Running head: CLINICAL PRACTICUM

Clinical Practicum Paper Jennifer R. Williams Ferris State University

CLINICAL PRACTICUM Abstract This paper contains an analysis of an INS practicum experience in the quality setting at MMCWM. There is a thorough overview provided of the practicum. Full immersion in the role, ongoing research, and incorporating change were all identified as initial challenges within the practicum. Ongoing issues and concerns including data accuracyintegrity, project timeline-scope creep, collaboration, and resistance to change were also discussed. Goal setting, collaboration, leadership growth, connecting with the role, communication, and building relationships were all identified as successful strategies within the practicum. An analysis of the internal project further acknowledges professional growth within the INS role. A narrative evaluation of the practicum reveals both the student and preceptors thoughts on the success of the practicum. The conclusion provides both highlights and significant insights of the practicum experience. Key words: Informatics, Practicum, Informatics Nurse Specialist, Project management, Data abstraction

CLINICAL PRACTICUM Clinical Practicum Paper The Informatics Nurse Specialist (INS) role has multiple components attached to it. Many disciplines utilize the INS to incorporate nursing knowledge into department processes. The INS in the quality setting is responsible not only for ongoing changes in the quality improvement setting, but also for monitoring multiple programs to enhance quality of care. In this case, it is essential to have adequate and successful processes to collect data. The INS assists in ensuring quality data through the creation, implementation, and integration of successful electronic documentation processes and procedures (ANA, 2008). Real-time and post-clinical data abstraction also assists the INS in working towards improving quality care and utilizing that data to submit to the Center for Medicare and Medicaid Services (CMS) and compare performance with Hospital Compare (a national hospital database). The utilization of informatics has been established as a precursor to the improvement of quality of care and higher quality measures performance (Poon et al., 2010). There are multiple quality initiatives currently in place and required by CMS. These initiatives include data on congestive heart failure (CHF), acute myocardial infarction (AMI), pneumonia, venous thromboembolism (VTE), emergency room throughput, and the surgical care improvement project (SCIP). Data collection, data analyzing, and recommendations for new practices to are utilized to improve and enhance quality outcomes (ANA, 2008). In addition to the current initiatives, the hospital-based impatient psychiatric services (HBIPS) are new to quality initiatives this year (project focus). The Joint Commission (2010) indicated that psychiatric hospitals would soon be required to submit

CLINICAL PRACTICUM measurable data regarding any restraint use. Required psychiatric reporting was slated to begin January, 2013. Since this is not real-time data, Memorial Medical Center of West Michigan (MMCWM; practicum site) had some leeway in reporting; however, it was essential that a new process be put in place as soon as possible. The overall quality objective for organizations now consists of finding a way to improve care quality while reducing cost and expanding health access. This now consists of a combination of information technology, informatics, and clinical quality initiatives (Marjoua & Bozic, 2012). This paper will review my practicum experience as an INS in the quality setting at MMCWM. There will be an overview of the practicum and the HBIPS project carried out within the practicum. Multiple challenges will be identified along with issues and concerns that arose related to both the practicum and project. Strategies and approaches utilized to resolve these challenges, issues, and concerns will also be reviewed. A narrative evaluation of the practicum experience will be provided along with the completed evaluation tools by both Ms. Saxton RN MSN (preceptor) and I. A conclusion will then highlight significant insights identified within the clinical practicum experience. Practicum Overview During my practicum experience, I was able to utilize my current knowledge regarding information technology, quality, and the utilization of data and apply it to the INS role. Both clinical quality and information technology assisted with my ability to obtain full immersion within this role. I was able to accomplish this through the utilization of gained knowledge from prior courses and assignments. The purpose of this practicum was to obtain knowledge from both the information technology and clinical

CLINICAL PRACTICUM quality departments to improve my competency in informatics technology and the connection to quality through the participation in the day to day activities of the INS role. This clinical practicum experience was completed at a small acute care hospital in Ludington Michigan; Memorial Medical Center of West Michigan (MMCWM). This setting was chosen related to the growing focus of quality initiatives in many areas of acute-care (MMCWM, 2012). In this case, an opportunity was identified during the organizational inquiry to work closely with both the clinical quality and information technology departments. The primary setting for the practicum was located within the clinical quality department at MMCWM. A large portion of the practicum experience was focused on the medical-surgical departments and the role of the INS in regards to data abstraction, data analysis, and implementation and the monitoring of quality care initiatives. The project portion of the practicum was based in the clinical quality department; however, was implemented in the psychiatric unit at MMCWM. The INS in the quality role completes multiple tasks throughout the day that include a large amount of data. Understanding and accuracy of the data are essential to this process. During my practicum experience, I was able to become proficient in both real-time and post-discharge data abstraction. These measures are collected and abstracted to identify any issues regarding required documentation for CMS. I initially found this type of data collection and abstraction challenging; however, during this process I was able to identify with the nurses on the floor and quickly realized that building a rapport and creating successful relationships with the staff would provide a successful strategy for ongoing improvement. The utilization of informatics has been established as a precursor to the improvement of quality of care and higher quality

CLINICAL PRACTICUM measures performance (Poon et al., 2010). It is essential for the INS to maintain a shared knowledge base with the information technology department (Gardener, 2011). When working in quality improvement, the INS will require excellent communication skills to obtain adequate technological literacy (ANA, 2008). Ongoing communication with the IT department is an essential component to this role. Ongoing collaboration with technical support personnel can also alleviate simple problems that may put outcomes at risk (Lee, McDonald, Anderson, & Tarczy-Hornoch, 2009). While managing the project within my practicum experience, I was excited to build upon this relationship to improve the overall success of the project. Challenges Initially, there were multiple challenges within the practicum that coincided with the student role. Difficulty encompassing the INS role from the outside, the ongoing need for research, maintaining an IT/quality balance, and working with poor processes were all identified as immediate obstacles. The INS is expected to perform successfully in multidisciplinary settings and in several functional areas (ANA, 2008). Attempting to become part of the organization as a visiting entity was a significant challenge. It was difficult to fully incorporate myself into the INS role initially. I had an initiative to become fully immersed in the INS role; however, this was difficult when staff visualized me as an outsider. I was aware that I would need to develop an effective strategy to build relationships within the organization in order to fully meet my practicum goals.

