Journal of Gerontological Nursing

Guest Editorial Free

Nursing Leadership in Skilled Nursing: A Journey to Clinical Excellence

Nina Flanagan, PhD, GNP-BC; Maryann Cortese-Rubino, RN, MS, NHA; Donna M. Fick, PhD, RN, FAAN

Abstract

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

Abstract

This article has been amended to include factual corrections. To read the erratum, click here. The online article and its erratum are considered the version of record.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The use of advanced practice nurses (APNs) in long-term care has been well documented in the literature. Specifically, a substantial body of literature exists documenting the efficacy of nurse practitioners in preventing unnecessary hospital transfers and admissions (Ouslander & Berenson, 2011; Rosenfeld, Kobayashi, Barber, & Mezey, 2004). Lyons, Specht, Karlman, and Maas (2008) introduced an evidence-based framework (i.e., “Everyday Excellence: A Framework for Professional Nursing Practice in Long-Term Care”), which focused on the following eight guiding principles for nurses in long-term care: value, envisioning, peopling, securing, learning, empowering, leading, and excellence. This framework stresses the importance of the professional nurse in long-term care, with an emphasis on generating a process for creating, implementing, and sustaining a professional practice model that provides nurses with a sense of commitment, enthusiasm, and belief in the value of nursing. The purpose of the current editorial will be to describe the authors’ journey to clinical excellence using some of the framework principles and to provide resources for others to take a similar journey.

Geisinger Mountain View Care Center (GMVCC) is an 180-bed geriatric rehabilitation center located in northeastern Pennsylvania. The center provides acute geriatric rehabilitation and chronic care management with a person-centered philosophy. GMVCC admits, on average, 350 residents per year, with 73% of those residents being discharged to community living after completion of their rehabilitation or a lesser level of care (i.e., assisted living, personal care, PACE program). GMVCC residents are medically and surgically complex, often with multiple comorbidities, such as diabetes, congestive heart failure, chronic kidney disease, and sepsis. Their average hospital length of stay is 3 days.

For the past 5 years, the center has had an advanced practice nursing model in place to manage the complex needs of GMVCC’s older adult residents. The model strategically places APNs in key roles to provide clinical leadership and education to the geriatric care team, ultimately driving quality and improving clinical outcomes. The clinical practice leadership team of nurses employed by the center consists of clinical nurse specialists/nurse practitioners in specialty roles of triage, education, rehabilitation, and wound care. The mission of the clinical team (led by nursing with the inclusion of physical, occupational, and speech therapy; nutrition; and social services) is to provide person-centered, evidence-based care, which enables the older adults served to attain their highest level of function. The clinical outcomes since the inception of the model have been exceptional. GMVCC’s 30-day hospital readmission rate is less than 7%, compared with the national average of 25% (Mor, Inrator, Feng, & Grabowski, 2010); the use of psychotropic drugs is 6.1%, compared with the national average of 23.9% (retrieved from http://www.qtso.com); and GMVCC has been completely restraint free for the past 12 years, whereas the national average for restraint use is 1.8% (retrieved from http://www.qtso.com).

This journey to clinical excellence began with a vision by the director of clinical care services and the commitment to clinical excellence accomplished through the following four pillars: education, research, evidence-based practice, and empowerment (Table 1). Although all four pillars are important, the foundational principles are education and empowerment. Without these, it is difficult to build in the other two principles. It is critical that the chief nursing officer (CNO) is master’s prepared and has both clinical expertise and an understanding of the “business” of long-term care (i.e., envisioning excellence). The partnership of the CNO/director of nursing (DON) and the administrator is pivotal in the process. The CNO/DON and administrator must be at the table with health system executives, payers (e.g., Medicare, commercial insurance), and boards to articulate clinical operations, current opportunities, and needs. The commitment to doing the right thing for residents translates into better outcomes and financial stability. Care drives dollars. A center with excellent clinical and financial outcomes and an established reputation will be appealing to leadership and consumers, as well as payers and providers.

Four Pillars of Nursing Excellence

Table 1:

Four Pillars of Nursing Excellence

The educational process began in 2001 when the center received a Hartford Scholarship to provide monies to five RNs to pursue a master’s degree as clinical nurse specialists in gerontology (i.e., valuing and peopling excellence). The center partnered with a local university’s nursing program to provide classes on site. The challenge was to flex staffing patterns to allow time for the nurses to attend classes. The nurses completed their degrees, and GMVCC had its first clinical specialists. This investment in education allowed the center to begin its journey to clinical excellence. The caliber of the center changed, and new talent was attracted, which also improved staff satisfaction. It must be noted that the CNO has been at the center for 20 years, and the turnover rate for direct care staff is less than 10%.

