Running head: NURSE OBSERVATION EDUCATION

Nursing Observation Education and Specialized Training

Pam Thompson
Bethel College

NURSE OBSERVATION EDUCATION

Nursing Observation Education and Specialized Training

Healthcare reform has placed a great deal of pressure on todays healthcare organizations.
The organization must continually strategize and identify ways to meet complex challenges in
healthcare. In addition, the organization must maintain quality of care, patient safety, and patient
satisfaction while maintaining financial viability.
With the implementation of the Two-Midnight Rule by Medicare and a high rate of audit
denials for 1-day length of stay for inpatient admissions, many healthcare organizations are creating observation units within their facilities. Observations are a distinct group of patients with
specific needs that could possibly be treated within 24 hours, but no more than 48 hours (Aston,
2012). For an observation unit to be successful, commitment and collaboration must occur between hospitalists, leadership, and nursing staff (Asudani & Tolia, 2013). Asudani and Tolia
(2013) further state it requires a well-managed unit, the implementation of specific evidencebased treatment protocols, and inclusion/exclusion criteria in order to improve quality of care
while also reducing costs of care.
Change Concept
Within the organization, there are two types of observation units. One within the
emergency room and the other intermixed with inpatient admissions on the medical surgical
units. The observation patients admitted to the medical surgical floors are treated just like an
inpatient admission. Due to long observation hours, there is concern for increased costs to both
the organization and the patient, loss of revenue, and potentially decreasing patient satisfaction.
In addition, observation patients admitted to the floor often are not informed of their correct
status and are unaware of accruing expenses under outpatient care or Medicare Part B (Andrews,
2013). This not only decreases patient satisfaction, but is a Medicare compliance issue as

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patients must be informed of their correct status. Having a specific observation unit can help to
eliminate these issues.
Assessment
It is important, before the implementation of any project, to assess any cultural variables
that may exist within the change environment. Identifying these variables brings an awareness
and understanding for effective planning and implementation of the change event. Giger and
Davidhizar (2008) developed a transcultural model for nursing to evaluate and determine cultural
considerations based on six phenomena consisting of biological variations, social organization,
communication, time, space, and environmental control. These six components were used to assess and identify concepts for the change project.
Biological Variations and Social Organization
The proposed change event will take place on the Cardiac Telemetry Unit (CTU) and is
comprised of 36 telemetry beds within a 200 bed medical center. The medical center serves as
part of a health system that contains two sister hospitals, an outpatient surgery center, a cancer
center, rehabilitation centers, long-term care facility, home care services, hospice services, and
affiliate physician practices throughout southwest Michigan region (Lakeland Health, 2015). The
health system strives to provide quality of care and has obtained several national accreditations.
The medical center is located in the city of St. Joseph, Michigan just off of a major interstate and sits along the Lake Michigan coast line. It is one of the most popular tourist areas due
to the beachfront attractions and close proximity to area wineries. Its neighboring city, Benton
Harbor, has the highest African-American population within the western Michigan region. In
addition, the medical center also sits within the Michigan fruit belt, which has a high population

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of Hispanic, migrant workers. The majority of these culturally diverse populations live below
poverty level using governmental insurance, Medicare-Medicaid, services.
Environmental Control
The CTU is a fast-paced, medical-surgical unit within the medical center. The unit has
four nursing stations separated by a core pathway for supplies and staff usage. The unit has a
high patient turnover rate compared to other medical-surgical floors within the facility due to the
types of patients that are cared for on the unit requiring telemetry. These patients in which the
nursing unit relies on can be defined as the external locus of control (Giger & Davidhizar, 2008).
The nurses within the unit have the power to affect change and are considered as the internal locus of control (Giger & Davidhizar, 2008).
Communication
Poor communication within a health system can be detrimental and can lead to adverse
events. It is important for all healthcare staff to communicate effectively for patient safety and
satisfaction. Giger and Davidhizar (2008) stated that communication can be a barrier when
working with diverse groups. It is important to assess the cultural barriers that can prevent effective communication and implement a plan that will prevent or eliminate them.
There are various verbal communication patterns that occur within this unit and can be
challenging at times. Fortunately, the majority of the patient information is communicated within the patients electronic health record. However for staff, verbal communication varies in
form and can either be face-to-face contact, telephone, voice badge, or email. If there is important information that the entire unit needs regarding patient care or policy changes, the managers will hold staff meetings or daily huddles. In addition, the nurses and nursing assistants re-

