 2009 CENTER faculty Clinical Informatics Staff Clinical Nurse Managers Staff Nurses Physicians from Medicine and Mental Health Service Lines 15

16. CIWA-Ar Implementation Action Facility-wide nursing documentation guideline approved by Nursing Professional Practice Council, October 2009 CIWA-Ar presented to Nurse Executive Leadership Council for possible implementation house-wide, November 2009 Physicians from Medicine Service Line invited to explore possibility of adopting symptom-triggered dosing protocol, March 2010 16

17. CIWA-Ar Implementation Outcomes One documented alcohol detox-related fall from 10/1/09 until 4/1/10 on Inpatient Psychiatry unit CIWA-Ar score <15 became one of the criteria for inpatient psychiatry transfer 17

18. CIWA-Ar Implementation Confounding Factors for Determining Effect Physicians with different prescribing habits assigned to Inpatient Psychiatry in time period when change to CIWA-Ar occurred Use of sitters increased at the same time as CIWA-Ar introduced 18

19. CIWA-Ar Implementation Next Steps CIWA-Ar to be piloted in MICU and 7 West after educational rollout to nursing staff and physicians, Summer 2010 Evaluate effectiveness of teaching strategies by measuring inter-rater reliability in using tool Compare Veteran outcomes (fall rate, length of stay) pre- and post-change in practice 19

20. In-House Service Learning Why did we start a service-learning project? To increase veteran satisfaction To increase student visibility To increase student-veteran interaction To increase student self-confidence Confidence is the belief in one's positive achievement, persistence to continue regardless of obstacles, and self-awareness (White, 2009) Service learning experiences can promote student confidence in their own abilities (Diambra, et al., 2009; Peterson & Schaffer, 2001) 20

21. In-House Service Learning Not all clinical learning is service-learning (Peterson & Schaffer, 2001) Service learning must be reciprocal (Needs of the community drive purpose of the activity) Allows for learner reflection and persistence in action Service learning benefits (Callister & Hobbins-Garrbet, 2000) Meaningful patient-centered service Teaches professional responsibility Strengthens the academic-clinical community 21

22. In-House Service Learning Implementation Regularly scheduled 1-hour student-run group �Communication Skills� started Fall 2008 Started in Opiate Substitution Clinic (OSC) Replicated in Addiction Treatment Program 5 clinical sections have participated (45 students) 2-year group total: 58 patient groups conducted Veteran attendance average per group: 5.46 (OSC) 22

23. In-House Service Learning 23

24. In-House Service Learning Student Confidence Measurement Student Group Facilitation Confidence Tool (14-items, 4-point Likert scale) administered at the beginning and the end of each semester 24

25. In-House Service Learning Post-SL Student Feedback Very helpful for my leadership skills and understanding the patient population better. Helped improve my teaching skills. Learned that it�s not as hard as initially thought. Learned a lot about communication in my personal life. 25

26. In-House Service LearningKristina�s Reflection ..While we are there to teach about certain communication skills, it is evident for me that the teaching and learning goes far beyond the material. �By integrating nursing students with the recovering Veteran population, barriers are broken and we all can connect on a human level�. the OSC teaching experience has changed my [previously] ignorant views [on Veterans with chemical dependency problems]. 26

27. In-House Service LearningNathaniel�s Reflection It really made me appreciate my experience here, and thankful for the opportunities that we have. �I hope, for the sake of psychiatric nursing, that this idea may spread to other clinical groups as a way to gain and retain nurses in this field. In clinical, there is a wealth of man power in the students that I think should be put to good use. Being involved in the OSC group has given me this. Just being able to say hi to staff members and Veterans as I walk down the hallway is a great feeling that gives me confidence in all the things that I do at the VA. 27

28. In-House Service Learning Benefits for Students Increased veteran-student engagement �Hands-on� group leadership skills Benefits for Veterans Group attendance part of their treatment plan Learning from and teaching student nurses Benefits for Staff Opportunity to work more closely with student nurses Benefits for VA Nursing Academy Faculty An organized foundation for student teaching Collaborative opportunity 28

