dartmouth hitchcock nursing year in review 2012

Dartmouth-hitchcock NursiNga Year in review2012

Dear nursing colleagues:

this special edition of D-h nursing serves as our 2012 nursing annual report, published annually during national nurses week. it is an opportunity to pause for a moment and consider the great work of our colleagues and peers over the past year. more specifically, it is an opportunity to highlight and celebrate the revision of the nursing Strategic Plan and the exciting direction it sets for the future.

in 2008, the nursing Practice council participated in a comprehensive review and development of a nursing Strategic Plan. Given the organizational changes of 2011 and 2012; however, the timing was perfect to review the plan and determine where revisions would be helpful. in February 2012, all members of house-wide shared governance councils, all chairs of unit-based councils, and nursing leaders were invited to a day-long retreat for the purpose of identifying revised or new goals for our nursing community and specific activities or issues to be addressed. as it turns out, the timing of the nursing Strategic Plan revision aligned perfectly with the development of the Strategic Plan for Dartmouth-hitchcock.

under the leadership of Dr. Jim weinstein, ceo and president, D-h has a clear focus and direction for the future: improving the health of the population, providing value-based care and moving to new reimbursement models. throughout 2012, the nursing community revised and developed the nursing Strategic Plan to flow from and align with the D-h Strategic Plan. in the fall of 2012, we were able to kick-off the revised nursing Strategic Plan in concert with our new shared governance year. the plan provides focus and direction for the work ahead of us as a professional nursing community and supports creating a sustainable health system to improve the lives of the people and communities we serve. it also incorporates our nursing mission and two high-level goals: a healthy care environment and a healthy work environment.

i am extremely proud of our nursing Strategic Plan because it reflects true collaboration between direct care nurses and

formal nursing leaders to set a direction for our nursing community that reflects our needs going into the future. the engagement of nurses throughout our unit-based and house-wide councils has been tremendous and the commitment to excellence expressed by all nurses is gratifying.

the following pages tell the story of this great work and of the commitment of each of you to provide care that is of the highest quality and safety and that creates true value over time. i am grateful to the leadership of cheryl abbott, your staff nurse executive chair, as she has been a driving force behind the strategic plan development as well as a revision to our Shared Governance structure. Beginning in april 2013, cheryl became a member of the newly revised D-h Board of Governors, the first direct care nurse in the history of our great organization to hold this position – certainly something to celebrate during national nurses week. i am confident she will represent you well in the same way. i am confident that you will continue to provide skilled and compassionate care to our patients and families every day.

my sincere thanks,

Linda

Linda J. von reyn chief nursing officer

Dear nursing colleagues:

we came together in early 2012 for an enthusiastic and thoughtful discussion of our nursing Strategic Plan. clear themes of communication, coordination and collaboration emerged from that conversation. in the setting of our evolution toward one D-h, redesigning Shared Governance is a significant achievement and a key strategy for communication, collaboration and coordination across our integrated health system.

we are dedicated to providing protected time and the right structure for this important work, and dedicated to appreciating the leadership and insight of nurses at all levels, in all practice areas. Leveraging that nursing leadership and insight will be essential to achieving our organizational and professional goals as we have described in the nursing Strategic Plan.

with our new bylaws, we welcome the innovative ambulatory clinical council, representing six D-h campus communities; and create the coordinating council, a groundbreaking group that opens the door for our colleagues throughout D-h to engage a diverse group of nursing leaders in organizational work. we appreciate the renewed focus and dedication of our unit-Based councils, Quality Practice council, research council and Professional Development council to achieving the healthiest possible environment of care.

in reflection of our shared commitment to working together in a culture of caring, for our patients, for the future of D-h and for the future of nursing, i thank you for a very exciting year and look forward to new challenges to come.

cheryl L. abbott, mSn(c), cnrn

Staff nurse executive chair, D-h Shared Governance

Professional Practice modelDefining and Differentiating nursing Practice at Dartmouth-hitchcock

At Dartmouth-Hitchcock (D-H), “nurses

are very focused and have a lot of specialty

expertise,” says Paula Johnson, BSN, MPA,

DA, RN, a note of pride evident in her

voice. “But it’s sometimes difficult to get

at what are the foundational principles

that guide nursing practice across the

entire organization.” That “but” is what lies

behind a relatively new initiative within

D-H Nursing — the introduction of a

Professional Practice Model (PPM).

Johnson, the clinical program coordinator for magnet and retention, is taking the lead on the initiative. its goal, she says, is that, “regardless of which setting you walked into, every single nurse could speak to how the Professional Practice model guide my practice and how does it come to life in my care setting.”

a PPm “drives nursing practice in a particular organization,” Johnson goes on, and “is made up of multiple elements as defined by the nurses at that organization.” the elements must be both meaningful to nursing staff and “in alignment, of course, with the organizational mission and vision and goals.”

PPms, which are becoming increasingly common, especially at magnet hospitals such as D-h, contain five common elements: a statement of values; a

STRATegic iNiTiATive: iMPRove PoPuLATioN HeALTH

declaration about professional relationships, both internal (such as collegiality) and external (such as participation in professional organizations); an approach to professional development; a description of the care delivery system; and a description of leadership and governance structures.

a given institution “then does the work of identifying what [each element] looks like for us as an organization,” says Johnson. the goal is to capture “what defines and differentiates nursing practice at D-h as opposed to another organization.”

She believes the way is paved for the smooth introduction of a PPm at Dartmouth-hitchcock, because “we have several of the elements of what would normally be in a model in place already.”

For example, “in the values category, we have a long-identified mission for nursing at D-h, about 20-years old now, to create an environment in which patients and families can heal.” another element that’s essentially in place is an articulation of nursing’s leadership and governance structures — as evidenced, Johnson says, by “Linda von reyn, as our chief nursing officer, driving and being responsible for nursing throughout the organization.” in addition, Johnson notes, “we have had shared governance in place since the 1980s and have continuously evolved it, to make sure that it keeps pace with changes in the organization and with where we want nursing to be within the organization.”

other existing programs or concepts that Johnson sees as fitting well into the PPm approach include: D-h’s vision to achieve the healthiest population possible, the Live well/work well employee wellness initiatives and the

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increasing focus on providing relationship-Based care. the work of putting flesh on the bones of a D-h

Professional Practice model has just gotten under way. however, says Johnson, “there are a lot of best practices out there that i’m sure we’ll be drawing from as we move forward.”

already, for example, she knows that familiarizing staff with the terminology and definitions specific to PPms will be essential. “this will provide a common language for nurses,” she explains, “so that everybody, regardless of where they’re practicing and what their role is, can identify with the model.”

