Background: A 26-bed solid tumor oncology unit saw consistently low patient satisfaction scores regarding education and discharge preparedness. Managers and staff wanted to improve patient education without adding to the workflow of bedside nurses with a 4:1 patient-to-nurse ratio on a unit with rising acuity.
Objectives: Staff sought to improve patient education and discharge preparedness for the inpatient population by utilizing principles of nurse navigation—primarily an outpatient care delivery model. Staff intended for their interventions to raise satisfaction scores, as well as reduce length of stay and readmission rates.
Methods: Management selected 4 Oncology Certified Nurses (OCNs) to implement a 6-month pilot project. The Resource Nurses were out of ratio and referred to as Resource-2 (R-2). Staff applied basic principles of nurse navigation to their inpatient population. Focus centered on tailored education for at-risk patients, relationship-based care, and discharge planning with postdischarge phone calls. Nurses followed identified patients consistently along more points of the continuum of care than individual bedside nurses could in a given shift.
Results: Patient satisfaction scores met or exceeded the national benchmark in 5 of the 6 months the project was in place. Unit length of stay reached its lowest point in nearly 2 years. Staff expressed satisfaction with the additional nurse resources available to them.
Discussion: The project had positive results for individual patients and nurses, as well as improved HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, demonstrating a correlative relationship between the project objectives and its intended recipients. Project limitations were cost, inconsistency, and role crossover with other disciplines.
Conclusion: Results suggest that there is a benefit to utilizing nurse navigation concepts in an inpatient setting by designating OCN staff to follow patients throughout and following their stay in the hospital. This can be beneficial to both staff and patients with complex interdisciplinary issues.
Oncology patients face a long and multifaceted journey. Not only do they face myriad complexities regarding their physical well-being and body image, they must also maneuver through an increasingly convoluted world of healthcare, insurance, family dynamics, durable medical equipment, and social issues, to name just a few examples.
Additionally, many patients face the likelihood of an increased number of hospitalizations.1 Here they will receive inpatient chemotherapy, biotherapy, or immunotherapy; pain management; symptom management; surgical interventions; palliative procedures; end-of-life care; or any combination of the above. Although hospitals offer direct nursing care as well as interdisciplinary care, patients can become overwhelmed and later be discharged without being fully prepared for their transition home despite the best and most evidence-based efforts of the inpatient interdisciplinary teams.2
UCLA Medical Center in Santa Monica, CA, includes a 26-bed solid tumor oncology unit offering leading-edge cancer therapies, as well as palliative and end-of-life care. The Solid Oncology Service can treat up to 40 patients in multiple units throughout the hospital. At the time of this quality improvement project, the unit’s nursing staff had an 81% Oncology Certified Nurse (OCN) certification rate. Despite this, the unit witnessed consistently low patient satisfaction scores via HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys regarding patient education and discharge preparedness. Bedside nurses operated with a 4:1 patient-to-nurse ratio. In addition, the staffing ratio included a Charge Nurse (responsible for bed management and throughput) and a Resource Nurse (responsible for bedside nurse support, break relief, 2nd registered nurse (RN) chemotherapy sign-off, and other unforeseen duties that varied from one shift to the next). Daytime shifts included the Unit Director and Clinical Nurse Specialist. All staff witnessed an increasing level of patient acuity over a short period, with increasing physical and emotional needs that could exceed the staff’s time constraints despite the staffing resources. This acuity, combined with patients’ observation of a lack in education and discharge preparedness, demanded action from staff and management to increase quality of the patients’ care and experience.
Objectives
Management and staff recognized an opportunity to improve the quality of patient care when funding became available for a 6-month trial period to add an additional full-time employee (FTE) for each 12-hour day shift. After an open dialogue, management and staff decided that the FTE should serve as an educational resource for patients, as well as an additional support for bedside staff. An important distinction was that the additional FTE would not replace the educational role of the primary bedside nurses; instead, the FTE would supplement the educational needs of high-acuity patients, whose consideration demanded more time than the current ratio allowed the primary nurse to dedicate. The goal was to meet these high needs without taking the primary nurse’s focus away from other patients within his or her assignment who also required due attention.