CLINICAL PRACTICUM It was also apparent that ongoing research would be an essential component of this role. I spent many challenging hours researching the requirements and regulations of CMS. These requirements change often and it is essential to stay apprised of the most recent regulations. Maintaining the appropriate knowledge within the INS role in the quality setting was challenging; however, evidence gained through clinical practice is an essential component to obtaining and applying accurate data to ensure the incorporation of quality. Best practice should be integrated along with appropriate evaluation of performance and outcomes (Salmond, 2013). Through ongoing research and the creation of an adequate learning resource list, I was able to begin to see the big picture and the relationship between informatics data and quality outcomes (see Appendix E). It was apparent that the connection between the two was essential to the role. The purpose of my practicum was to obtain knowledge from both the information technology and clinical quality departments to improve upon my current knowledge regarding information technology and the correlation of this identified competency to the quality department. I became more aware of the need to promote success in binding technology and quality through the evaluation of informations technology (Black et al, 2011). It was also apparent that ongoing review of current electronic processes in multiple department collaboration was an essential component to the role. In addition, ongoing education through seminars and webinars was identified as a significant portion of the role. The amount of information available on how to appropriately implement all of the requirements of meaningful use was overwhelming. I was able to learn something new every day while maintaining the philosophy that continued research and education will be an ongoing process throughout my career.

CLINICAL PRACTICUM As I began working on the real-time data abstraction process, there were multiple areas of missing documentation and data. Physician and nurses were contacted regarding these concerns, needed orders were placed to correct these issues, and I continued to work diligently to build an ongoing report with the staff in order to correct some of the issues associated with the missing information. There continued to be some ongoing difficulty in communicating with some of the staff. It was assumed that it would take some time for this change and to become familiar with them. Personal anxiety can often affect self-directed learning; continued support through stable relationships can correct this issue and thus emphasize the essential need for accurate documentation (Bassendowski et al., 2011). Issues & Concerns In addition to the immediate challenges, there were also multiple issues and concerns that were recognized within the practicum. Data Accuracy and Integrity, project timeline and scope creep, and resistance to change were three prominent areas that maintained significant relevance throughout the practicum experience. The ability to promote strong systematic interactions, in support of the implementation of the plan, is essential to the INS role (ANA, 2008). Meeting organizational needs is also considered an essential component of the INS role. In order to do this adequately, it is important to identify problems that may interfere with this process (Hamelin, 2007). Data Accuracy-Integrity The INS in the quality role completes multiple tasks throughout the day that include a large amount of data. Understanding and accuracy of the data are essential to this process. Meaningful use is a major part of what the INS role entails. Meaningful use

CLINICAL PRACTICUM is part of the Patient Care Act and contains the guidelines that were set in place to target hospitals, physicians offices, and other public health providers to implement the utilization of health information technology systems with certified electronic health record applications per the federal governments requirements. The government is providing incentives and rewards to hospitals that meet these requirements by the year 2015. Those providers that do not meet the meaningful use requirements will be penalized by set percentages of revenue. These percentages will rise over a three year period causing greater penalties as time goes on (Hoffman, & Podurski, 2011). The role of the quality analyst is highly involved in this process. CMS is placing heavy guidelines on hospitals as well. Data analytics is now necessary to maintain trust in clinical data. Accountable Care Organizations (ACOs) will need to link their practices to a common standard of care. These organizations will now depend on analytics to maintain a functional a profitable bottom line (Hoffman, & Podgurski, 2011). CMS is expecting that hospitals should be able to improve their ability to submit data electronically with the requirements of meaningful use. Therefore, it is essential that adequate strategies are put in place within this role to meet all requirements from both meaningful use and CMS (Hoffman, & Podurski, 2011). Informatics systems can be increasing complex and prevent clinical staff members from communicating electronic documentations adequately and accurately (Hoffman, & Podgurski, 2011). I now realize that as we continue on with real-time data collection and abstraction, post clinical data collection, abstraction, analysis, and submission should continue to improve. Nurses and clinicians must be educated on the importance of embracing healthcare quality, safety, efficiency, and performance to guide their care

CLINICAL PRACTICUM through practice and accurate documentation of that practice (Arling, Doebbeling, & Fox, 2011). Accurate clinical documentation for data abstraction is essential in improving reliability of data collection in post-processing analysis and was an essential component to my role in the practicum. Data verification through abstraction can be successful if implemented appropriately to create efficient and effective data dependability (Monsen et al., 2011). This process includes the selection of baseline data regarding the current level of performance and determining safety, accuracy, and workflow for the clinical setting. Without the accuracy of baseline data, performance cannot be measured nor can changes in performance be implemented (McCollough, 2012). As I worked through the abstraction process, I found some concerns with the timeframe for availability of the data. This was a challenging barrier to obtaining accurate data through both the real-time and post-discharge data collection process. Project Timeline-Scope Creep Estimation involvement was utilized to determine the activity timelines for the project within my clinical practicum. During this process, the estimation of each task was determined by assigned staff and department availability. Each involved department was included in the task estimation as that task or section of the project was being determined. However, it was evident that unforeseen circumstances could interfere with the original project timeline and that it would be important to adjust the timeline as needed. It was essential that even with changes that every attempt is made to meet the original final deadline of the project (Tran, 2011).

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CLINICAL PRACTICUM The project portion of this practicum has allowed for additional experience regarding the diversity of informatics and my ability to become familiar with other disciplines care processes. In order to successfully work in the informatics area, it was essential to incorporate and understand the needs of other disciplines as resources. This will also leads directly to my improved knowledge in the informatics competency knowledge and skills in organization and human behavior (ANA, 2008, p. 35). Project management, risk management, and intra-professional communication are also significant aspects of this competency (ANA, 2008). I had some concerns regarding the project timeline and the delays in relation to the IT department schedule. Ms. Saxton and I discussed future resolutions that could be put in place when managing a project. She explained that each project is different and will have its own unique components and challenges. In this case, it is apparent that the CPOE project took precedence over my small project in HBIPS. It was evident that in a real-time scenario that the HBIPS project would have been pushed forward and not scheduled at the same time as the CPOE project. I was then able to move forward with less anxiety regarding the project timeline; however, it remained my goal to maintain the original timeline if possible. Resistance to Change It was apparent that resistance would be a barrier in the project. In healthcare, the adoption of change is often met with resistance (Morton & Wiedenbeck, 2010). Experience also told me that it is within some individuals nature to dislike change. This resistance can often time result in the failure to adopt the technological solutions to problems in healthcare quality (Morton & Wiedenbeck, 2010). The success of the