The empowerment principle builds on the education principle. The nursing leadership and administration must recognize the talents and gifts of their staff to create the vision for clinical success. The clinical leadership team, which includes the direct care staff (i.e., licensed nurses), must be enabled to challenge the process, make decisions, and act on those decisions. This process includes a “growing your own experts” philosophy. Knowledge is power. The clinical leadership team is involved every day in providing education and guidance to direct care staff in a trusting, respectful manner. Direct care staff, including nurse aides, are included in care rounds and daily decision making, as well as in ongoing, in-the-moment education on best practice for the interprofessional team. GMVCC’s greatest success in this area is exemplified in the low use of antipsychotic agents. Since 2001, GMVCC has been one of two training sites in the state of Pennsylvania to reduce physical and chemical restraints. The interprofessional team has developed a process to treat physical and emotional pain and recognize delirium superimposed on dementia. A professional nurse leads the team by coaching the staff through assessments, team discussion, and medication review prior to a call to the provider. Therefore, when providers are contacted, the team has recommendations for intervention on hand. The provider is part of the team and is not the only decision maker. This interprofessional team persevered by continuing to listen, educate, and support staff, residents, and families in this cultural change (i.e., securing excellence). This interprofessional team approach can enable residents to be treated in place for acute illnesses, such as pneumonia, congestive heart failure, and sepsis.

This journey has not been without challenges. The biggest challenge was getting staff on board to change their approach to care. At times, physicians were resistant to team recommendations. Families were also resistant to recommendations for decreasing medications or treating in place rather than at the hospital.

We are always learning, changing, and growing, and that is what feeds our passion of providing the best care for older adults in skilled nursing and geriatric rehabilitation care. Table 2 provides resources for beginning the journey to excellence.

Resources for Clinical Excellence in Skilled Nursing and Rehabilitation

Table 2:

Resources for Clinical Excellence in Skilled Nursing and Rehabilitation

Nina Flanagan, PhD, GNP-BC

Geriatric Nurse Practitioner

Geisinger Mountain View Care Center

Scranton, Pennsylvania

Assistant Professor of Nursing

Decker School of Nursing

Binghamton University

Binghamton, New York

Maryann Cortese-Rubino, RN, MS, NHA

Director of Nursing and Clinical

Operations

Geisinger Mountain View Care Center

Scranton, Pennsylvania

Donna M. Fick, PhD, RN, FAAN

Professor of Nursing

College of Nursing

The Pennsylvania State University

University Park, Pennsylvania

References

  • Lyons, S.S., Specht, J.P., Karlman, S.E. & Maas, M.L. (2008). Everyday excellence: A framework for professional nursing practice in long-term care. Research in Gerontological Nursing, 1, 217–228. doi:10.3928/00220124-20091301-08 [CrossRef]
  • Mor, V., Inrator, O., Feng, Z. & Grabowski, D. (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, 29, 57–64. doi:10.1377/hlthaff.2009.0629 [CrossRef]
  • Ouslander, J.G. & Berenson, R.A. (2011). Reducing unnecessary hospitalizations of nursing home residents. New England Journal of Medicine, 365, 1166–1167. doi:10.1056/NEJMp1105449 [CrossRef]
  • Rosenfeld, P., Kobayashi, M., Barber, P. & Mezey, M. (2004). Utilization of nurse practitioners in long-term care: Findings and implications of a national survey. Journal of the American Medical Directors Association, 5, 9–15. doi:10.1016/S1525-8610(04)70038-9 [CrossRef]

Four Pillars of Nursing Excellence

Pillar Description
Education

Master’s-prepared Chief Nursing Officer who has clinical expertise and is business minded

Partnership (i.e., shared governance)

Master’s-prepared clinicians (i.e., triage, rehabilitation nursing, Director of Education, infection prevention)

On-site nurse aide training

Eden Alternative-trained associates

Research

Partnering with universities and medical schools for clinical training, preceptors, and participation in research studies

Conducting clinical research

Evidence-based practice

Establishment of clinical teams to disseminate evidence-based practice to direct care staff

Development of evidence-based protocols embedded in e-charting, with daily clinical application with direct care staff

Empowerment

Enabling others to act

Complementing, not competing

Supporting the clinical team and staff to challenge the process, make decisions, and act

Expert collaboration for building trust and fostering relationships

Hiring the passion, teaching the skill

Resources for Clinical Excellence in Skilled Nursing and Rehabilitation

Organization/Initiative Web Site
Advancing Excellence in America’s Nursing Homes www.nhqualitycampaign.org
Leading Age www.leadingage.org
AMDA: The Society for Post-Acute and Long-Term Care Medicine www.amda.com
The Eden Alternative www.edenalt.org
Pioneer Network www.pioneernetwork.net

10.3928/00989134-20141015-01

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