SE9EO

 

Commitment to Professional Development SE9EO

 

Using the required empirical outcomes (EO) presentation format, provide an example, of an improved patient outcome associated with knowledge gained from a nurse’s(s’) participation in a professional development activity.

 

 

Example: Nurses’ Participation in Safe Sleep Infant Fall Prevention

Problem

Increased infant fall rate at Catholic Health Initiatives (CHI) St. Vincent Hot Springs (SVHS) Labor Delivery Recovery Postpartum (LDRP) unit.

 

Pre-Intervention

The CHI SVHS LDRP unit experienced an infant fall during the week of February 13 to 19, 2024. The clinical nurse assisted a father with swaddling the infant at shift change and exited the room. Upon returning to the room about 15 minutes later to complete a lab draw and assessment, the clinical nurse found the infant on the floor and the infant’s father asleep on the couch.

 

The infant was assessed by a physician and nurses with continued monitoring. The CHI SVHS LDRP infant fall rate was 6.25 per 100 deliveries. This rate was calculated by taking the number of infant falls, divided by the number of deliveries for the week, multiplied by 100.

 

Amy Gates, BSN, RN, Nurse Manager, Cribs for Kids Safe Sleep Ambassador, is responsible for LDRP quality outcomes. The infant fall was unexpected and distressing for the LDRP team, which prompted Gates to immediately pull her nurses together for a debrief. On February 17, 2024, the LDRP nursing team, including Gates, discussed the event at the unit-based safety huddle and determined a need for a professional development activity to address fall safety measures to prevent infants from falling in the future.

 

Gates identified gaps in knowledge related to safe sleep practices. Subsequently, on February 19, a root cause analysis (RCA) was completed on the infant fall. RCA participants included Teresa Lambert, MBA, BSN, RN, Vice President of Patient Care Services and Associate Chief Nursing Officer (role of CNO); Tonya Baier, MBA, BSN, RN, Clinical Director of Nursing; Renee Fechuch, MSN, RN, Clinical Director of Nursing; Kaitlyn Atkins, MSN, RN, CPN, Clinical Director of Nursing; Kathryn Goad, BSN, RN, Patient Safety Manager; Gates; and the clinical nurse involved in the event. The RCA identified a gap as the father was not following the instructions given to him regarding safe sleep for infants.

 

The leaders determined the need for rapid process improvement to include education for the LDRP nursing team. Gates immediately pulled together a professional development activity to address safe sleep competencies for all LDRP nurses. The unexpected and distressing event necessitated quick action by Gates so that the team was supported and had the information, knowledge, and skills needed to prevent a recurrence of an infant fall.

 

The professional development activity included a review of the fall and Safe Sleep policies, Safe Sleep education with parents, Safe Sleep contract with parents, the steps to take in the event of parent noncompliance with safe sleep practices, and communication board expectations that are reviewed with the patient and family during the bedside shift report.

 

Goal Statement

Decrease the CHI SVHS LDRP infant fall rate.

 

Participants

 