in addition, Johnson says, staff “will want to

STRATegic iNiTiATive: iMPRove PoPuLATioN HeALTH

understand why this is important — what does it mean to me as a nurse practicing here. ... it’s something that will have to involve every nurse throughout the organization, as far as the dialogue about what is meaningful, what are the elements we think are important. what takes the time is [fostering] real engagement across the organization.”

a Professional Practice model is, in other words, not a spectator sport. So Johnson may be serving as its spokesperson right now, but “this is something that we’re going to expect everybody to participate in the development of over the coming year or two years,” she concludes. ●

In the values category, we have a long-identified mission

for nursing at D-H, about 20 years old now, to create an

environment in which patients and families can heal.”- Paula Johnson, BSn, mPa, Da, rn

Left to right: Janice chapman, BSn, rn; Paula Johnson, BSn, mPa, Da, rn;

mildred Sattler, BSn, rn, ccrn

Shared Governance redesignexceptional commitment to transformational Leadership and Structural empowerment

“Shared Governance is not unique to

Dartmouth-hitchcock,” points out

cheryl abbott, mSn(c), cnrn, the staff

nurse executive chair of D-h’s Shared

Governance structure. “But we make

a commitment to Shared Governance

that really stands out, even among our

magnet peers.” abbott, who is a certified

neurosciences registered nurse, was elected

by her peers from across the organization

to lead Shared Governance at D-h.

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cheryl abbott, mSn(c), cnrn, right mary Jean mueckenheim, rn, left

STRATegic iNiTiATive: iNTegRATeD HeALTH SySTeM

8


what makes D-h nursing Shared Governance stand out, abbott explains, “is the engagement of nurses at all levels, from all practice areas in the strategic planning process. that creates a forum for feedback, new ideas and goals to emerge.” the Shared Governance structure then adapts to support the work. “my role, as staff nurse executive chair, is dedicated to nurturing that structure.”

the latest evidence of this dedication was a

redesign of the Shared Governance structure to expand participation and improve commuication and coordination among clinical nursing staff leaders. abbott notes that Shared Governance has evolved over at least three decades at D-h. its structure and terminology have changed over the years, but there have been three constants: fostering communication, advancing nursing practice and improving patient care.

c o o R D i N A T i N g c o u N c i L

● More funding from the central Shared governance budget for the uBcs to give their chairs “a little more protected time,” explains Abbott, “to do the very important work of both participating in a house-wide forum, and then taking that work back to their unit for local feedback and implementation.”

u N i T - B A S e D c o u N c i L

UBC UBC UBC UBC

Professional Development

Council

Research Council

Quality Practice Council

Ambulatory Clinical Council

H o u S e - W i D e c o u N c i L S

Nursing Senior

Leadership

$ $ $ $

● More alignment in the way the unit-based councils (uBcs) function.

● Inclusion of the UBCs in the D-H Shared governance Bylaws.

● Reconfiguration of the house-wide councils. There are now four such groups. Two have had a consistent focus for some time: the Professional Development council and the Research council. And two are new additions: the Quality Practice council (a merging, to avoid duplication of effort, of previously separate Quality and Practice councils) and the Ambulatory clinical council (“one of our challenges,” notes Abbott, “has always been coordinating with our colleagues in the ambulatory-care clinics”.)

● The creation of a Coordinating Council, made up of the chairs of all the unit-based councils, the chairs of the four house-wide councils and Nursing’s senior leadership. “The units were feeling that they were not in as close touch as they wanted to be with the house-wide councils,” says Abbott, “and the coordinating council functions as a two-way conduit for information.”

The recent redesign — the outcome of a retreat in February 2012 that brought together over 100 nurses from across the organization — included the following changes:

the coordinating council, she notes, is proving to be “a wonderful networking forum for unit-based leaders to talk to each other about what they’re doing on their units,” while at the same time serving as a locus for “more strategic work, organizational work — issues, policies and concerns that generalize across the organization.” By contrast, she says, “the Quality Practice council is focused a little closer to the point of care — deep diving into care-delivery, nursing practice and nursing quality issues.”

an important goal of the changes, abbott points out, was “seeking to engage direct-care staff as early and often in the policy-making process as we possibly can.” input from the front lines “is necessary to get the best patient outcomes, to promote a feeling of accountability [among staff] for their own professional practice and growth, and to give those people that want to develop professionally the resources to do so.”

Grace St. Pierre, BSn, rn-Bc, a staff nurse on the 2 west inpatient Surgery unit, represents a case in point. “i’m a unit-based council chair,” she explains, “and with the redesign, that has given me a seat on the coordinating council and on the Quality Practice council.” when a matter comes up at the coordinating council or at a house-wide council level, part of the charge for people in positions like hers, says St. Pierre, is to “bring that information back to the units and make it real and applicable” at that level. the uBc chairs have a further charge, she adds. another “part of their responsibility is to bring back information from the house-wide councils to the uBc.” From there, the uBc members “disseminate the information with the rest of the floor, because we all may not work together on the same day or see the same people.”

while the structural changes are too new for their long-term effect to be clear quite yet, “we think there’s been an energizing effect,” says abbott. She believes the uBc chairs appreciate “the expanded protected time for that work,” as well as “the commitment to giving direct-care staff an opportunity to both provide feedback and gain insight in the policy-making stage.”

St. Pierre agrees. already, she says, she is observing “richer discussion on the unit level. i think that there’s less misinformation out there,” she adds, plus a feeling among frontline staff of being more involved stakeholders.

“i’m really excited to see what the future holds for Shared Governance at Dartmouth-hitchcock,” she concludes. ●


Grace St. Pierre, BSn, rn-Bc, centerJulia coffin, BSn, rn, right

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the value institute Process improvement at its Best

“wax on, wax off”: no one who has seen

the movie Karate Kid is likely to forget

the way mr. miyagi teaches Daniel the

importance of process.

nor is anyone trained at D-h’s value

institute likely to forget the importance

of process improvement. take Buffy

meliment, BSn, rn, who’s been at D-h

since 2001. “i’ve worked on a lot of issues

through the years,” she says. “historically

it could be frustrating, because you have a

lot of opinions and a lot of conversation”

... but she felt it was not always clear

how to make actual improvement. this

could be because not everyone was

approaching the process in the same way.

the value institute, established in 2011,

“gives us a common language around the

improvement process and the tools to

work through the process in a systematic

way, so you actually see improvement

happen,” continues meliment. “and not

only happen, but be sustained.”