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CLINICAL PRACTICUM implementation of new electronic procedures is reliant on acceptance of the change by staff members. Having an understanding of factors that influence staff perceptions and acceptance of change prior to the implementation of an EHRS can assist the INS in reducing or preventing staff resistance (Morton & Wiedenbeck, 2010). During meetings with both the psychiatric director and staff, there was a consensus of hesitancy from the regarding changes in the documentation. The process that was currently in place had been utilized for many years. In addition, there was a significant amount of staff that had longevity within the field and not yet confident that electronic documentation is a feasible or productive way to document. I was successful in presenting some ideas for the process that may be workable within the environment, although many of the nurses remained skeptical about the change. It is no surprise to find that there is power in numbers. I am aware that building adequate relationships will assist in providing support that would not normally be available if an individual were to pursue a change on their own. In this case, a group of individuals with the same goals can use their power of persuasion to bring about change (Kegler, Rigler, & Honeycutt, 2010). Through ongoing discussion with the clinical director of the psychiatric unit, it was identified that there was a process in place in which the night shift employees are to document the total number of patients in restraints prior to midnight. It was obvious at that point that a compromise could be made in order to capture the needed requirements for this initiative. It was agreed that this process could be set up electronically. The night nurse would then be given the task of completing this process in the EMR with some additional data to meet the initiatives regulations. The only barrier identified to the new process was that it was currently not something that is done on a consistent basis. Per the

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CLINICAL PRACTICUM clinical director, getting the staff to complete the process every night would be the only challenge. The HBIPS project has a large focus on electronic documentation. The fact that the psychiatric department still completed an abundance of written documentation was a significant barrier. In addition, the process that was currently in place did not necessarily align with the requirements of the quality initiative. My preceptor and I discussed the compromise of maintaining the written process and utilizing the daily census/restraint/seclusion documentation on the night shift to meet the requirements of this measure. It was determined that the night documentation would be an appropriate solution to the issue; decreasing barriers to the final implementation of the project. On the other hand, I was fully aware that there would be some ongoing challenges within the project. Strategies & Approaches Goal Setting During my practicum, I was able to successfully apply the goal-setting theory to assist in overcoming challenges and issues. The Goal-Setting Theory relates to the individuals ability to set goals as an active participator and the ability to gauge his or her own progress (Consolvo, McDonald, & Landay 2009). It was evident that setting reachable goals assisted in this process. Setting reachable goals related to change and technology usability assists in the persuasion of the need for technology to improve quality in the healthcare setting (Consolvo, McDonald, & Landay 2009). I continually revamped my short term goals during the practicum and identified the need to change processes and behaviors to reach these goals. I feel as though I successfully created a

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CLINICAL PRACTICUM good workflow that fulfilled my practicum requirements and allowed for a successful experience. One example of goal-setting was creating a rapport with the staff during the abstraction process. It was obvious that there was a process issue that prevented the nursing staff from documenting the data in a timely manner. In this case, I was able to adjust my goal of creating relationships with the staff to improving the process in order to improve workflow. The staff was then able to identify my commitment to the role and began to become more receptive to my presence. Collaboration With the new realization that resistance to change was inevitable, I was beginning to realize my previous connection to the critical theory. The critical theory focuses on the perspective that the full participation of all individuals involved in a new process will support quality outcomes (Shaw & Stahl, 2011). It is essential to educate those involved in the change on the importance of the connection of informatics and quality. This theory also acknowledges the social needs of human beings and their need to voice an opinion regarding change (Shaw & Stahl). This led me to believe that I would need to address the concerns of the psychiatric clinical director and ensure that there was full consideration of these concerns during the technology build process. Therefore, utilization of the Critical Theory assisted in encouraging direct communication between the IT, clinical quality, and psychiatric departments. The connection between technology and healthcare can sustain improved data quality to support the change through quality initiatives (Shaw & Stahl, 2011).

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CLINICAL PRACTICUM Leadership Growth It was essential to reflect upon my leadership growth during the practicum process. Having an appropriate vision for an organization environment is essential to explore adequate communication techniques, create successful relationship, and to establish a structured and successful culture (Paroby, & White, 2010). Versatility within the INS role allowed for the identification of cultural differences within the organizational environment. However, just like any other individual, I was able to identify areas that I could improve upon through appropriate communication techniques and leadership approaches. During the practicum I was able to identify a true balance in my personality, knowledge, and values. These components were then applied to my leadership style and inspired others to improve their current environment. With the data collection and abstraction process, I was able to accomplish a significant connection with my individual leadership style and the need to utilize these skills within my role. A true leader must instill confidence in his/her followers through trust, integrity, and respect (Shriberg, D., & Shriberg, A., 2011). I was able to further identify that individual personality and perception have a large impact on leadership approach and the need to be aware of my environment at all times. This process allowed me to adapt to approaches that encouraged my followers and enhanced their ability to perform. Having an appropriate vision for an organization environment is essential to explore adequate communication techniques, create successful relationship, and to establish a structured and successful culture (Paroby, & White, 2010).

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CLINICAL PRACTICUM Connecting with the Role Throughout my practicum experience, I attempted to focus on the insights, experience, and examples that my preceptor encompasses. Through her experience, Ms. Saxton (preceptor) holds that we are in the midst of a healthcare transformational change. She is focused on federal, state, and community initiatives that are currently underway to develop, test, and implement health information technology that will improve the quality of health care. Ms. Saxton views herself as a leader amongst this transformational change process at MMCWM (personal communication, September 15, 2012). Ms. Saxton and MMCWM have come to a mutual agreement regarding the allowance of the practicum in addition to the practicum goals, objectives, activities, and estimated dates; contact information for all parties are provided within the agreement. Being directly involved in change management as a project manager was very challenging. My preceptor was excellent in offering me full autonomy and the ability to work independently throughout the practicum. The practicum was often overwhelming; however, through my preceptors guidance I was able to learn a great deal through the power of physical experience; therefore, each of the goals of the practicum were met. I found that I have grown as a leader and that I have obtained the ability adjust to a particular situation in order to trouble shoot and problem solve. It was essential to successfully incorporate my current knowledge regarding information technology, quality, and the utilization of data and apply it to the INS role. Through the practicum process, I have been able to transform my knowledge into wisdom. Experience and education can promote wisdom in any individual. Wisdom is illustrated through those who are first led and then further understand their true potential