Management selected OCN staff who currently rotated in the Resource Nurse role. The Resource Nurses selected the title of the new role to be Resource 2 (R-2). Together, with management, the R-2s developed the following objectives (Table 1):
- Improve the HCAHPS unit scores regarding the questions,3 “During this hospital stay, how often did nurses listen carefully to you?” and “During this hospital stay, how often did nurses explain things in a way you could understand?”
- Decrease the average length of stay (LOS) on the unit by offering earlier interventions throughout the hospitalization rather than leaving the intervention time closer to the anticipated discharge date
- Increase relationship-based care using a 2-fold method: (1) develop relationships with patients through individually tailored educational designs, and (2) support staff on non-oncology units housing patients on the solid tumor oncology service
- Follow up with patients after discharge to ensure continuity of the discharge plan; answer outstanding questions patients may have about medications and follow-up appointments; confirm that discharge plans had taken effect as intended
Methods
The R-2s utilized principles of nurse navigation, traditionally an outpatient model of care delivery, to form the interventions that would meet the inpatient population at more points in their continuum of care than the standard practice allowed. Initially, nurses did a needs assessment that confirmed the concern that high-acuity patients on the unit required more time than the bedside nurses had to dedicate. Patients who most commonly fell into this group were, in no particular order, newly diagnosed oncology patients admitted for their first multiday chemotherapy/biotherapy treatments; patients with newly placed devices requiring home care (tracheostomies, colostomies, biliary drains, drainage catheters for malignant effusions or ascites, gastrostomy/jejunostomy tubes); and/or patients with newly inserted central venous catheters (CVCs).
The needs-based assessment found that most of these patients received education on their therapies or new drains/lines at the start of therapy, at the time of placement of lines/drains, and again at the time of discharge. Many times, patients would feel ill-prepared to go home and would require additional time in the hospital to work with the interdisciplinary team to adequately prepare for their time at home. Although bedside nurses worked tirelessly to prepare patients, the time allotted with a full assignment was not always substantial enough to accommodate the patients and caregivers with high needs.
At this point, the R-2s reviewed concepts of nurse navigation. R-2s performed a literature review confirming why many patients felt ill-prepared for discharge. Health literacy and patient education continue to be a challenge across ages, education levels, and socioeconomic status.4 Navigation was introduced in the 1990s to reduce barriers to treatment and to decrease health disparities in the experience of cancer patients.5 Patients’ expectations are exceeded when they feel that their care is personalized and that their nurses listen actively; yet satisfaction scores indicated that the current practice was falling short of the patients’ needs. UCLA utilizes members of a full interdisciplinary team in both the inpatient and outpatient settings, but not nurse navigators specifically. Since navigators remain a part of the patients’ care team from diagnosis through survivorship, the R-2s wondered if they could apply a short-term version of this concept to the inpatient stay by connecting with patients not just at the time of admission and discharge but throughout their hospitalization and treatment, with continued follow-up after discharge. By personalizing care throughout and after their stay, could R-2s offer more support to the patients and staff along the greater care continuum?
R-2s developed interventions along 3 realms of patient care: education, relationship-based care, and discharge planning. Each morning, the assigned R-2 sat for Interdisciplinary Rounds (IDRs) with the care team, primary RN, attending physician, clinical nurse specialist, case managers, and social worker. Here the R-2 could perform a needs assessment and prioritize interventions based on the needs of each patient on service (up to 40 patients).
Education
Top priority was devoted to patient education, the catalyst of the pilot project. Any patient scheduled for admission to receive first-time chemotherapy, biotherapy, or immunotherapy was automatically flagged to receive an education session with the R-2. The R-2 utilized the teach-back method, assessed for gaps in knowledge, and reported those gaps to the primary RN for additional follow-up throughout the shift. All topics addressed during the education session were documented in a separate nursing note in the patient’s electronic record under an Education Consult. In this fashion, R-2s who rotated throughout the patient’s stay assessed the need for follow-up. They then added to the note regarding patient progress, understanding of early/late side effects, chemotherapy safety at home, infection prevention, bleeding precautions, prevention of nausea and constipation, etc. Staff followed the patients daily to reinforce education. An education binder that included printed educational materials and a chemotherapy schedule was provided to each new chemotherapy patient (Figure). Patients with newly placed CVCs received illustrations and printed materials regarding line care and infection prevention. Non–English-speaking patients received their education through a video interpreter at the bedside; printed materials were available in English and several other languages. Many patients were hospitalized for multiday chemotherapy regimens; the daily visits from the R-2 provided an opportunity to evaluate comprehension and recall from the original education session.