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STRATegic iNiTiATive: LeADeRS iN vALue

<< Buffy meliment, BSn, rn


her regular job is as a pediatric staffing resource team nurse. She became acquainted with the value institute thanks to two temporary roles — as a project specialist supporting nursing quality improvement and patient safety, and as a master of Science student at the Dartmouth institute for health Policy and clinical Practice.

the value institute follows the Dmaic — define, measure, analyze, improve and control — model of the Six Sigma process-improvement system. it comprises four levels of training. “whitebelt training is a series of six online learning modules that employees are expected to do when they’re hired,” meliment explains. two-day Yellowbelt training is for staff who serve on a project team. Five-day Greenbelt training is for team leaders. “Blackbelts go through much more extensive training,” meliment concludes, “then provide mentorship and coaching to Greenbelts or Yellowbelts.”

meliment earned her Yellowbelt in December 2011, then served on a team looking at pediatric readmissions. in June 2012, she got her Greenbelt and led a project aimed at reducing catheter-associated urinary-tract infections (cautis).

in the past, she says, “everybody would have an opinion” about how to fix a given problem. indeed, “when we brought [the cauti team] together, there were a lot of thoughts about why these infections were happening.”

But “with the tools from the value institute, we’re able to measure what actually happens.” in the case of cautis, “what we felt from working on the clinical unit — anecdotal evidence — was very different from what the data showed us.” the team thought what needed fixing was adherence to best practices, such as keeping catheters secured to the patient’s leg, below the bladder and off the floor. But staff “felt we were using catheters for appropriate reasons,” says meliment, “so that’s not what we needed to look at.”

in fact, “we found that catheters were secured, they were below the bladder and they were rarely on the floor. we were performing much better than the nurses thought in that area. But catheters were being used for indications that were not

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appropriate,” though nurses “felt we were using them appropriately.”

the improve and control steps followed close behind. “we were able to achieve 100 percent [compliance with usage guidelines] within two weeks,” says meliment. “i can’t say we’re at 100 percent every week since then, but the nurses are continuing to use the tool on a regular basis.”

“other nurses have had the same experience,” she adds. “as you use the tools and start to see meetings that really move forward, there’s been great buy-in.” meliment believes the program’s hands-on and coaching aspects are key. “this isn’t just a class you sit in, where you learn some tools that you

in the past everybody would

have an opinion about how to

fix a given problem. indeed,

when we brought [the cauti

team] together, there were a lot

of thoughts about why these

infections were happening.”


might use some day. You’re involved in a project where you immediately start to use the tools.” and, she says, “you’re not just left with ‘here’s your five days of training, go perform,’ but you have ongoing mentorship.”

karen Pushee, rn, ma, the nursing manager of the cardiovascular critical care unit and the intermediate cardiac care unit (iccu), is another fan of the value institute. She’s currently leading a project on the iccu patient discharge process from the perspective of nurse practitioners. the hope is “to get patients out earlier,” since iccu beds are at a premium.

this project hasn’t reached the improve stage yet, but “we’ve begun to appreciate all that goes into a discharge,” Pushee says. it’s a process with lots of moving parts — such as ensuring that all tests get done, that a skilled nursing bed is available if the patient is going into rehab, or that a ride is available if the patient is going home — and lots of opportunities for glitches — such as a patient who’s ready to leave by 11:30 am but a ride that can’t be there until 5:30 pm.

Pushee echoes meliment on the program’s mentorship aspect. her coach has helped her understand that “if you jump to easy fixes, you may be missing some big pieces of the process that will be an obstacle down the road.” once you “appreciate the process,” she says, “then you have faith in it.” ●

Once you appreciate the process,

then you have faith in it.” - karen Pushee, ma, rn

agewiSe ProgramSharing knowledge; Professional renewal

When her elderly patient's brother asked

how his sister was doing — and then

started to cry — Meghan Poperowitz, BSN,

RN, immediately “recalled Mike's story.”

Poperowitz, a staff nurse on 1 east, is a recent graduate of D-h’s agewiSe nurse residency program. the story she remembered at that critical moment — shared with agewiSe participants by mike waters – D-h's director of treasury and investments for the Finance Department — was about when first his mother and then his father were near death in health-care facilities in rockland county, new York.

“there were incredible nurses that were kind and considerate,” waters says, “but the nurse we’ll remember forever is one who yelled at my dad and made an awful situation 10 times worse.” the family had just agreed that his mother should go on a ventilator, and this nurse “actually scolded my father — said, ‘i can't believe you're doing this. She has end-stage cancer. what's the point?’ Something very harsh.” the family, “stung by the comment,” had received no palliative-care counseling.

a couple of years later, waters and his siblings had just decided to put their dad on comfort measures only (cmo), after nine months of decline following a massive heart attack. “a nurse who didn't know us, didn’t know my dad ... said to us that we were making a huge mistake, that we would regret it for the rest of our lives — something like ‘You should be ashamed of yourselves.’”

“we got great care in the sense of the technology,” waters says, “but we got so little guidance. ... none of the nurses, none of the doctors, framed any of

the options for us. So what i’ve told the agewiSe group on behalf of patients and families like mine is ‘talk to us.’” he also reminds them that “if, in just one moment, you don’t treat the family with respect and honesty, you can ruin all the good work you’ve done.”

it was these lessons that Poperowitz recalled when her patient's brother approached her. She wrote about the incident for an agewiSe newsletter put out by massachusetts General hospital, which established the program and invited D-h to be one of 12 institutions to pilot it. the brother, Poperowitz related, “asked me again what i thought was happening. although we were always told to put the question back to the person asking, i recalled mike’s story, and i felt obligated to share my observations and feelings. i told him i thought she was dying. he grabbed my hand and said ‘thank you.’ he said he felt the same.” after the patient was put on cmo, “the brother kept returning to me, thanking me for being ‘honest.’”

Stories like this gladden the heart of Deanna orfanidis, mS, rn. as the administrative director for critical care and surgical services, she is agewiSe's

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STRATegic iNiTiATive: iNNovATioN

site director at D-h. “a lot of this work isn't quantitative,” she explains, “it's more qualitative. But our sense is absolutely it's having an impact,” thanks to stories like Poperowitz’s.

agewiSe is a six-month residency in geropalliative nursing care and policy for direct-care nurses. they spend two days a month in classes — and listening to speakers like waters — then apply what they’ve learned on their units. it’s been such a success at D-h that orfanidis is “in discussion with Linda von reyn, our nurse executive, about developing a budget for agewiSe to continue it here” after the pilot funding ends. much of the credit for its success, she adds, goes to “nancy Scalise and Jeannette hoag, who have done 80 percent of the work. they were in the first cohort,” she notes. “we've seen leadership grow out of that cohort.”

in fact, she adds, “that's one of the core concepts — how do you spread [the learning] to your colleagues.” For that reason, those chosen for agewiSe include both senior nurses, with 20 or more years of experience, and junior nurses, with two to five years of experience. “the more experienced nurses then

mentor the junior nurses,” orfanidis explains.Professional renewal is another core principle, she

says. “You're giving folks an opportunity to debrief around this really tough work.”