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CLINICAL PRACTICUM as a human being (Shriberg, D., & Shriberg, A., 2011). I see a person with wisdom as an individual that is well rounded while combining knowledge, experience, education, personality, and character and applying it to their approach. A leader is able to incorporate their wisdom into their leadership approach (McKenna, Rooney, & Boal, 2009). It is apparent that research will continue to be essential component of this role. I spent many hours researching the requirements and regulations of CMS. These requirements change often and it is essential to stay apprised of the most recent regulations. Evidence gained through clinical practice is an essential component to obtaining and applying accurate data to ensure the incorporation of quality. Best practice should be integrated along with appropriate evaluation of performance and outcomes (Salmond, 2013). Through ongoing research and self-education, I was able to identify the relationship between informatics data and quality outcomes. It is apparent that the connection between the two is an essential component to this role. Communication & Relationships While completing real-time data collection and abstraction, my initial lack of rapport with the clinical staff was clear. With ongoing work regarding communication, my relationships on the clinical floor continued to strengthen. I was able to build some good relationships with nurses and physicians and they grew to expect my presence in regards to needed changes in orders and documentation to improve quality data. Improving communication of shared goals through relationships assists in enhancing knowledge to clinical staff.

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CLINICAL PRACTICUM Cross-organization coordination will improve with adequate relationship building and the quality and efficiency of patient care should improved (Gittell, 2009). Therefore, it is my assumption that with an ongoing attempt to build rapport and relationships, the staff could only improve upon my ability to collect and abstract accurate and clean data. It became apparent that the clinical staff was highly aware of the quality process, however may not have always had time to consider all of the needed documentation to support the quality of care that had been delivered. I continued to work diligently to support the clinical staff and assist them to understand the need to document the quality care that they provide so that it is recognized. Attending a communication seminar assisted me in finding a successful way to focus on emotional intelligence and how it impacts the success of customer and peer relationships in organization. Emotional intelligence is the understanding of specific behavior and attitudes of individuals involved in social interactions. It is thought that emotional competencies are built through specific learning of social context (Youseff, A., & Youseff, H., 2011). This concept was intriguing to say the least and was proven successful during my practicum. I agree with the need to identify with other individuals behaviors and attitudes while participating in any team. When communicating with others, an individual should always fully engage the other person and identify their needs. This process also reinforces positive communications and relationships between team members (Communication Seminar, January 31st, 2013). I was able to identify with the suggestions of this seminar utilize them while continuing to develop a rapport with the clinical staff.

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CLINICAL PRACTICUM Consistent reinforcement with staff also allowed for sustainable use of appropriated tools within practice. Personal anxiety can often affect self-directed learning; continued support can correct this issue and thus emphasize the essential need for accurate documentation (Bassendowski et al., 2011). For the most part, I was able to gain significant ground with reinforcing the need for change and have been able to correct many issues in regard to patient quality and required documentation for CMS data. Accurate real-time clinical documentation data is essential in improving reliability of data collection in post-processing analysis. It was further evident that communication was an essential component to the project management process. I believe that a combination of coalition building and friendliness is the best strategy of influence. Both of these techniques were utilized throughout the practicum experience. Coalition building can be successful through creating trusting relationships (Shriberg, D., & Shriberg, A., 2011). I have identified through this experience that building relationships assists in getting support of other individuals when your need it. Friendliness goes hand in hand with coalition. Validating others with flattery and recognition and assisting others in a time of need will almost guarantee that they will reciprocate these same actions when it is required (Shriberg, D., & Shriberg, A., 2011). Approaching individuals with kindness and support further opens up the door to trusting relationships. If an individuals feels support from another individual, they will return the favor. Therefore, friendliness and coalition building are complementary in obtaining adequate influence over change (Gano-Overway et al, 2009). I have worked with many teams in which relationships were a priority. Friendliness and coalition

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CLINICAL PRACTICUM building are directly connected to building successful relationship. Through this experience, it was clear that utilizing kindness to persuade others can assist in creating power in numbers. Coalition building and friendly persuasion have proven to be a successful combination when trying to influence change. Throughout the practicum, there was a significant focus on successful relationships, process quality, and evaluation of staff needs as key methods to improve the delivery of care. These relationships will continue to play a pivotal role in improving workflows related to quality data (Batini, Cappiello, Fancalanci, & Maurino, 2009). These insights have allowed me to become more relaxed within the role and to open my eyes to an experience that allowed me to strengthen my skills within the INS role. Analysis of Clinical Project The project portion of my practicum was focused on the HBIPS quality initiative and core measures related to restraint utilization in the psychiatric setting. Knowledge is an indispensable part of data creation and visualization. The INS maintains apprised of information literacy and is able to apply gained knowledge to practice (ANA, 2008). The utilization of restraints in the psychiatric setting continues to be controversial, however has been deemed necessary to maintain patient and staff safety (Recupero et al., 2011). Research identified that reduction or elimination of psychiatric restraints does not necessarily increase the benefits of therapeutic treatment. Therefore, appropriate monitoring of the utilization of this process is necessary to regulate adequate utilization of this intervention (Recupero et al., 2011). As I worked in collaboration with other departments and disciplines on the project, I identified with the idea that a plan must be continually adapted in changing

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CLINICAL PRACTICUM circumstances (Turner, 2008). The goal of this project was to create a successful electronic process to capture restraint and seclusion data. Daily decisions often needed to be made to extend certain portions of the project and possibly shorten others to meet project deadlines. Even then, it was not always feasible to maintain the initial project schedule. While trying to work with an already stressed and busy IT department, I was able to realize the challenges of managing a project. Throughout the project process, I was able to increase my knowledge of and feel more comfortable as a change manager. It was further realized that keeping an open mind regarding the planning and build process, assisted in creating significant relationships within the project team and with those involved in the change. It was also evident that the change manager should be fully informed of the project components as well as the requirements for the final product in order to fulfill the expectations of all stakeholders. Teamwork is an essential component when leading a group or team (Shriberg, D., & Shriberg, A., 2011). Leaders must focus on building team relationships and identifying trust issues when they arise. In addition, leaders should deal with individual team members that do not pull their wait or that are not participating appropriately with the team. I was further able to recognize that trial and error is a good way to adapt a project successfully and that communication is key to isolating the appropriate approach to successfully implement a change (Shriberg, D., & Shriberg, A., 2011). Throughout the practicum, I began to become more comfortable with the project management process. A good rapport was established with the quality, IT, and psychiatric department staff and decreased the resistance associated with the planned change. The INS tracks the progress of the plan while reporting and documenting any