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spectively give report to one another at shift change. The nurse and nurse assistant team may
briefly meet to plan the care that will be carried out during the current shift.
The adopters of the proposed change will be the patient care nurses. The mode of communication for this proposed change event will be presented verbally using power-point documentation at a nurse staff meeting. Specialized training sessions will also be required for each
nurse to attend. The communication for this project will be a collaborative effort between the
change agent, the units Clinical Resource Nurse (CRN), and unit Super Users (SU) and represents a major relationship within the proposed change event. There will be a fair amount of contact with the unit manager with minimal contact between the assistant manager, the nurse assistants, and the unit clerks. Despite the types of linkages that may exist within the change event,
maintaining good relationships is important for successful implementation.
Time
Good time management skills are important for nurses to master so he/she can perform
tasks effectively and efficiently. It isnt about working faster to complete your tasks as this may
cause medical errors. It is about working smarter by prioritizing tasks and delegating particular
tasks that can be done by other support staff members.
Time isnt just patient-focused. It also includes time for self. It is important, especially
during a 12-hour shift, that nurses take some time to rest and refuel. If a nurse does not recuperate, it can also lead to medical errors and potentially harm to the patient.
When presenting the proposed change project, time could also play a factor in the education and training process. Some of the nurses may have to provide patient care and would not
get all of the information provided during the education process. Consideration of the nurses
time and preparing the right plan is crucial to the outcome of this project.

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Space
The majority of the patient rooms are private with their own personal bathroom. The
rooms have a couch that pulls out into a bed for family members to stay with their loved one.
Each room also contains state of the art equipment to assist in patient care. However, there are
six rooms that are semi-private and contain two beds with curtains to separate each bed. This
can lead to potential privacy issues especially when discussing personal health information with
patients and their families.
While not enough space can be an issue, so can too much space. Previously, it was mentioned the nurses stations were separated into four functioning units and divided by a core intersection. Nurses in one station may not know what is going on in another. Each station however
is well equipped with communication tools to help decrease a segregated atmosphere. For most
observation units, the concern of noise and constant flow of the observation unit could be a patient satisfaction concern and a disadvantage for the unit. However, with the amount of space
and segregation and implementing the 15-bed observation unit close to the elevators, using
nurses stations one and four, would help decrease this concern. In addition, there are doors that
separate these stations from two and three, which would also help in noise reduction of an observation unit.
Change Environment
The CTU medical-surgical unit is staffed appropriately with a nurse manager, an assistant
nurse manager, a CRN, patient-care nurses, nurse assistants, and unit clerks. The organizational
model representing the change environment was based off of the Hierarchy Control Design, representing a vertical direction so that staff will perform the right processes given by management
(Porter O Grady & Malloch, 2011) (see Appendix A).