Participants also undertake specific projects. “the first cohort created a symbol — a daisy with a falling petal,” says orfanidis. “if that's posted outside a patient’s room, it means comfort measures only.” So, for example, “dietary doesn't come in, and you know to keep the noise down.”

the current cohort “is working on what we call a Get-to-know-me poster. especially in the critical-care setting, we often have patients who are unresponsive. But who is that person? they’re a father, they’re a mother, ... maybe they’re an engineer.”

waters has been “really impressed” with the participants. “they ask the right questions, honest questions.” as he watched junior nurses interacting with more experienced peers, he recalls thinking, “how great for them that they’ve come to work at an organization where they’re encouraged to be active in this process, to improve their skills. i walked out feeling very hopeful.” ●

The brother asked me again what I thought was

happening. Although we were always told to put the

question back to the person asking, I recalled Mike’s story

and I felt obligated to share my observations and feelings.” - meghan Poperowitz, BSn, rn

the word “unique” is often misapplied

to things that are merely unusual or

innovative. But a program at Dartmouth-

hitchcock (D-h) that goes by the acronym

of i-SurF-n is not just uncommon or

novel but actually unique — one of a kind.

the “SurF” part of the program’s name stands for Summer undergraduate research Fellowship. the “i” refers to its funding source — a $15.4-million federal grant from the iDea (institutional Development award) networks of Biomedical excellence, or inBre. and the “n” salutes the fact that it's the only inBre grant in the nation to include a nursing component.

the 24 inBre programs nationwide are intended to foster collaboration among institutions with significant federally funded research programs and small undergraduate schools in the same state. D-h and the university of new hampshire (unh) are the lead institutions for the new hampshire inBre.

when the grant's principal investigator, a professor at the Geisel School of medicine, asked if D-h was interested in having nurses involved in the initiative, the response was an enthusiastic yes. But, recalls mary Jo Slattery, mS, rn, the clinical program coordinator for nursing research at D-h and i-SurF-n's program director, “i looked high and low and couldn’t find anything to model it on. So we developed it from scratch.”

i-SurF-n is now entering its third year. undergraduate nursing students from Saint anselm college, colby-Sawyer college and unh apply to

spend the summer between their junior and senior years at D-h. they’re introduced to three different nursing research roles: "one of those roles is nurses conducting nursing research,” says Slattery. another is nurses who coordinate clinical trials, often drug trials at D-h’s norris cotton cancer center. “the third role is translation of research at the bedside,” concludes Slattery, “an advanced practice nurse involved in either evidence-based practice or quality improvement.”

During nine weeks of the 10-week i-SurF-n program, students are paired with both a nurse researcher and an advanced practice nurse and work on two projects simultaneously with their mentors. For the other week, says Slattery, “they go to the cancer center and work one-on-one with a nurse there who coordinates a clinical trials research experience, so they're exposed to Phase 1, Phase 2, and Phase 3 clinical trials.”

numerous other experiences are woven throughout the 10 weeks — from a weekly research roundtable to seminars on quality improvement methodologies. the students also attend Grand rounds, meetings of the tumor Board and the committee for the Protection of human Subjects, learn how to conduct complex literature searches, and complete the nih's citi (collaborative institutional training initiative) module. in short, students come away realizing that “nursing research covers a broad span and quite a bit of depth,” says Slattery. “we try to immerse them in a variety of experiences.”

the benefits of the program for the students are obvious. But Slattery says the institution most definitely benefits, as well. the program “brings

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STRATegic iNiTiATive: DiSTiNcTive eDucATioN AND ReSeARcH

D-h Program offers “unique” experience for nursing Students

nursing research more to the forefront” and “helps create a cohort of staff nurses interested in nursing research quality improvement.” in addition, “those folks now think of themselves as mentors, where they haven’t been formal educators before. i think that’s very good for them professionally.” not to mention the fact that “any time you have students around, it provides stimulation.”

Slattery has observed one other benefit — “a point we never really thought about,” she says — and that's been the program’s positive impact on nurse recruitment. “that has been an unexpected benefit. these are students from around the state, and you might think they would tend to go back home. But in the first cohort there were four students, and two of them are now working here — one in our intensive care unit and one on the neurology floor.” and even

though the 2012 i-SurF-ns are still in school, one has already been accepted into a new D-h graduate perioperative training program. and two others remain involved in the D-h research they worked on last summer, as part of a senior honors thesis. Slattery is hopeful that they too may end up at D-h.

“this is really exciting for us,” Slattery explains, partly as a proactive response to the nursing shortage, but also “because it’s a very select program. these students are encouraged to apply by the chairs of their nursing departments — they’re at the top of their class.”

in fact, two of the 2012 i-SurF-ns will be back this summer "working in kind of a student coordinator role," says Slattery, helping this year's participants appreciate nursing's role in “the bigger picture —the bigger health-care picture.” ●

STRATegic iNiTiATive: DiSTiNcTive eDucATioN AND ReSeARcH

The program brings nursing research more to the forefront and helps create a cohort of staff nurses

interested in nursing research quality improvement. Those folks now think of themselves as mentors,

where they haven’t been formal educators before. I think that’s very good for them professionally.

Not to mention the fact that any time you have students around, it provides stimulation.”- mary Jo Slattery, mS, rn

Mary Jo Slattery, MS, RN, left; Bianca Fortier, BSN, RN, right

engagement Survey resultsa Focus on Professional Development and communication

You can’t discuss a survey without discussing hard numbers — response rates, midpoints, means and so on. But at the same time, some surveys attempt to quantify soft concepts, like engagement.

Such a challenge is one that Dartmouth-hitchcock (D-h) tackled for the first time last year, measuring employee engagement — as opposed to measuring employee satisfaction — in a survey conducted by an outside firm. the instrument assesses whether employees understand D-h’s goals, whether they’re willing to put discretionary effort into their work, and whether they have an emotional attachment to the organization.

the survey, administered in april 2012, posed questions in 16 categories. in some areas, such as Performance evaluation and training & compliance, D-h’s results were well above national benchmarks for such surveys. But in others, there was room for improvement. “when we looked at the results for nursing,” says Johanna Beliveau, BSn, mBa, rn, “we highlighted opportunities in two specific areas that we felt were priorities and were within the span of influence of the nursing leadership team to address. those two things were professional development and communication.”