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CLINICAL PRACTICUM need to modify from the original strategy (ANA, 2008). Changes in a project plan can sometimes increase resistance; therefore, it is essential that these changes are handled with appropriate education for the need to adapt the project timeline. The INS must be able to identify with the fears associated with the change and understand the barriers associated with this fear of change (Reid & Gallagher, 2011). Understanding resistance can aid in strengthening organization and individuals during change (Reid & Gallagher, 2011). I was able to sense that I had been able to assist with the understanding of the need for this change and assist in reflecting the resistance that I have received from staff. It was then obvious that most staff members were on board with the change and effectively participated in the process to make the change a success. During the project, I was a little intimidated by the build process. This was new to me and it has been challenging trying to understand all of the ins and outs of this process. It was invaluable to have the IT department to consult with during my third objective. It became evident that in order to build an appropriate electronic documentation process that will monitor and collect adequate data for restraint utilization; I would need to utilize all of my available resources. Effective communication between the involved disciplines has been an essential component to the management of this project. The INS maintains adequate communications and relationships with other disciplines (ANA, 2008). It was further realized that direct communication between all involved stakeholders would be imperative to implement an effective process (Gardner et al., 2009). I eventually began to find my way in the development of processes in informatics. Though many of these tasks were new to me, I was able to obtain a great deal of

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CLINICAL PRACTICUM knowledge regarding creating, maintaining, and obtaining data to improve care quality. The INS continues to engage in the development, implementation, and evaluation of procedures that improve quality practice (ANA, 2008, p. 79). During this process the INS will also identify factors that will be efficient in improving quality care and safety (ANA, 2008). The project has been successful and the new restraint/seclusion documentation process will be implemented in May. The project deliverable is available for view in the appendix section of this paper; this includes the new work instruction and the visual education products (see Appendix C; see Appendix D). Evaluation of Clinical Practicum The purpose of this practicum was met through my ability to obtain knowledge from both the information technology and clinical quality departments to improve my current knowledge regarding information technology and the correlation of this identified competency to the quality department. My first goal was to obtain competency in data abstraction, data analysis, and the implementation of core measures. I was able to meet this goal by becoming proficient in the real-time and post-discharge data abstraction process. In addition, I was able to support the implementation of core measures with the development of a new process of real-time abstraction. The ANA standard nine for informatics nurses was utilized to support my first goal. This standard defines quality of practice and quality of care through effective informatics practice. The INS should demonstrate utilization of quality improvement results to initiate change in nursing practice. In addition, there should be efficient participation in quality improvement activities such as data collection, data analyzing, and recommendations for new practices to improve and enhance quality outcomes (ANA,

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CLINICAL PRACTICUM 2008).

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All objectives were completed and met in relation to the first goal. I continued to work closely with the information technology and quality departments throughout the practicum. Adequate and essential relationships were built and maintained between these disciplines. Organizational relationships, along with improvement of process qualities and evaluation of benefits are key methods to improve patient quality. These relationships were essential in improving workflows related to capturing quality data (Batini, Cappiello, Fancalanci, & Maurino, 2009). Quality initiatives are essential to creating a higher performance standard in healthcare (Damberg et al., 2010). The second objective to meet the first goal was to obtain improved knowledge of the ANA informatics information technology knowledge and skills competency (ANA, 2008). This competency includes identification of software methodologies and processes, analysis and design of new systems, and management/design of an existing database (ANA, 2008). This competency is essential to the nurse informatics specialist role. I was able to meet this goal through collaboration with my preceptor in identifying significant processes in the creation and maintenance of data and recognizing the importance of data integrity. The second goal was to participate in a project within the psychiatric unit at MMCWM. In order to meet this goal, I worked in collaboration with the IT and psychiatric departments to create a new documentation process to capture restraint and seclusion minutes. Quality initiatives related to HBIPS and the required core measures for psychiatric units were utilized as a framework for this project. This project was

CLINICAL PRACTICUM essential to the quality department as the National Quality Forum has now created a required initiative for 6 of the original 7 measures (The Joint Commission, 2010). The second goal was supported by the informatics standard nine. The INS will engage in the development, implementation, and evaluation of procedures that improve quality practice (ANA, 2008, p. 79). During this process the INS will also identify factors that will be effective in removing or decreasing barriers to quality care and safety (ANA, 2008). I was able to identify multiple barriers to the project and arrive at an adequate compromise with both the clinical quality and psychiatric staff regarding the creation of the new documentation process. The project portion of this practicum has allowed me to obtain additional experience regarding the diversity of informatics and my ability to become familiar with other disciplines care processes. In order to successfully work in the informatics area, it will be essential to incorporate and understand the needs of other disciplines as resources. This has led to my improved knowledge in the informatics competency knowledge and skills in organization and human behavior (ANA, 2008, p. 35). Project management, risk management, and intra-professional communication are also significant aspects of this competency (ANA, 2008). The first objective was to research information regarding the HBIPS quality initiative and core measures related to restraint utilization in the psychiatric setting. Informatics competencies can be developed through literature review with a focus on utilization of this knowledge to build skills (Westra & Delaney, 2008). It is evident through my experience that research was an ongoing aspect of this process. I was able to gain an abundance of knowledge regarding the INS role and apply it to my practice

