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Turning a two-way street into shared community
Spring 2008  
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Turning a two-way street into shared community
By Sylvia Wrobel

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Watching the nurses at a School of Nursing faculty retreat or at a meeting in an Emory Healthcare (EHC) nursing leadership conference, it is not always easy to tell which are faculty and which just left a patient's bedside 10 minutes ago. Everyone likes it that way.
     "To truly prepare our students for the immense changes taking place in health care—and the opportunities those changes offer to nursing—we need to work in collaboration with our clinical colleagues in ways we haven't done before," says Gerri Lamb, who holds the Independence Foundation and Wesley Woods Chair in nursing.
     That goes both ways, says Noel Hunter, nursing administrative supervisor at Emory University Hospital. "Nurses in clinical practice need faculty in the nursing school as much as they need us, now more than ever. The school is educating the nurses we are going to bring into our hospitals, and we want the transition between school and our evolving nursing practice to be as smooth as possible."
     This collaborative sea change began in April 2007, when nursing Dean Marla Salmon and Emory Healthcare Chief Nursing Officer Susan Grant created a joint nursing task force. The group was charged with identifying opportunities—and barriers—to more closely align nursing education, service, and research. Chaired by Marsha Lewis, associate dean of education in the nursing school, the task force was made up of Lamb, Hunter, nursing instructor Kelly Brewer, and Sharlene Toney, director of nursing research for EHC. Meeting biweekly, the nurses barraged each other, and many of their colleagues, with calls, emails, and mounting enthusiasm.
     The team knew proposed initiatives needed to mesh with the strategic goals and the shared values of both organizations. They also quickly established priorities related to what is widely agreed to be the major issue in health care today, at Emory and nationwide: improving the quality and the safety of patient care.
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      Nursing in a time of change

Across the country, the push to improve patient safety has rapidly accelerated the evolution of nursing as a discipline. Addressing safety issues, such as avoiding medical errors or identifying places where the system could work better, requires empowering nurses and other members of the health care professions to have a greater voice in how patient care is provided across the system, as well as in their own practice.
     At Emory Healthcare, nurses have gained new power and new responsibilities through such changes as a new system-wide shared decision-making structure and unit practice councils in specific clinical areas. For example, when the unit practice council in Emory's groundbreaking neuro-ICU identified bloodstream infections and ventilator-associated pneumonia as areas of concern, clinical nurse specialists in the ICU researched the issue and found that diligent hand-washing by clinical staff and regular mouth care given to patients every four hours markedly lowered infection: evidence-based medicine that made a real difference in patient care.
     Looking at these changes, the joint nursing task force focused on three types of activities and plans: new methods of collaborative teaching; increased emphasis on the role and education of clinical nurse specialists, seen as change agents in the new environment; and visibility, ensuring that all nurses across the Emory family were aware of and felt part of the expanded collaboration.

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      Collaborative teaching: real-world lessons

For the school and the hospitals, teaching has always been a busy, collegial two-way street: students were sent to the hospitals for clinical teaching, and practicing nurses headed back to school when they wanted a master's degree or postgraduate training, as more and more do. It's far less compartmentalized, far more integrated today, says Lamb. She and Emory Healthcare's Toney recently co-taught a senior leadership course so that students could learn the tools and policy implications of new quality and safety initiatives and gain a sense of its day-to-day power from nurses who are living and leading these changes. With both of us teaching, says Lamb, these changes take on a new immediacy for students.
     Members of the task force visited and attended a symposium on the Dedicated Collaborative Unit at the University of Portland and came away convinced this new way of providing nursing education was key to the enhanced collaboration they sought at Emory. In traditional clinical rotations, students work with a different nurse each shift. In the Dedicated Collaborative Unit, staff nurses complete a clinical instruction course before being assigned one or at most, two students, with whom they work throughout the student's clinical experience. This allows these new "clinical faculty" to develop a better working relationship and more accurately track the student's development and skills set. The task force is writing up a proposal to develop the units at Emory's hospitals.
     Other collaborative initiatives in process include a possible nursing student exchange between the school and the nursing program at Napier University in Edinburgh, Scotland, and Kings College in London. Not only are there plans for student exchange, but Emory Healthcare is working on a staff nurse exchange with the Royal Infirmary Hospital and Western General Hospital in Edinburgh.
     But students aren't the only ones who are learning from the collaboration. Practitioners also are teaching each other. For example, two of the clinical nurse specialists who helped lower rates of infection and ventilator-associated pneumonia, as described earlier, presented these and other quality and safety improvement initiatives during the School of Nursing's faculty development day. Faculty now jump at invitations to attend nursing leadership meetings in the hospital and participate in key Emory Healthcare committees, exchanges that didn't happen just a year ago. In addition to numerous faculty presentations in the hospital, plans are under way to develop a research mentorship model in the hospitals, including dedicated clinical and faculty time (time being one of the barriers to collaboration identified by the task force).
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      An expanded emphasis on the clinical nurse specialist

As improving patient care quality and safety take on increasing importance at Emory Healthcare (as in all leading hospitals in the country), the strong, versatile role of the clinical nurse specialist (CNS) becomes ever more important, say task force members. Like all advanced practice nurses, a CNS receives a graduate degree from a nursing school and then passes a demanding national certification examination. But whereas clinical nurse practitioners focus on the diagnosis and care of individual patients, a CNS also focuses on populations of patients and how care can be improved in the health care system, whether in a particular hospital unit or the hospital itself. That effort is always evidence-based (integrating clinical expertise with the best available research evidence) and may involve teaching of other nurses and patients, research consultation, and management.
     Lewis, herself educated as a clinical nurse specialist, says the training and focus of CNSs uniquely position them to help advance the quality and safety agenda at Emory Healthcare. That's why the School of Nursing is currently having communication, she says, not only with Emory Healthcare but also with Emory's health care partners in the community, about interest in new education programs to allow more nurses to become eligible for CNS certification and take advantage of the growing opportunities that exist for CNS nurses.
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      Drilling down into the culture

The new collaborative initiatives began at the leadership level but for maximum power it has to become part of the culture throughout Emory nursing, say task force members. That begins with getting the word out. Today faculty and staff nurses regularly exchange columns in newsletters and include each other in orientation programs and special events. Initiatives soon to begin include preceptor and clinical faculty awards, joint recognition programs during Nurses Week, and joint Grand Rounds.
     Less than a year since the joint nursing task force was formed, collaboration and teamwork between the school and the hospitals, between nursing faculty and nurses in practice, are markedly more visible and front of mind—so much so that they've renamed the task force the Partnership Committee. "Our students already feel the impact," says Lewis, "and the faculty are increasingly excited at what appear to be almost boundless opportunities for collaboration to build nursing excellence together."
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