Beliveau, the administrative director for inpatient maternal child health and Psychiatry, also serves as “employee engagement champion” within nursing. She explains some of the steps that have been undertaken as a result of the 2012 survey.

in the communication arena, for example, a key

change was the institution of a 10- to 15-minute “huddle” on every unit at the beginning of each shift. the agendas for the huddles are simple, bulleted information points. the list may include clinical issues (a recap of patient acuity levels, for example), but also brief mention of policy changes or drug shortages or nursing scholarships with deadlines approaching.

a weekly leadership huddle was also instituted, as well as more regular rounding by the nursing leadership. the template for unit-based council meetings is also being standardized.

Several actions were taken on the professional development front too: improving in-house education and training offerings; helping nurses prepare for specialty certification exams; expanding nurses’ access to outside professional development

STRATegic iNiTiATive: PeoPLe

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intensive care unit, 7 am change-of-shift huddle

opportunities, such as conference attendance; and increasing their awareness of scholarships and grants, to enable them to take more advantage of external opportunities.

Beliveau sees it as a plus that D-h typically has a good response rate on the survey, compared to national benchmarks. “i think the response rate is indicative of the fact that people feel it’s important to share their perspectives — that [someone] is going to take action with the information.”

“this is ongoing work,” she emphasizes. “we’ve made some steps in putting actions into place, but we’ll be interested to see how we’re doing on our next survey,” which is scheduled for later this year. “the goal is to keep a good pulse on our performance,” Beliveau adds. “we know that there’s more to do, and

that feedback will help us continue to prioritize what’s important to the staff and where our biggest gaps are.”

She finds one other aspect of the effort especially heartening — and that is the attention given to the findings not only within nursing but also at the institution’s highest levels. She sees “a real commitment from senior leadership on action planning related to the data and to our responses.” even Dr. James weinstein, ceo and president of D-h, she says, “routinely asks his senior officers for updates on what has been happening within their divisions.”

at the same time, reports on this progress note that employees themselves bear some responsibility — to actively participate in huddles, to ask clarifying questions, and to both offer and listen to feedback. the effort is, in other words, a circular process. ●

Linen managementcost Savings one Bedspread at a time

“a bedspread here, a bedspread there, and

pretty soon you’re talking real money.”

that adaptation of an adage about

government appropriations — “a billion

here, a billion there, and pretty soon

you’re talking real money” — aptly sums

up a new linen awareness project at

Dartmouth-hitchcock (D-h). it was

piloted on 3 west in the fall of 2012 and

implemented on several other units

beginning in late December. Just a few

months later, as of mid-march, the project

had already led to $41,567 in savings. one

bedspread at a time.

the project was identified as a cost-saving

opportunity based on a comparison to

national benchmarks, explains katrina

Geurkink, mS, manager of operational

excellence, Supply chain management.

D-h’s inpatient linen usage averaged 26.2

pounds per patient day, compared to a

national average of 16.6 pounds.

21

<< morgan merchand, BSn, rn

STRATegic iNiTiATive: fiNANce

22 “From there, it has been very straightforward in terms of just going in and sharing the data with the nursing units,” she says. “they’ve immediately identified some things they can change.”

kate Bryant, BSn, rn, the chair of 3 west’s unit-Based council (uBc), was an early convert. “Being a surgical floor, we go through lots of linen,” she explains. “we don’t think about how much we use on a daily basis because of the fast-paced environment.” But once her team saw the data on linen use, Bryant says they brainstormed ideas and quickly implemented them. the changes ranged from reducing the amount of linen routinely brought into patients’ rooms to making more informed choices regarding which item to use in a given situation.

For example, says Geurkink, usage at D-h of “what we call bath blankets,” a lightweight but very warm blanket, “was lower than [usage of] bedspreads, which appear to be heavier and warmer — but they’re actually not. and,” she adds, “bedspreads cost quite a bit more to launder than bath blankets.” So using bath blankets instead of bedspreads when patients are chilly both saves money and serves patients better.

Bryant offers another example, noting that 3 west has reduced the number of blankets, towels and washcloths that are routinely brought into patient rooms. this has not only saved money but also lightened the load of the Lnas on the unit. in addition, says Bryant, “by minimizing the amount of linen in the rooms, we create a safer, more clutter-free environment, reducing the risk of patient falls.” Furthermore, she notes, if rooms are overstocked when patients are discharged, unused excess linen must be relaundered.

another change piloted on 3 west was working closely with Linen Services to reduce the standard inventory of linen supplies kept on the unit.


“In any health-care setting, the next biggest expense after labor is supply chain,” explains Michael Durkin, MHA, RN, who holds a new position that sits at the intersection of supply chain management, purchasing and clinical decision-making. His title is clinical products and value analysis coordinator, and his role involves evaluating clinical products and equipment — their cost and effect on patient outcomes, certainly, but also quality (do gloves tear, for example?), ease of use (does a device require costly training?), waste stream impact, ergonomic considerations, storage requirements and so on.

He draws on a range of resources — from the published literature, to teams

26.2 lb/day

16.6 lb/day

national average

Value

aNalysis

averaGe inPatient

Linen uSaGe

By minimizing the amount of linen in the rooms, we

create a safer, more clutter-free environment, reducing

the risk of patient falls.” - kate Bryant, BSn, rn


23Geurkink identifies several keys to the

project’s success so far:

Data: She says personnel on the units have found the facts on linen usage very persuasive.

Dialogue: this has been an essential element, Geurkink believes. “we felt it was really important to engage nurses early in the process — go talk to them before we suggest any improvements and just say, ‘hey, here’s what we’re seeing. how does this match or not match what you’re seeing on your units, what you’re living every day?’”

Teamwork: She ticks off a long list of departments and people involved in the effort — the pilot and early-adopter units (2, 3, and 4 west); the nurse managers who supported the changes on these units; the nursing staff and others who made the changes and offered feedback; and personnel in Supply chain management, including Project Leader michael colburn, Linen Supervisor Laurie Smidutz, and Supply hospital chain Support Services manager michael kenney.