UCLA employs a team of Wound, Ostomy, and Continence Nurses who lead education for patients receiving new ostomy devices. However, these nurses are not available on weekends or holidays. R-2s supplemented their teaching, thus increasing continuity of care during these times. This frequently occurred on weekends, when visiting caregivers required hands-on teaching that often exceeded the time constraints of the primary RN.
Pleural and abdominal drainage catheters are frequently placed for solid tumor populations. Managing supplies and self-drainage can be a daunting task, and many patients and caregivers have high levels of anxiety about new devices. Primary nurses provide much bedside teaching; however, education and return demonstration could take an hour or more of bedside time. During IDRs, R-2s learned which patients had received newly placed devices and followed the patients and families daily to provide in-depth, hands-on education, demonstration, and teach-back using videos and printed materials. These methods were also employed for patients with tracheostomies, gastrostomy/jejunostomy tubes, and biliary drains. The teaching techniques were initiated by primary nurses and supplemented throughout the stay by R-2s, with continuous documentation.
Relationship-Based Care
Solid oncology patients were housed on other units in the hospital; examples are intensive care and step-down units. The exceptional nurses on these units were not specifically trained in oncology. R-2s rounded on the oncology patients to offer peer support to their primary nurses. Some examples of educational interventions included management of drainage catheters and accessing implanted ports. Moreover, patients maintained contact with the familiar oncology nurses, thus providing ease of anxiety and maintenance of relationships.
During this period, the division of care among case managers had shifted from service-based to unit-based. Therefore, R-2s could serve as a resource to case managers and discharge planners coordinating plans for oncologic needs, such as arranging colony-stimulating growth factors and complex home care regimens on a more frequent basis than they had previously experienced. This served to impact continuity of patient care as well as cultivation of peer education.
Discharge Planning
IDR gave R-2s the opportunity to work with case managers on discharge planning, and to provide earlier identification of potential discharge barriers that could impact LOS. By receiving earlier and more consistent education throughout the hospitalization, patients and caregivers were less in need of “1 more day” before they felt adequately prepared to go home. Oftentimes, complex family dynamics, or lack of a clear, designated caregiver, led to increased LOS. Addressing the complex needs of these patients earlier in their stay allowed more time for caregiver preparedness, thus thwarting the need for additional hospital time. R-2s worked with the interdisciplinary team to anticipate the need for services such as physical therapy and occupational therapy evaluations, which would impact discharge times but were often left until the last minute, thus lengthening the patients’ stays while they awaited these consultations and recommendations.
Once discharge plans were in place, R-2s placed discharge calls within 24 to 72 hours of any discharge from the service. This gave patients an opportunity to speak directly with OCNs who followed up on medication instructions, symptoms and side effects, and education reinforcement. R-2s could also troubleshoot any gaps in the discharge plan, such as receipt of home care services and supplies—all of which could potentially lead to readmission. In one case, a patient who had just received inpatient R-EPOCH had missed his appointment to receive growth factor. This appointment was rearranged by the R-2 over a weekend, to avoid the patient’s readmission with potentially life-threatening sepsis. R-2s provided emotional support for frightened patients who had several days between the stress of hospitalization and their scheduled outpatient visits with their primary oncologists. The phone calls provided support and continuity between the inpatient and outpatient settings.
Outcomes
The 6-month pilot project lasted from August 2017 through February 2018. Elements of the project remained in effect until April 2018, although R-2s had been placed back into the standard ratio during those months and were not performing interventions with the same consistency.
The Unit Director compiled data from HCAHPS survey scores submitted during this time (Table 2). Responses to the question regarding nurses listening carefully met or exceeded the national benchmark in 4 of the 6 months. Responses remained elevated in the months following the official end of the pilot, when some of the interventions were still taking place. Responses to the question regarding nurses explaining things in a way that patients could understand met or exceeded the national benchmark in 5 of the 6 months, again remaining elevated during the subsequent months. The scores during the pilot period demonstrated an overall increase in patient satisfaction and perceived personalization of care when compared with data from previous months.
