Natural Problem Solvers

Natural Problem Solvers

This article originally appeared in the Summer 2015 issue of Brigham and Women's magazine.

When patients and their loved ones enter the hospital, they leave behind what is known—the comfort of home, the familiarity of daily routines, and the sense of being in control. To find their balance, they need to lean on someone who is trustworthy and singularly focused on helping them. That is where nurses come in. Their ability to listen, educate, and partner with patients helps them feel safe and provides an incredible source of strength in the face of uncertainty.

“What distinguishes nursing care at Brigham and Women’s Hospital is the caring and healing intention that nurses bring to the bedside and their focus on the whole person,” says Jackie Somerville, PhD, RN, senior vice president of Patient Care Services and chief nursing officer at BWH.  

“Brigham nurses are great at tuning into patients’ needs and finding ways to help them,” adds Sharon Levine, BSN, RN, a nurse in the Cardiac Intensive Care Unit (ICU). “It could be taking simple steps to make a patient more comfortable or coordinating something more complex, such as bonding time for a mother and infant who are critically ill.”

Every day, Levine and other BWH nurses bring individualized care to the next level. They show that looking at the big picture to develop solutions can have a wide-reaching impact on patients, as well as loved ones. Here are their stories.

Helping ICU patients recover psychologically

“The ICU is extremely stressful for any patient or family,” says Levine, a 34-year veteran of the Cardiac ICU nursing team. “When someone is hooked to so many tubes, is exhausted, and sees so many people coming in for consultations, it’s very difficult to process. Many patients develop anxiety, depression, or delirium.” 

For years, Levine thought these psychological effects resolved once patients returned home. Then she came across a research study that found as many as one in three patients who spend time on a breathing machine suffer from post-traumatic stress disorder (PTSD), with symptoms that can last for years.

“I realized, even when patients recover physically from the ICU, they didn’t always recover mentally,” she says. “I felt a responsibility to see if we could help.” 

Diving into further reading, Levine learned that some patients suffer flashbacks or hallucinations from experiences during their ICU stay, or have severe gaps in their memory. For decades, several critical care units in Europe have been using a tool called the ICU diary, with research studies showing the diary significantly lowers rates of PTSD.

In July 2014, Levine started a formal research study to test the diary in BWH’s Cardiac ICU, along with five colleagues. Nurses and family members keep a daily account of medical events, and patients take the binder with them when discharged. The nursing team calls patients in the subsequent weeks to follow up.

“One patient told me, ‘It filled in so many memory gaps for me. I didn’t remember anything from the ICU except the doctors telling me to wiggle my toes. Two weeks after discharge, I read the diary and it helped me make sense of it,’” Levine recalls. “If something as simple as keeping a diary would help people, why wouldn’t we do it?”

Levine notes some entries might be a page long; some might be four lines, depending on the day. “We’re just hoping the reassuring explanations remind patients of how we cared about their whole being. I have high hopes for it.”    

Cultivating an environment of innovation

For projects like Levine’s to get off the ground, they need cooperation from nurse directors and colleagues, and an environment that supports clinical inquiry and professional growth.

BWH’s Mary Fay Enrichment Award, funded by the Karsh Family, Marshall A. Wolf, MD, and the Department of Nursing, gave Levine the resources needed to attend a conference and work with her co-investigators to develop the ICU diary as an educational guide, including a glossary of medical terms and photos of Cardiac ICU equipment. 

“When we invest in the professional practice environment, it benefits both nurses and patients,” Somerville explains. The department encourages professional development through awards, nursing committees, and partnerships with external programs.

“Everything we do as nurses is based on the professional practice model we’ve developed for a caring, inclusive environment,” she says. “It guides our work to put the patient and family at the center, to provide nurses with opportunities for education, collaboration, leadership, and recognition, and to improve the way we deliver care.”

Using technology to help keep patients safe

Each year, between 700,000 and 1 million patients across the country fall during hospital stays, with 30 to 51 percent of falls leading to injury. “Patients can become confused or weak due to illness, medication, surgery, or increasing age,” explains Senior Nurse Scientist Susan Lee, PhD, RN.

One of the safeguard measures BWH uses for patients at the highest risk for falls is direct observation by a patient care assistant (PCA). In the fall of 2014, the department began a pilot study to test a new method of observation called continuous virtual monitoring (CVM). By placing a monitoring device in patient rooms, a PCA in a central location can see and hear a live stream of multiple rooms and speak privately with each patient. Even in darkness, patients are viewable, thanks to the device’s infrared capability.