“even though we’ve just begun working with some units and are well past the midpoint of FY 2013,” says colburn, “i still expect to see a cost savings of $100,000 this fiscal year.” the project’s eventual savings target is $200,000 annually.

the linen project has even prompted 3 west “to look at other personal care supplies we bring into the rooms,” explains Bryant. now, “we’re trying to encourage staff to offer these items as needed,” instead of, for example, automatically giving all patients a toothbrush, since they may well have brought one from home. this approach is both “cost-effective and environmentally friendly,” she adds.

“as a unit,” Bryant concludes, “3 west realized the impact that this project could have: by saving money, we then have more resources to care for our patients. these are little things that make a huge difference.” ●

michael Durkin, mha, rn

$41,567

Cost savings since implementation

(Dec.-Mar.)

$100,000

Expected cost savings this fiscal year

$200,000

Projected cost savings

annually

of subject matter experts, to vendor fairs, to the group purchasing muscle of two hospital networks that D-H belongs to.

Durkin says “cost-saving is important, but my work is not judged just on price.” Nor is he “in a position of saying yes or no” about purchases. Instead, his role “is about weighing all the pieces and helping clinicians come to a decision.”

Most decisions involve input from both physicians and nurses. “Between 70 and 80 percent of all the things that are purchased around the patient experience are touched by Nursing,” he says. “Nurses right now are weighing in on the use of a negative pressure wound therapy device, an enteral feeding pump [and] advanced life support

monitors.” He also assesses products “as simple as disinfecting wipes. We’re looking to standardize on the wipe that has the most broad spectrum kill, but the least impact for the people who are using them.”

When his position was created by the Office of Professional Nursing in June 2012, Durkin thought it “sounded like an amazing opportunity. I have a curious background,” he says. “I have a master’s in health-care administration, and prior to becoming a nurse I worked in the business world.”

His work, Durkin adds, “has broad implications across the hospital, but Nursing made the decision to create the position. That’s a credit to Nursing leadership here.”

Linen awareneSS ProJect SavinGS

aacn

Certified Critical Care Nursetracy anderson, rn, ccrn

chris apel-cram, rn, ccrn

Jeannette hoag, rn, ccrn, rn-Bc

Janice narey, mSn, rn, ccrn

millie Sattler, BSn, rn, ccrn, enPc

Joan Schwertner, BSn, rn, ccrn

Jane womack, BSn, rn, ccrn

megan Zerega, BSn, rn, ccrn

american aSSociation oF neuroScience nurSinG

Certified Neuroscience Nursewanda handel, mSn, rn, cnrn

american aSSociation oF PerioPerative reGiStereD nurSeS

Certified Operating Room NurseLinda alongi, BSn, rn, cnor

Jana Beth Stevens, rn, cnor

american BoarD oF Peri-aneStheSia nurSinG

Certified Ambulatory Peri-Anesthesia NurseDella Lynde, BSn, rn, caPa

american coLLeGe oF SurGeonS

National Surgical Quality Improvement Program Surgical Clinical Reviewer Certificationerin Boettcher, rn

american nurSeS creDentiaLinG center

Certified Adult Nurse PractitionerJanette Stender, mSn, anP-Bc

Certified Family Nurse Practitionerremy Bacaicoa, mSn, FnP-Bc

Certified Medical-Surgical Nursemarianne Diaz, BSn, rn-Bc

nina Funari, rn-Bc

Grace St. Pierre, BSn, rn-Bc

Certification in Gerontological NursingJeannette hoag, rn, ccrn, rn-Bc

timothy Stockton, rn-Bc

Certification in Pediatric Cardiologymichelle adams, BSn, rn-Bc

Psychiatric and Mental Health Nursingclaire ketteler, rn-Bc

Certified Pediatric NurseDeborah Gardner, BSn, rn-Bc

aSSociation oF cLinicaL Documentation SPeciaLiStS

Certified Clinical Documentation Specialistcindy Goewey, BSn, rn, ccDS

aSSociation oF vaScuLar acceSS

Vascular Access Board Certifiedtimothy Bray, BSn, rn, va-Bc

mary coutermarsh, BSn, rn, va-Bc

Patricia Gilbert, rn, va-Bc

BoarD oF certiFication For emerGencY nurSinG

Certified Pediatric Emergency Nursemillie Sattler, BSn, rn, ccrn, enPc

caSe manaGement SocietY oF america

Certified Case Manageramelia emerson, mS, rn, ccm

nationaL aSSociation oF orthoPeDic nurSeS

Certified Orthopedic NurseSusanna Gadsby, BSn, mBa, rn, onc

nationaL certiFication corPoration

Low Risk Neonatal Nursing tammy murray, BSn, rnc-Lrn

Neonatal Intensive Care Nursingrachelle kleber, rnc-nic

caryn mccoy, mSn, rnc-nic

Inpatient Obstetric Nursingkimberly Boulanger, mSn, rn-c

Certified in Electronic Fetal Monitoringkathleen Brochu, BSn, rn, c-eFm

oncoLoGY nurSinG certiFication corPoration

Oncology Certified NurseJulia Beaulieu, rn, ocn

maureen Stannard, rn, ocn

Pam wider, rn, ocn

marie miller, BSn, rn, ocn

Certified Breast Care NurseSarah whicker, rn, cBcn

Picc exceLLence

Certified PICC Ultrasound Insertermary coutermarsh, BSn, rn

Patricia ward, rn

SocietY oF cLinicaL reSearch aSSociateS

Certified Clinical Research AssociateLaurie rizzo, rn, ccrP

eDucation uPDateS

Received Bachelor’s Degreeroseanne arnett, BSn, rn, operating room

kelly Brandis, BSn, rn, mho

erin cartier, BSn, rn, occupational medicine

Linda coutermarsh, BSn, rn, neuro Special care unit

Julie Dellinger, BSn, rn, icu

todd Gardner, BSn, rn, vascular access Services

c. heidi Lacasse, BSn, rn, cnrn, neurosciences

Lisa Lamadriz, BS, rn, iBcLc, Lactation Services

Jason osborne, BSn, rn, icu

tracy webster, BSn, rn, ccrn, cen, cFrn, Dhart

Received Master’s Degreeremy Bacaicoa, mSn, FnP-Bc, icu

kimberly Boulanger, mSn, rn-c, Birthing Pavilion

Janice narey, mSn, rn, ccrn, icu

christopher o’connell, mSn, rn, cFrn, trauma Program

una Shworak, mSn, rn, care management

Stephanie Stone, mS, rn, Quality assurance and Safety

Steve thomas, mSn, rn, ccrn, icu

SchoLarShiPS awarDeD

Elsa Frank Hintze Magnet Scholarship for Nursing Excellence ellen Parker, rn

The Levine Nursing Continuing Education AwardJudith Long, rn

carissa thurston, rn

Gladys A. Godfrey Scholarshipmaria melendy

Evidence-Based Nursing Practice Awardterri Farnum, rn

The Patient Safety Training Center Innovation in Nursing Education Scholarshipcatherine rodriguez, mSn, rn