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CLINICAL PRACTICUM within the practicum. The second and third objectives were met in sequence including ongoing meetings with all disciplines to agree on and create and electronic process that would be successful when implemented. The INS will need to apply appropriate educational strategies and theoretical frameworks throughout any change process to support success of the change (Gardner, et al., 2009). The fourth objective was met through the creation and implementation of an educational strategy for the new restraint documentation process. I was able to meet with the psychiatric nursing staff to review the process. There was also an online education format provided for the nurses that were unable to attend the educational in-service. Objective five was met through the creation of the restraint/seclusion work process. The INS works to create system policies and procedures and serves while serving as a leader in projects (ANA, 2008). The procedure process was also utilized to plan the implementation of the new documentation process. Objective six will be met on April 13th, 2013 when the project is finally implemented. The INS interprets across disciplines and with IT professional to insure adequate understanding of the implementation process (ANA, 2008). A full and detailed review by both the student and preceptor is provided in the appendix of this paper (see Appendix A; see Appendix B). Conclusion Through the analysis of my practicum experience, it has been identified that there was full immersion in the role. Acceptance, research, and change were all identified as initial challenges within the practicum. In addition, ongoing issues and concerns including data accuracy-integrity, project timeline-scope creep, collaboration, and resistance to change were also identified throughout the practicum. With the utilization of

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CLINICAL PRACTICUM successful strategies, I was able to overcome these obstacles and effectively move forward. The internal project assisted in obtaining both professional growth and improved leadership skills. A review of the practicum revealed a significant amount of success within the practicum. The worth of collaboration and the full identification of the INS role were both revealed as significant keys to an excellent educational experience. Through a significant amount of knowledge and applied wisdom, all identified goals and objectives were successfully met.

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CLINICAL PRACTICUM References American Nurses Association. (ANA). Nursing Informatics: Scope & Standards of Practice. Silver Spring, MD: Nursebooks.org Arling, P. A., Doebbeling, B. N., Fox, R. L. (2011). Improving the implementation of evidence-based practice and information systems in healthcare: A social network approach. Healthcare Information Systems and Informatics, 6(2), 123.doi:10.4018/jhisi.2011040104 Bassendowski, S., Petrucka, P., Breitkreuz, L., Partyka, J. M., MacDougall, L., . & Ayers, K. (2011). Integration of technology to support nursing practice: A Saskatchewan initiative. Online Journal of Nursing Informatics, 15(2), 1.12. Retrieved from http://ojni.org Batini, C., Cappiello, C., Fancalanci, C., & Maurino, A. (2009). Methodologies for data quality assessment and improvement. ACM Computing Surveys, 41(3), 1-5. doi:10.1145/1541880.1541883 Black, A. D., Car, J., Pagliari, C., Anandan, C., Cresswell, K., Bokun, T., . . . Sheikh, A. (2011). The impact of eHealth on the quality of safety of health care: A systemic overview. PLOS Medicine, 8(1), 1-16. doi:10.1371/journal.pmed.1000387 Consolvo, S., Mcdonald, D. W., & Landay, J. A. (2009). Theory-driven design strategies for technologies that support behavior change in everyday life. CHI, Online, 405414. Retrieved from http://homepage.psy.utexas.edu/ Dalrymple, P.W., Rogers, M., An, Y. (2009). Effect of early requirements analysis and participative design on staff in an urban health clinic: Civic engagement through collaboration. Faculty Research and Publications. Retrieved from

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CLINICAL PRACTICUM http://hdl.handle.net/1860/3152 Gardner, R. M., Overhage, J. M., Steen, E. B., Munger, B. S., Holmes, J. H., Williamson, J. J., Detmer, D. E. (2009). Core content for the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16, 153-157. doi:10.1197/jamia.M3045 Gano-Overway, L. A., Newton, M., Magyar, T. M., Fry, M. D., Kim, M., & Guivernau, M. R. (2009). Influence of caring youth sport contexts on efficacy-related beliefs and social behaviors. Developmental Psychology, 45(2), 329-340. Gittell, J. H. (2009). High Performance Healthcare: Using the Poser of Relationships to Achieve Quality, Efficiency, and Resilience. New York: McGraw-Hill. Hoffman, S., & Podgurski, A. (2011). Meaningful use and certification of health information technology: what about safety? Journal of Law, Medicine & Ethics, 39(1), 77-80. doi:10.1111/j.1748-720X.2011.00572.x Federal Register. (2006). Part IV: Department of Health and Human Services. Center for Medicare & Medicaid Services, 42 (482), 71378-71392. Kegler, M. C., Rigler, J., & Honeycutt, S. (2010). How does community context influence coalitions in the formation stage? A multiple case study based on the community coalition action theory. BMC Public health, 10(90), online. doi:10.1186/1471-2485-10-90 Lee, E. S., McDonald, D. W., Anderson, N., & Tarczy-Hornoch, P. (2009). Incorporating collaborator concepts into informatics in support of translational interdisciplinary biomedical research. International Journal of Medical Informatics, 78(1), 10-21. doi:10.1016/j.ijmedinf.2008.06.011

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CLINICAL PRACTICUM Marjoua, Y., Bozic, K. (2012). Brief history of quality improvement in U.S. healthcare. Current Relevant Musculoskeletal Medicine, in press. doi:10.1007/s12178-012-9137-8 McCollough, C. (2012). Automated data mining of exposure information for dose management and patient safety initiatives in medical imaging. Radiology, 264, 322-324. doi:10.1148/radiol.12121152 Memorial Medical Center of West Michigan (n.d.). Retrieved from About Memorial Medical Center; Memorial Medical Center of West Michigan website, http://www.mmcwm.com/AboutMMC Monsen, K. A., Lytton, A. B., Ferrari, S., Halder, K. M., Radosevich, D. M., .& Brandt, J. K. (2011). Evaluating reliability of assessments in nursing documentation. Online Journal of Nursing Informatics, 15(3), 1-12. Retrieved from http://ojni.org Morton, M. E. & Wiedenbeck, S. (2010). EHR acceptance factors in ambulatory care: A survey of physician perceptions. Perspectives in Health Information Management, 7(1), 1-17. Nasca, T. J., Philibert, I., Brigham, T., Flynn, T. C. (2012). The next GME accreditation system Rationale and benefits. The New England Journal of Medicine, 366(11), 1051-1056. Paroby, D., & White, D. W. (2010). The role of shared vision and ethics in building and effective learning organizations. Southern Journal of Business & Ethics, 2, 133142. Poon, E. G., Wright, A., Simon, S. R., Jenter, C. A., Kaushl, R., Volk, L. A., . . . Bates,