“CVM has helped us keep patients safe in more ways than we expected,” says Deb Mulloy, PhD, RN, associate chief nurse of quality at the Center for Nursing Excellence. “We had one instance where a patient’s condition deteriorated rapidly and the PCA’s call for the patient’s nurse led to quick, life-saving care. We’ve also interrupted patients before they mistakenly drank hand sanitizer, and prevented a number of falls.”

“Surveys of family members are overwhelmingly positive,” she adds. “They’re worried about their loved ones and appreciate the added layer of safety.”

“We are excited to be one of the first in the country to develop a formal training process using surveillance to improve safety for patients at risk for falls,” says Lee. “We are so grateful to the Commonwealth Corporation for the Patient Care Associate Technology Grant that is helping to fund this pilot study. The grant is helping us to train 36 monitor technicians and to create a training curriculum other institutions can use.”

 

Left: Patient Care Assistant Brooke Kent observes patients using CVM.
Right: Cynthia Scherers, RN, brings a monitoring device to a patient’s room.

Improving sleep for inpatients

Between beeping monitors, voices and light from the hallway, and frequent interruptions from clinicians, sleep can be a challenge for patients staying in any busy hospital.

“This problem is not unique to the Brigham—it’s everywhere,” says Lichuan Ye, PhD, RN, a Haley Nurse Scientist at BWH whose research is funded through a joint program with the Boston College Connell School of Nursing created by donors Steven and Kathleen Haley. Ye’s goal is to identify patients’ barriers to sleep and build sleep improvement measures into everyday practice.

“Sleep is so important for recovery,” Ye notes. “Lack of sleep can lead to falls, delirium, higher levels of pain, and other complications.”

Ye and her colleagues did 24-hour monitoring for light and noise on the surgical unit and found the decibel level was much higher than recommended. But noise is just one small piece. Interruptions for medications, vital signs, and other care also contribute to sleep barriers.

Interestingly, Ye’s findings show one size does not fit all. “Some patients need the TV on, some need complete quiet, some need white noise,” she says.

With BWH’s health information technology team, Ye has applied for a federal grant to develop a software application to give each patient a tailored experience. She explains, “With the software, you select what disturbed your sleep and it generates recommendations the nurses can follow.”

Ye believes BWH can be a pioneer in this work. “At a practical level, nurses are so busy, but sleep quality assessment can be integrated with daily care,” she says. “We evaluate pain every day, evaluate vital signs—why not sleep?”

Healing body, mind, and spirit

The stress of illness takes a physical and mental toll on patients and family members, as well as on caregivers and clinical staff. To help support healing of body, mind, and spirit, Pat Reilly, MSN, RN, and BWH’s program director of Caring and Healing Modalities since 2002, offers integrative therapies—such as Reiki, guided imagery, and auricular acupuncture—to patients and staff.

“With almost 1,000 patient beds and only one of me, I knew I needed to be multiplied,” Reilly says. She enlisted the help of a Reiki coordinator to create a volunteer-based Reiki program, a therapy that provides healing energy to the recipient through touch and visualization techniques.

Today, BWH has the biggest Reiki volunteer program in the country with 60 volunteers who have provided more than 35,000 treatments over the past five years. In the spring of 2014, the hospital held a seminar for other institutions on how to start this kind of program, and hospitals from throughout New England attended.

“There’s an impressive body of research showing Reiki’s healing effects,” Reilly says. “Many times, patients become so relaxed they fall asleep. Nurses also request Reiki for themselves and staff on their unit.”

In the past decade, Reilly has expanded the program to provide seminars and consults for nurses in self-care and healing methods for patients. Her team also offers music therapy, pet therapy, and meditation.

To magnify their reach, they are creating educational offerings for patients. “Patients will be able to scroll through a menu on their bedside televisions and select videos created to help manage symptoms such as anxiety, pain, and nausea using self-Reiki and other integrative therapies,” explains Teresa Buchanan, RN, the program’s project manager. “We also recorded video of our music therapist, Nancy Kleiman, playing the harp, and are excited about opportunities to make these therapies more accessible.”

Igniting a passion for lifelong learning

“Nurses are natural problem solvers,” says Levine, who spoke at a BWH Nursing Grand Rounds session in June, urging her colleagues to keep asking questions and finding ways to improve patient outcomes.

“When we encourage nurses to pursue academic advancement, they develop the tools to come back to the practice setting and bring that lens of clinical curiosity,” says Somerville. “It helps them frame the question, design the methodology, and study innovative approaches that can ultimately advance care of our patients.”