James W. Varnum Scholarship Awardskimberly allen, LPn, Family medicine

Sydney allen, rn, Perioperative Services

Lisa Barrett, Laboratory Support Services

ashley Beaulieu, 4 west

Stephanie Berman, rn, General internal medicine

Lise Bernardi, rn, medical Specialties

michelle Buck, rn, Patient Placement Services

Jorda chapin, aPrn, eD

marylan clark, rn, medical Specialties

katrina colby, rn, radiation oncology

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amanda cote, LPn, cheshire medical, D-h keene

michelle cutler, rn, hScu

kathleen czarnec, rn, Pediatrics

Susan DiStasio, aPrn, 1 west

Steven Doyle, inpatient Pharmacy

Jane eaton, rn, iccu

Linda evans, LPn, cardiology

melissa Garland, rn, 4 west

wanda handel, rn, oPn

tristin henson, rn, 3 west

christine kelly-terena, iccu

rachel kendall, rn, oB-GYn

misty-anne koloski, iccu

rebecca Lacasse, 3 west

meredith LeBlanc, Psychiatry

Jodi Lee, rn, or

katrina masure, rn, icn

Jennifer mesrobian, D-h manchester, nccc

nichole moorhead, rn, or

randy mcDonald, rn, cvcc

katherine mcGuire, LPn, D-h keene Family medicine

amy Parthum, rn, Patient Placement Services

Susan Perron, medical Specialties

Jedidiah Peterson, rn, eD

Beverly Poljacik, rn, icu

angela Price, rn, 2 west

Sara roebuck, rn, hematology oncology

mildred Sattler, rn, eD

erika Seitz, 3 west

carly Sheehan, rn, nashua women’s health

Lauren St. Pierre, manchester Family Practice

rachel traendly, or

Jennifer walker, rn, or

Jennifer wasilauskas, rn, or

Lisa wesinger, rn, hScu

heather worster, LPn, D-h manchester, nccc

kerry wulpern, rn, iccu

other awarDS

Areté Awardsamy arbour, rn, hScu

Diane Beattie, rn, or

catherine Bourgon, rn, oSc

kate Bryant, rn, 3 west

Barbara condon, rn, iccu

terri Farnham, rn, iScu

Susan Gordon, rn, Birthing Pavilion

Greg Jenkins, rn, Life Safety

myra kebalka, rn, nScu

christopher killam, rn, Pacu

Sarah king, rn, Same Day Surgery

Sharon markowitz, rn, care management

Perri maxham, rn, icu

Sterling moffat, rn, icn

Sundi morgan, rn, ortho clinic

Susan nyberg, rn, 2 west

kristal renaudette, rn, hematology-oncology St. Johnsbury

allison rosmus, rn, cvcc

valerie rude, rn, 4 west

kimberly Shannon, rn, 1 west

Laura walker, rn, Pediatrics

tracy webster, rn, Dhart

katharine weeks, rn, Pediatric clinic

The Deborah Miller, ARNP, CNM, MPH, Award for Advanced Practice in Nursingmargaret Bishop, aPrn

The Barbara Agnew, RN, Magnet Award for Mentorshipwendy Piburn, rn

The Marianne Markwell, RN, Commitment Award for Neuroscience NursingBecky campbell, rn

The Rolf Olsen Partnership in Nursing AwardStephen Burlew

The Donna Crowley Excellence in Nursing Leadership Awardkaren Pushee, rn

New Knowledge, Innovations and Improvements Awardmark alderson, rn

Sheila Johnson, rn

DAISY Awardsneuro Special care unit

Janice Gregory, rn, infectious Disease

renee thompson, rn, Same Day Surgery

Sara mcmillan, rn, iScu

amelia cormier, rn, 2 west

chelsea curran, rn, icn

Laura walker, rn, Pediatrics

Sarah Brannigan, rn, 4 west

ansel erickson-Zinter, rn, 3 west

elizabeth mcDaniels, rn, Psychiatry

Sharlene Jacques, LPn, merrimack Family Practice

Sandy williamson, rn, medical Specialties

cheryl abbott, mSn (c), cnrn received the 2012 Clint Jones New Hampshire Nursing Award of the New Hampshire Foundation for Healthy Communities

Barbara Bradford, rn, cohn received the Medique Award, provided by participating state associations to an outstanding Occupational Health Nurse Member who has exhibited leadership in participating in the association and professional activities.

Julie Buelte, mSn, cnm, aPrn received the Giesel School of Medicine Excellence in Teaching Award.

Lynne chase, mPh, rn received Dr. Pamela Fuller Founder’s Scholarship through Sigma Theta Tau for her research study, “The Role of Nursing in Health Policy Development in the Middle East: An Exploratory Study.”

michael Durkin, mha, rn received a certificate in the Fundamentals of Value-based Health Care from The Dartmouth Institute.

Deborah Gardner, BSn, rn-Bc received the Travel Award 2012 from the Association of Child Neurology Nurses.

Debra hastings, PhD, rn-Bc was awarded the Honorable William D. Paine II Award from the NH Department of Justice, Office of the Attorney General. Debra was also inducted into the NH Coalition against Domestic and Sexual Violence Hall of Fame.

carly Sheehan, rn received a Reproductive Endocrinology and Infertility Nurse Certificate from the American Society for Reproductive Medicine.

Steve thomas, mSn, rn, ccrn was selected to participate in the 2013 AONE Nurse Fellowship Program.

GrantS awarDeD

James n. Dionne-odom, mSn, rn received a 2013 AACN-Sigma Theta Tau Critical Care Grant for his proposal, “Generating a Theoretical Model of the Psychological Processes of Surrogate Decision Making at Adult End of Life in the ICU Using Cognitive Task Analysis.”

ProFeSSionaL activitieS

Barbara Bradford, rn, cohn Secretary, nh association for occupational health nurses

Janice chapman, rn member, vermont cardiac network conference committee

elda cordero-Goodman, mS, aPrn President, Bedford Lions club and Zone chairperson

Joyce Dupont, rn notary Public, national notary

Debra hastings, PhD, rn-Bc editorial review Board: Duchscher, J.e.B. From Surviving to thriving: navigating the First Year of Professional nursing Practice. nursing the Future, canada.