Infant Fall Work Group
Name/Credentials	Discipline	Title/Role	Department
Amy Gates, BSN, RN	Nursing	Nurse Manager, Lead	LDRP
Teresa Lambert, MBA, BSN, RN	Nursing	Vice President of Patient Care Services, Assistant Chief Nursing Officer (role of CNO)	Administration
Tonya Baier, MBA, BSN, RN	Nursing	Clinical Director of Nursing	Nursing Administration
Kaitlyn, MSN, RN, CPN	Nursing	Clinical Director of Nursing	Nursing Administration
Renee Fechuch, MSN, RN	Nursing	Clinical Director of Nursing	Nursing Administration
Kathryn Goad, BSN, RN	Nursing	Patient Safety Manager	Risk Management
Carla Buttrum, RN	Nursing	Patient Care Coordinator	LDRP
Jennifer Edgar, BSN, RN	Nursing	Patient Care Coordinator	LDRP
Lindsey Bishop, RN	Nursing	Clinical Nurse	LDRP
Shelby Goss, RN	Nursing	Clinical Nurse	LDRP
Kris Faulkner, BSN, RN	Nursing	Clinical Nurse	LDRP
Kim Smith, RN	Nursing	Patient Care Coordinator	LDRP
Jordan Stewart, BSN, RN	Nursing	Clinical Nurse	LDRP
Amanda Wood, RN	Nursing	Clinical Nurse	LDRP
April Edwards, RN	Nursing	Clinical Nurse	LDRP
Mary Smith, BSN, RN	Nursing	Clinical Nurse	LDRP
Kathrine Russell, BSN, RN	Nursing	Clinical Nurse	LDRP
Linda Taylor, RN, RNC-OB	Nursing	Clinical Nurse	LDRP
Erika Wilson, RN	Nursing	Clinical Nurse	LDRP
Haley Griffith, BSN, RN	Nursing	Clinical Nurse	LDRP
Lacey Kennedy, RN	Nursing	Clinical Nurse	LDRP
Jade Owens, NP, FNP-C	Nursing	Nurse Practitioner	LDRP
Joy Cannon, RN	Nursing	Patient Care Coordinator	LDRP
Kari Weston, RN, RNC-OC, C-EFM	Nursing	Patient Care Coordinator	LDRP
Hilda Buckley, RN	Nursing	Clinical Nurse	LDRP
Crystal Sibley, RN	Nursing	Clinical Nurse	LDRP
Lexi Bassett, RN	Nursing	Clinical Nurse	LDRP
Ally Henderson, RN	Nursing	Clinical Nurse	LDRP
Lindsey Burton, RN	Nursing	Clinical Nurse	LDRP
Makyla Thornberry, RN	Nursing	Clinical Nurse	LDRP
Kathy Yates, RN	Nursing	Clinical Nurse	LDRP
Candace Achorn, RN	Nursing	Clinical Nurse	LDRP

 

Description of the Intervention

February 20 to 26, 2024
Led by Gates, the professional development activity took place during unit-based safety huddles for the LDRP day shift and night shift. Education for this professional development activity for the LDRP nurses included:

• Reviewing the CHI St. Vincent Hospital Fall Prevention and Management Policy
• Reviewing the Safe Sleep-Infant Safe Sleep Policy
• Ensuring Safe Sleep Education with parents is covered during admission and throughout the stay
• Reviewing the Safe Sleep Contract with parents and ensuring it is signed and placed in a paper-lite chart
• Reviewing communication board expectations with the patient and family during bedside shift report day and evening shift changes

 

The objectives of the professional development activity were:

• Discussing the importance of active listening and being present when educating parents on safe sleep practices
• Explaining the need for the initial and ongoing assessments of safe sleep practices with parents
• Recognizing parent noncompliance with safe sleep practices and explaining the steps to take in those situations

 

The professional development activity to address competencies associated with infant fall prevention was fully reviewed and implemented with LDRP nurses by the week ending on February 26, 2024.

 

Knowledge gained from LDRP nurses’ participation in a Safe Sleep Fall Prevention professional development activity was associated with an improvement in the CHI SVHS LDRP infant fall rate.

 

References

Feldman-Winter, L., & Goldsmith, J. P. (2016). Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. American Academy of Pediatrics, 138(3). https://doi.org/10.1542/peds.2016-1889

 

Heafner, L., Suda, D., Casalenuovo, N., Leach, L. S., Erickson, V., & Gawlinski, A. (2013). Development of a tool to assess risk for falls in women in hospital obstetric units. Nursing for Women’s Health, 17(2), 98–107. https://doi.org/10.1111/1751-486x.12018

 

Raines, D. A. (2018). Factors that influence parents’ adherence to safe sleep guidelines. Journal of Obstetric, Gynecologic & Neonatal Nursing, 47(3), 316–323. https://doi.org/10.1016/j.jogn.2018.01.010

 

Quick Safety 40: Preventing newborn falls and drops. The Joint Commission. (2018). https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-40-preventing-newborn-falls-and-drops/

 

Outcome

• (Evidence SE9EO-1, LDRP Infant Fall Rate Graph)