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Also, there are two hospitalist physicians and their resident assistants or mid-level providers assigned to the unit. A care manager and discharge planner also serve on the unit to help
facilitate the needs of patients at discharge. There are other ancillary staff assigned as needed
depending on specific services ordered by the hospitalists or specialists that serve on the unit.
The shifts within the unit mainly consist of two 12-hour shifts. The day shift consists of
the more experienced staff and requires more staffing than the night shift, which consists of the
newer staff members. There is a frequent turnover rate as the patient-care nurse is an entry level
position and often takes promotional positions offered throughout the organization.
Problem and Diagnosis
Originally, this facility formed a committee to determine how best to serve patients that
did not meet criteria for an inpatient admission but could not be safely discharged after
emergency treatment. A decision was made to admit patients to the medical-surgical floors
when the emergency observation room was full and inter-mixing the observation patients with
the inpatient admissions was the best option instead of a designated observation unit. Patientcare nurses were not informed of this decision and lack educational information on observation
status. The considered NANDA diagnosis is deficient knowledge related to lack of educational
information regarding observation status as evidenced by long observation hours, increased
costs, and potential revenue loss.
In order for the change to be successful, it is imperative to build good, strong
relationships with the adopters of change. If the relationships are weak, the project is at risk for
ineffective relationships as evidenced by lack of desire or participation by the patient care nurses.
Moreover, affecting patient safety and patient care outcomes.

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Plan

Planned change requires proper staff education and training so that staff will find value in
the change. Implementing a servant leadership model would also prove beneficial for this
proposed changed event as it brings about an atmosphere of leading others versus directing
others. Kumar (2010) states that one of the most important aspects of servant leadership is
leading with love from within; which, in turn, promotes the growth of others and empowers them
to succeed. Furthermore, a servant leader is committed to the growth of others, possesses a
strong sense of stewardship, and builds a sense of community within the organization.
The nurses would be provided with education and training on caring for observation
patients. Once properly trained, nurses could collaborate with physicians to help determine an
appropriate plan of care and facilitate a faster and safe discharge. The nurses would also help
inform the physician of the observation time and possibly consider inpatient status if the patient
qualifies.
Nurses can be sure the patient and family are informed regarding their status during this
time. It considered best practice to train all necessary staff involved in observation care and
develop proper protocols to follow for a faster throughput. Thus reducing cost to the
organization and the patient, increase patient satisfaction, and potentially increase revenue.
Understanding the vision and mission of the healthcare organization is a necessary part of
the planning stage. It is also important to establish who the key stakeholders will be in order to
build strong relationships that are necessary for the success of the change event. Approval of
this proposed change event would have already taken place and approved by the medical centers
upper management team, which would include the floor manager and change agent. Therefore,

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the CTU manager and change agent would have already established a fair relationship (see
Apendix B).
Facilitation of the change would be done through the CRN and would have major
relationships with all key stakeholders of the change event within the unit. The change event
would also require a major relationship with the SU team, team of seasoned nurses that are
considered as experts within a unit. Establishing an SU team engages the point of care nursing
team in the decision-making process and strategically establishes a shared governance
atmosphere. This will then establish credibility and trust of the change agent, and successful
implementation of the change event with all key stakeholders.
Another planning consideration is the necessary resources needed when considering the
implementation of change. The resources needed for this project consist of time, people, and
minimal financial costs. As previously stated the core team, the change agent, the CRN, and the
SU team, consisting of three nurses each from the day and night shift, will meet weekly to
collaborate together and develop a plan of action for successful implementation of the change.
The attentive meeting plan for the core team will be to meet twice a month for four
months. The first month would be to build relationships, establish expectations, explain the
change event, and provide knowledge and data of functionality of the observation unit. The
second month would be to establish pre and post-tests, give the pre-test to the other patient care
nurses on the unit, and evaluate their responses. The third month would be to develop an
education plan and evaluate the sub-sets used by the emergency room observation unit to
determine if they could be utilized on the unit. During the fourth month, preparation of the
education and training and roll out would be finalized and approved.

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Outcomes

These key components help the change agent and key stakeholders to develop specific
outcomes of change. The outcomes that will show success of the change event for this project
are:

Increased nursing knowledge and competencies of an observation unit;

Improved collaboration amongst leadership, hospitalists, and nursing;

Improved quality of care, patient safety, and satisfaction; and

Improved utilization, decreased length of stay, and decreased costs.