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CLINICAL PRACTICUM D. W. (2012). Relationship between use of electronic health record features and health care quality: Results of a statewide survey. Medical Care, 48(3), 203-209. doi:10.1097/MLR.0b013e3181c16203 Recupero, P. R., Price, M., Garvey, K. A., Daly, B., Xavier, S. L. (2011). Restraint and seclusion in psychiatric treatment settings: Regulation, case law, and risk management Journal of the American Academy of Psychiatry and the Law Online, 39(4), 465-476. Reed, J. & Gallagher, M. (2011). Resistance to change: Friend or foe. Health Progress, 92(4), 14-19. Retrieved from http://www.chausa.org/2011_Annual_Index.aspx Salmond, S. W. (2013). Finding the evidence to support evidence-based practice. Orthopaedic Nursing, 32(1), 16-22. doi:10.1097/NOR.0b012e31827d960b Shaw, M. C., & Stahl, B. C. (2011). On quality and communication: The relevance of critical theory to health informatics. Journal of the Association for Information Systems, 12(3), 255-273. Shriberg, D., & Shriberg, A. (2011). Practicing leadership: principles and applications (4th ed.). Hoboken, NJ: John Wiley and Sons, Inc. The Joint Commission (2010). HBIPS core measure set now required for certain freestanding psychiatric hospitals. The Official newsletter of The Joint Commission, 20(10), 1-8. Tran, C. (2011). Project Management: The Delphi Technique. Retrieved from www.helium.com Turner, J. R. (2008). The Handbook of Project-based Management (3 ed.). New York: McGraw-Hill Professional.

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CLINICAL PRACTICUM Vaduganathan, M., Bonow, R., Gheorghiade, M. (2013). Thirty-day readmissions: The clock is ticking. Journal of the American Medical Association, 309(4), 345-349. Westra, B. L., & Delaney, C. W. (2008). Informatics competencies for nursing and healthcare leaders. AMIA Annual Symposium Proceedings Archive, Online, 804808. Retrieved from www.ncbi.nlm.nih.gov/ Youssef, A. B., & Youssef, H. B. (2011). Social networking on web 2.0: From emotional intelligence to cyber emotional intelligence. Management Information Systems, 6(2), 021-028.

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CLINICAL PRACTICUM Appendix A Completed Evaluation Tool Preceptor

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CLINICAL PRACTICUM Appendix B Completed Evaluation Tool Student

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CLINICAL PRACTICUM Appendix C Project Deliverable Work Instruction

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Memorial Medical Center of West Michigan

Ludington, Michigan, 49431

Hadley Restraint/Seclusion Electronic Minutes Submission

POLICY: Memorial Medical Center monitors, measures, analyzes, and continually improves the quality management system in order to demonstrate conformity of service delivery and ensure the effectiveness of the quality management system and facilitates process improvement. PROCEDURE: This online data tool will be utilized to capture actual restraint and seclusion events (in minutes) carried out in Hadley. The Hadley restraint tool was created to ensure that quality measurement data submitted to the Centers for Medicare and Medicaid (CMS) data warehouse for Medicare reimbursement is valid and accurate. SCOPE: Hadley Nursing Unit WORK INSTRUCTION: General Information: 1. The Hadley Restraint Website can be accessed at: http://us/restraint/ 2. This website will populate with current patients daily at 11:45 PM 3. This website is password protected 4. Submission of data is expected to be entered between 12:00 midnight and 12:30 AM on a daily basis. 5. This website contains three working pages: the Hadley Restraint login page, the Restraint Data Collection Worksheet page, and the Data Entry Worksheet page.

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Hadley Restraint/Seclusion Electronic Minutes Submission (cont.)

Entering Minutes into the website 1. The Nurse/Psych Tech/Hadley Employee will continue to document restraint/seclusion minutes as previous. 2. The restraint and seclusion minutes should be tallied separately at the end of each shift to ensure an accurate daily count. 3. The Nurse/Psych Tech/Hadley Employee will access the website through the following web address: http://us/restraint/ 4. The Nurse/Psych Tech/Hadley Employee will then need to enter in the provided password. 5. A list of incomplete dates will then appear in the Restraint Data Collection Worksheet page. 6. The Nurse/Psych Tech/Hadley Employee will then select the appropriate date to enter the daily restraint/seclusion minutes. 7. Current patients will then appear on the Data Entry Worksheet page. 8. There is a separate field on the Data Entry Worksheet provided for both restraint minutes and seclusion minutes. 9. The Nurse/Psych Tech/Hadley Employee will submit the total minutes for the appropriate event in the appropriate fields. 10. If there is no restraint or seclusion totals available for a particular patient, that field (restraint, seclusion, or both) should be completed with 0. 11. After the appropriate total has been entered into each field, the Nurse/Psych Tech/Hadley Employee will click the submit button at the bottom of the Data Entry Worksheet page. 12. If the submission was successful, the entered date should no longer be accessible from the Restraint Data Collection Worksheet page.

CLINICAL PRACTICUM Appendix D Project Deliverable Education

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CLINICAL PRACTICUM Appendix E Learning Resource List American Nurses Association (ANA). Nursing Informatics: Scope & Standards of Practice. Silver Spring, MD: Nursebooks.org Apter, J. (2010). Informatics nurse specialist role: Integrating technology into practice. Clinical Nurse Specialist, 24(2), 97. doi:10.1097/01.NUR.0000348939.60210.39 Batini, C., Cappiello, C., Fancalanci, C., & Maurino, A. (2009). Methodologies for data quality assessment and improvement. ACM Computing Surveys, 41(3), 1-5. doi:10.1145/1541880.1541883 Betts, H. J., & Wright, G. (2009). Observations on sustainable and ubiquitous healthcare informatics from Florence Nightingale. Connecting Health and Humans, 91-97. doi:10.3233/978-1-60750-024-7-91 Black, A. D., Car, J., Pagliari, C., Anandan, C., Cresswell, K., Bokun, T., . . . Sheikh, A. (2011). The impact of eHealth on the quality of safety of health care: A systemic overview. PLOS Medicine, 8(1), 1-16. doi:10.1371/journal.pmed.1000387 Botsis, T., Hartvigsen, G., Chen, F., & Weng, C. (2010). Secondary use of EHR: Data quality issues and informatics opportunities. AMIA, 1-5. Retrieved from http://www.ncbi.nlm.nih.gov/ Bourgeois, F., Olson, K. L., & Mandi, K. D. (2010). Patients treated at multiple acute health care facilities: Quantifying information fragmentation. Archives of Internal Medicine, 170(22), 1989-1995. Doi:10.1001/archinternmed.2010.439 Bowman-Hayes, J. (2009). The role of the informatics nurse specialist. AORN Journal, 90(6), 922-924. doi:org.libcat.ferris.edu/10.1016/j.aorn.2009.11.042