Sharon houle, BSn, rn member, Division of child Youth and Family advisory committee

Lisa Lamadriz, BS, rn, iBcLc co-chair, nh Breastfeeding task Force

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kyle madigan, mSn, rn, cmte, cFrn, ccrn, cen, ctrn chairperson, examination construction review committee member at Large, Board of Directors: air & Surface transport nurses association

kim maynard, BSn, rn treasurer, Local chapter of the oncology nursing Society

elizabeth mcGrath, mSn, aG-acnP-Bc, aocnP, achPnPresident, nh/vt chapter, oncology nursing Society

christopher o’connell, mSn, rn, cFrn Battalion executive officer, 405th combat Support hospital uSar colonel, uSar nurse corps

kelly Smith, BSn, rn ambassador, medtronics for Deep Brain Stimulation (DBS) Guest Speaker, Parkinson’s Disease and et support groups regarding DBS

Grace St. Pierre, BSn, rn Director at Large, Board of Directors, new hampshire nurses association

evie Stacy, mS, aPrn President elect, nh nurse Practitioner association co-chair, education committee, nh nurse Practitioner association

maureen Stannard, rn, ocn Secretary, Susan G. komen For a cure vt/nh affiliate

Linda thompson, BSn, rn, cnor treasurer, aorn, nh chapter

Patricia tobin, LPn Guest Speaker, nhti Pinning ceremony for LPns Board of Directors, national Federation of Practical nurses membership chair and President’s chair, national Federation of Practical nurses association

Lynne weihrauch, mSn, FnP member, nh hiv/aiDS Planning Group

colleen whatley, mSn, cnS-Bc, rnc-oB coordinating team member, nh association of women’s health, obstetric and neonatal nurses

PuBLicationS

Didehbani, t., martin, c.B., Szczepiorkowski, Z., Dunbar, n., klinker, k. (2012). nurse’s Perspective on Symptom management of citrate toxicity during extracorporeal Photophoresis Procedures where acid citrate Dextrose (acD-a) is used as anticoagulant. Journal of Clinical Apheresis, 27(1), 50.

Dionne-odom, J.n., Bakitas, m.B. (2012). why Surrogates Don’t make Decisions the way we think they ought to: insights from moral Pyschology. Journal of Hospice and Palliative Care, 14(2), 99-106.

George, h., Davis, S., mitchell, c., moyer, n., toner, c. (2012). abstraction of core measure Data: creating a Process for interrater reliability. Journal of Nursing Care Quality, 28(1), 68-75.

kirkland, k., homa, k., Lasky, r. (2012). impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series. BMJ Quality & Safety, 21(12), 1019-1026.

Splaine, m., Brown, J., melon, c., Lasky, r., Foster, t., Batalden, P. (2012) Better System Performance: approaches to improving care by addressing Different Levels of Systems. in Paul Batalden and tina Foster (eds) Sustainably Improving Health Care: Creatively linking outcomes, system performance and professional development. new York, nY: radcliffe Publishing.

wood, m. (2012) Diabetes mellitus. in t. Buttaro, J. trybulski, P. Bailey, J. Sandberg-cook (eds) Primary Care: A Collaborative Practice. St. Louis, mo: elsevier.

PreSentationS

abbott, c. and Golightly, m. Anti-depressants and the Neuro Patient: Emerging Evidence for Multi-facted Benefits.

Gadsby, S. Sports Concussion, Implications for School Nurses. Sports Safety. nashua, nh (october).

Gardner, D. Handle with Care. Association of Child Neurology Nurses. huntington Beach, ca (october).

martin, c. Nurse’s Perspective on Symptom Management of Citrate Toxicity during Extracorporeal Photopheresis Procedures where Acid Citrate Dextrose (ACD-A) is used as anticoagulant. american Society for apheresis annual meeting. atlanta, Ga (april).

martin, D. Shoulder Dystocia Update: Minimizing risks to mothers, babies, and providers. american college of nurse-midwives annual meeting. Long Beach, ca (June).

maynard, k. Hemovigilance and Transfusion Safety. Patient Blood management: Patient care and outcome Strategies workshop. Boston, ma (october).

mcGrath, e., Pace, c., urquhart, L. Dimensions of Survivorship: Are We Prepared? 15th annual Breast cancer conference. Burlington, vt (october).

Pelletier, A. Helpful Apps for the Health Office. School nurse Symposium. Bedford, nh (october).

Smith, S. Retained Surgical Items. cnor review course, aorn Local chapter. Lebanon, nh (november).

Stacy, e. ADHD: Management in Children and Adolescents. northeast regional nurse Practitioner conference. manchester, nh (may).

thompson, L. Minimally Invasive Surgery. cnor Study course, aorn Local chapter. Lebanon, nh (november).

tobin, P. Laughter for the Weary LPN. national Federation of LPn association. Las vegas: nv (october).

wood, m. The Hospitalized Patient with Diabetes: Enhancing Clinical Practice. Diabetes in the 21st century: raising the Bar. Plattsburgh, nY (may).

wood, m. Conventional and Newfangled Diabetes Medications. Diabetes today conference. whitefield, nh (november).

PoSter PreSentationS

Doton, k.a. Improving Access to Patient and Family Centered Spina Bifida Care with a Multidisciplinary Group Medical Appointment. the Future is now Second world congress on Spina Bifida research and care. Las vegas, nv (march).

Lloyd, D., mecchella, J., albert, D. Baseline Screening Recommendations for Rheumatoid Arthritis Patients Treated with Disease Modifying Anti-rheumatic Drugs: Does an Educational Intervention Change Practice in an Outpatient Clinic? american college of rheumatology. washington, Dc (november).

mcGrath, e., Pace, c. Barriers and Facilitators to Implementing Survivorship Care Plans. nnecoS annual meeting and Palliative care Symposium. rockport, me (october).

Prior, e., wasilauskas, J. Chocolate Treat Preferences Study: A Deliciously Easy Approach to Learning about Research. Fourth annual nursing research and evidence Based Practice Symposium: creating a research environment. Burlington, vt (november).

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cover: emiLY Brown, nurSe extern, coLBY-SwaYer coLLeGe, center; anD DanieLLe cantin, BSn, rn, riGht | inSiDe Back cover: nancY Lee vaDnaiS, rneDitorS: victoria mccanDLeSS; anne cLemenS. DeSiGn: erin hiGGinS. writer: Dana cook GroSSman. PhotoGraPhY: mark waShBurn. ProJect manaGement: katherine BeinDer

dartmouth hitchcock nursing year in review 2012

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