29. Learning from Veteran Art Visits to the National Veterans Art Museum since Fall 2006 Purpose is to promote student understanding of the veteran experience before, during, and after military service 20 clinical sections, approximately 200 students, attended Part of Nurse Residency Program Teaching Methods Reflective journaling Clinical conference discussion 29

30. Learning from Veteran ArtStudent Reflections Overall, I was really impressed with the losses, the guilt and the sheer enormity of pain conveyed through the art, which provided a glimpse into the inner life of the Veterans I will be working with at the VA. I left with a deeper appreciation of their sacrifices and attempts to process their experiences. 30

31. Learning from Veteran ArtStudent Reflections Although I cannot relate to being in combat, I can sympathize with the emotions expressed in the paintings. The work was both raw and honest, and I appreciated the opportunity to reflect on how the experience must have changed his life. It's a way for us to understand a little bit more from where the Veterans are coming from. 31

32. Learning from Veteran Art Benefits Increased empathy for the Veteran Improved understanding of Veteran lived-experience Seeing the Veteran experience within sociocultural context Reflection of oneself as a therapeutic agent in clinical practice Valuing art as an expressive therapy 32

33. Learning from Veteran Art Future Directions Measure outcomes of student confidence, knowledge, and skills Measure outcomes of Veteran satisfaction and the impact of this pedagogy on patient-centered care Incorporate experience into all mental health clinical groups Extend the experience to nursing employees 33

34. References: CIWA-Ar �Addiction medicine essentials clinical institute withdrawal assessment of alcohol scale, revised (CIWA-Ar),� 2001, January-February. Supplement to ASAM News (16)1. Hartikainen, S. & Lonnroos, E. (2010). Systematic review: use of sedatives and hypnotics, antidepressants and benzodiazepines in older people significantly increases their risk of falls. Evidence-Based Medicine, (15), 2, 59. Sullivan, J., Sykora, K., Schneiderman, J., Naranjo, C. & Sellers, E (1989). Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). British Journal of Addiction, 84, 1353-1357. McKay, A., Koranda, A. & Axen, D. (2004). Using a symptom-triggered approach to manage patients in acute alcohol withdrawal. MedSurg Nursing(13), 1, 15-31, Ntais, C., Pakos, E., Kyrzas, P. & Loannidis, J.P.A. (2008). Benzodiazepines for alcohol withdrawal (review). The Cochrane Collaboration, 3, 1-111. Reoux, J., & Oreskovich, M. (2006), A comparison of two versions of the clinical institute withdrawal assessment for alcohol: the CIWA-Ar and CIWA-Ad. The American Journal on Addictions, 15, 85-93. 34

35. References: Service-Learning Bailey, P. A., Carpenter, D. R., & Harrington, P. (2002). Theoretical foundations of service-learning in nursing education. Journal of Nursing Education, 41(10), 433-436. Bell, A. Horsfall, J., & Goodin, W. (1998). The mental health nursing clinical confidence scale: A tool for measuring undergraduate learning on mental health clinical placements. Australian and New Zealand Journal of Mental Health Nursing, 7, 184-190. Callister, L. C., & Hobbins-Garrbet, D. (2000). "Enter to learn, go forth to serve": Service learning in nursing education. Journal of Professional Nursing, 16(3), 177-183. Diambra, J. F., McClam, T., Fuss, A., Burton, B., & Fudge, D. L. (2009). Using a focus group to analyze students' perceptions of a service-learning project. College Student Journal, 43(1), 114-122. Peterson, S. J. & Schaffer, M. A. (2001). Service-learning: Isn�t that what nursing education has always been? Journal of Nursing Education, 40(2), 51-52. White, K. A. (2009). Self-confidence: A concept analysis. Nursing Forum, 44(2), 103-114. 35