Implementation

The patient care nurses would require a two-hour session for education and training.
During this time, the core team will provide data and guidelines to implement the specific
training and their role within the observation unit. At the end of the training session, post-tests
will be given to assess the effect of these sessions and the need for additional training.
When the specified observation unit is implemented, the SU team will take responsibility
in guiding and overseeing the patient care nurses. This shared governance will ensure that the
mission, vision, and the goals of the change event are met and successfully implemented.
The costs incurred in both the planning and implementation phases should be minimal.
The staff will be paid educational hours for each hour served for both the SU team and the
patient care nurses. These two teams consist of approximately 40 nurses. Additional costs may
include the development of subsets within the electronic health record for the use in the
observation unit and may involve the information technology department.

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Evaluation

Evaluation is an essential part of every change event in order to determine the success of
the change. Pre and post-tests will be given to evaluate how much knowledge the adopters of
change know and understand what observation status means and how to work within an
observation unit. The patient care nurses will also be given the opportunity to take an online
survey regarding the education/training process to evaluate staff satisfaction. It is also important
to evaluate the effect of the education that it has on the unit to ensure provision of the highest
quality of care, patient safety, patient satisfaction, and decreased costs for both the patient and
the facility. Since documentation is now entered into the electronic health record, it will be easy
to pull certain data pertaining to length of stay, cost analysis, and reimbursement information.
Another source of information can be obtained through Hospital Consumer Assessment
of Healthcare Providers and Systems (HCAHPS), a quality assurance tool used for data
collection and public reporting system used by Medicare/Medicaid (Hospital Consumer
Assessment of Healthcare Providers and Systems, 2015). HCAHPS measures patient safety and
satisfaction through a survey sent to the patient after their hospital stay (Hospital Consumer
Assessment of Healthcare Providers and Systems, 2015). Evaluating this evidenced-based data
from the patients perspective will provide feedback to determine the success of the change event
or the need for further assessment and planning.

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References

Andrew, M. (2013). Observation units may ease burdens of ER care, but benefits to patients
come at a price. Retrieved from https://www.washingtonpost.com/national/healthscience/observation-units-may-ease-burdens-of-er-care-but-benefits-to-patients-come-ata-price/2013/02/08/84ddf37e-706d-11e2-a050-b83a7b35c4b5_story.html
Aston, G. (2012). Observation units: a tightrope act. Hospitals & Health Network, 86(2), 32-36.
Retrieved from http://cmsanj.org/userfiles/Observation%20units%20Nov%202013.pdf
Asudani, D. & Tolia, V. (2013). Pros and cons of clinical observation units.
Retrieved from http://www.the-hospitalist.org/article/pros-and-cons-of-clinicalobservation-units/2/
Giger, J. N., & Davidhizar, R. E. (2008). Introduction to transcultural nursing. In J. N. Giger &
R. E. Davidhizar (eds.), Transcultural nursing: Assessment and intervention (6th ed.)
(pp. 2-19). St. Louis, MO: Mosby Elsevier.
Hospital Consumer Assessment of Healthcare Providers and Systems. (2015). Hospital
Consumer Assessment of Healthcare Providers and Systems profile. Retrieved from
http://hcahpsonline.org/Files/HCAHPS_Fact_Sheet_June_2015.pdf
Kumar, K. (2010). A new culture of leadership: service over self. Journal of Christian
Nursing27(1), 46-50. doi: 10.1097/01.CNJ.0000365992.54345.a6
Lakeland Health. (2015). Lakeland Health profile. Retrieved from
http://www.lakelandhealth.org/patient-visitor-guide/about-lakeland
Porter-O Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing innovation,
transforming health care (3rd ed.) (p. 5). Boston: Jones and Bartlett.

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Appendix A

Cardiac Telemetry Unit Hierarchy

Manager

Assistant Manager
Clinical Resource RN

Patient-Care RN's
Nurse Assistants

Unit Clerks

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Appendix B
Communication Map

Manager
Assistant
Manager
r

Educator
Change Agent

Clinical
Resource RN

Super
Users

Patient Care RNs

Major Relationship

Fair Relationship

Minor Relationship

Nurse Asst.
Unit Clerks