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CLINICAL PRACTICUM Chen, M., Ebert, D., Hagen, H., Laramee, R. S., vanLiere, R., & Silver, D. (2009). Data, Information and knowledge in visualization. Computer Graphics and applications, 29(1), 12-19. Retrieved from http://ieeexplore.ieee.org/ Chassin, M. R., & Loeb, J. M. (2011). The ongoing quality improvement journey: Next stop, high reliability. Health Affairs, 30(4), 559568.doi:10.1377/hlthaff.2011.0076 Consolvo, S., Mcdonald, D. W., & Landay, J. A. (2009). Theory-driven design strategies for technologies that support behavior change in everyday life. CHI, Online, 405414. Retrieved from http://homepage.psy.utexas.edu/ Dalrymple, P.W., Rogers, M., An, Y. (2009). Effect of early requirements analysis and participative design on staff in an urban health clinic: Civic engagement through collaboration. Faculty Research and Publications. Retrieved from http://hdl.handle.net/1860/3152 Damberg, C. L., Shorteel, S. M., Raube, K., Gillies, R. R., McCurdy, R., . . . Adams, J. (2010).Realationship between quality improvement processes and clinical performance. The American Journal of Managed Care, 16, 601-606. Ford, E. W., Menachemi, N., Huerta, T. R., Yu, F. (2010). Hospital IT adoption strategies associated with implementation success: Implications for achieving meaningful use. Journal of Healthcare Management, 55(3), 175-188. Retrieved from http://biomedsearch.com Gardner, R. M., Overhage, J. M., Steen, E. B., Munger, B. S., Holmes, J. H., Williamson, J. J., Detmer, D. E. (2009). Core content for the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16, 153-

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CLINICAL PRACTICUM 157. doi:10.1197/jamia.M3045 Gibbons, M. C., & Casale, C. R. (2010). Reducing disparities in health care quality: The role of health IT in under resourced settings. Medical Care Research and Review, 67(5), 155S-162S. doi:10.1117/1077558710376202 Hwang, J. (2011). Factors associated with nurses informatics competency. CIN: Computers, Informatics, Nursing, 29(4), 256-262. doi:10.1097/NCN.0b013e3181fc3d24 Jean-Jacques, M., Persell, S. D., Thompson, J. A., Hashain-Wynia, R., & Baker, D. W. (2012). Changes in disparities following the implementation of a health information technology-supported quality improvement initiative. Journal of General Internal Medicine, 27(1), 71-77. doi:10.1007/s11606-011-1842-2 Lee, E. S., McDonald, D. W., Anderson, N., & Tarczy-Hornoch, P. (2009). Incorporating collaborator concepts into informatics in support of translational interdisciplinary biomedical research. International Journal of Medical Informatics, 78(1), 10-21. doi:10.1016/j.ijmedinf.2008.06.011 Lewandrowski, K., Gregory, K., & Macmillan, D. (2011). Assuring quality in point-ofcare testing: Evolution of technologies, informatics, and program management. Archives of Pathological Laboratory Medicine, 135(11), 1405-1414. doi:10.5858/arpa.2011-0157-RA McCollough, C. (2012). Automated data mining of exposure information for dose management and patient safety initiatives in medical imaging. Radiology, 264, 322-324. doi:10.1148/radiol.12121152 Marjoua, Y., Bozic, K. (2012). Brief history of quality improvement in U.S. healthcare.

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CLINICAL PRACTICUM Current Relevant Musculoskeletal Medicine, in press. doi:10.1007/s12178-0129137-8 Lewandrowski, K., Gregory, K., & Macmillan, D. (2011). Assuring quality in point-ofcare testing: Evolution of technologies, informatics, and program management. Archives of Pathological Laboratory Medicine, 135(11), 1405-1414. doi:10.5858/arpa.2011-0157-RA Marjoua, Y., Bozic, K. (2012). Brief history of quality improvement in U.S. healthcare. Current Relevant Musculoskeletal Medicine, in press. doi:10.1007/s12178-0129137-8 Pinsonneault, A., Dakshinamoorthy, V., Reidel, K., & Tamblyn, R. (2012). The impact of IT on quality of care: Evaluation of an integrated chronic disease management system. 45th Hawaii International Conference on System Sciences, 2947-2956. doi:10.1109/HICSS.2012.569 Poon, E. G., Wright, A., Simon, S. R., Jenter, C. A., Kaushl, R., Volk, L. A., . . . Bates, D. W. (2012). Relationship between use of electronic health record features and health care quality: Results of a statewide survey. Medical Care, 48(3), 203-209. doi:10.1097/MLR.0b013e3181c16203 Shaw, M. C., & Stahl, B. C. (2011). On quality and communication: The relevance of critical theory to health informatics. Journal of the Association for Information Systems, 12(3), 255-273. Snyder, C. F., Wu, A. W., Miller, R. S., Jensen, R. E., Bantug, E. T., & Wolff, A. C. (2011). The role of informatics in promoting patient-centered care. National Institute of Health Manuscript, 17(4), 211-218.

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CLINICAL PRACTICUM doi:10.1097/PPO.0b013e318225ff89 Taylor, K., Mammen, K., Barnett, S., Hayat, M., dosReis, S., & Gross, D. (2012). Characteristics of patients with histories of multiple seclusion and restraint events during a single psychiatric hospitalization. Journal of the American Psychiatric Nurses Association, 18(3), 159-165. doi:10.1177/1078390311432167 The Joint Commission (2010). HBIPS core measure set now required for certain freestanding psychiatric hospitals. The Official newsletter of The Joint Commission, 20(10), 1-8. Weissman, J. S., & Hasnain-Wynia, R. (2012). Advancing health care equity through improved data collection. The New England Journal of Medicine, 364(24), 22762277. Westra, B. L., & Delaney, C. W. (2008). Informatics competencies for nursing and healthcare leaders. AMIA Annual Symposium Proceedings Archive, Online, 804808. Retrieved from www.ncbi.nlm.nih.gov/

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