LOS and expected bed days (EBD) also saw a decrease during the last quarter of 2017 and the first quarter of 2018 during the time of the pilot. It is also noted that patient acuity was elevated during this period, yet LOS and EBD decreased.
Discharge callers intercepted gaps in the discharge plans. At times, home care did not commence at the time patients expected, and calls were made to the agencies to troubleshoot issues, reassure patients, and provide continuity. This was particularly beneficial on weekends when outpatient clinics were closed, and patients might not know how to advocate for themselves. R-2s also assisted by calling pharmacies to advocate for patients who had difficulty filling narcotic prescriptions on weekends. R-2s had the opportunity to connect with outpatient clinic staff to advocate for patients with high needs, fostering increased communication among the various institutions serving the patients they had in common.
Discussion
The measured project outcomes demonstrated a correlative relationship between the R-2 interventions and the overall improvement of patient satisfaction, discharge timeliness and preparedness, and patients’ perceived interactions with nursing staff. Informal, qualitative feedback from nursing staff was positive overall. Charge Nurses could maintain their workflow by utilizing the R-2 to manage complex discharges or troubleshoot gaps in the discharge plans.
Based on hourly pay rates, the pilot cost was $48,208 over 6 months. A longevity plan would require 1 FTE in the role. A cost saving of $28,058 was estimated based on decreased LOS and increased throughput. However, a 6-month period was deemed too short to adequately judge a true potential cost saving over time.
Despite many positive outcomes, the project still had limitations. The cost to unit budget, ultimately, was the largest hurdle. In addition, a lack of clarity existed among some staff, who had difficulty discerning the role of the R-2 from the traditional Resource Nurse, leading to underutilization of the R-2 at times. There was also an element of crossover with case managers and task duplication; a longer pilot would have provided more opportunity to develop the roles. Inconsistency was another problem; for example, if the unit was short-staffed, the R-2 would flex back into the standard ratio on a given shift, leaving the role unfilled for the day. Finally, there was concern that less experienced nurses or new graduates had fewer opportunities to develop their patient-teaching skills when the R-2 took on the role; boundaries needed to be set with some staff members to allow patient needs to be met while continuing to foster a rich and supportive environment for newer staff members.
Conclusion
Navigation principles provided individualized care in the inpatient setting at more points along the continuum of care. R-2s changed clinical practice through tailored patient care, with uninterrupted education as well as postdischarge follow-up for continuity of care. Data indicated that goals were achieved during the pilot period, demonstrating a correlative relationship between navigation-based interventions and desired outcomes.
Educational tools utilized by R-2s are still in use on the unit. Patient satisfaction, decreased LOS, and decreased EBD show that there is a place for a permanent role on the unit. Although the pilot was discontinued after its designated time frame, the Unit Director, Clinical Nurse Specialist, and R-2s continue to seek buy-in to allow a permanent role. With more time, R-2s believe they could have a greater impact on patient education and discharge preparedness, and an overall greater cost saving for the unit and hospital. Moreover, the potential exists to form a more seamless transition for patients between inpatient settings and community practice clinics, with greater communication and understanding among all realms of healthcare providers.
Acknowledgments
I would like to acknowledge the following staff members from UCLA Medical Center, Santa Monica, CA: Patricia Jakel, RN, MN, AOCN; Jason Kulangara, MSN, MBA, RN; Franz Cordero, BSN, RN, OCN; Laura Alfonso, BSN, RN, OCN; Rebecca Hoh Bank, BSN, RN, OCN; and Samantha Thomas, BSN, RN, OCN.
References
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- Hospital Consumer Assessment of Healthcare Providers and Systems. CAHPS Hospital Survey. www.hcahpsonline.org/en/survey-instruments. Accessed April 7, 2019.
- Simmons RA, Cosgrove SC, Romney MC, et al. Health literacy: cancer prevention strategies for early adults. Am J Prev Med. 2017;53:S73-S77.
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