Summary of fellowship:

The fellowship was instigated by Southlake Regional Health Centre's first Nurse Practitioner (NP). This individual paved the way for many NPs to come within the institution and felt the impetus to improve the Inpatient Surgical unit with the introduction of a new NP role. The fellow had a long history working as a Registered Nurse (RN) on the unit and had recently completed a Master in Nursing with a Primary Health Care Nurse Practitioner designation. Combining the experience of a surgical RN with the new scope of practice (SOP) of the NP, the fellowship came to light. It was felt that the NP had the potential to address shortcomings of the inpatient setting by providing consistent, evidence-based, equitable, safe, and patient-centered care on a unit that had recently transitioned through a tremendous staff turnover. The staffing changes left many inexperienced staff to care for increasingly complex surgical patients. Inpatient surgery was in dire need of a continuous, advanced practice role and clinical leadership. Coupled with changes in the current health care system and the lack of residents or fellows, it was felt that the organization could support the continued emergence of the NP role to provide patients with accessible, comprehensive, high-quality, cost-effective, and efficient care.

The overarching goal of the fellowship was to improve communication via knowledge translation between all attending faculty, staff nurses, patients, allied healthcare workers, and care physicians while providing high levels of patient centered care. This goal was achieved and the success was captured amongst several surveys, verbal feedback to upper management, and a notable decline in patient complaints.

The overall goals of the fellowship were improved intraprofessional care, knowledge translation and enhanced patient satisfaction.

The need for intraprofessional team work is becoming more important due to factors such as an aging population that has complex co-morbidities and increased frailty. This commonly results in the fragmentation of care, in order to meet the complex needs (Nancarrow, et. al, 2013).  The complementary primary care background of the NP helped to lessen fragmentation of care by use of evidence based guidelines. When presentations were beyond the SOP, specialists were brought to the circle of care and a team approach was implemented. Verbal feedback from specialists to the NP and surgeons, was positive and accepting. The NP was fortunate to have existing relationships with the intraprofessional team which heightened respect and trust, both of which are key in collaboration.

Knowledge acquisition was grossly derived from translation. The surgeons were readily willing to fill in the knowledge gaps of the NP by discussing operative findings, diagnostic interpretations and subsequent clinical presentations. This allowed the NP to convey the information to the nursing staff and patients, thereby enhancing understanding of care goals.

Skill acquisition was broad. The improved wound care competency was realized by shadowing the wound care RN and vascular surgeons, and discussing treatment plans with the general surgeons. Advanced assessment skills were enriched by the fellowship due to the acuity of the patients. Noting declines in patients and taking the appropriate steps in each unique case were discussed with the MRPs and suitable actions were implemented.

The proposal suggested that expertise would be incurred via the creation of therapeutic, patient-focused plans of care using advanced health assessment and interpretation of diagnostic tests. Each morning, the fellow would take report from the night shift RNs, review labs and vital signs, and assess any change in patient status. For new admissions, operative or admission notes, best possible medication histories, etc… were all reviewed to garner a holistic sense of the patient and to identify any unmet needs. After the review and discussion with the surgeon, descripts summary notes were compiled for the chart and shared with the primary RN.

Outcomes:

The patient population experienced accessible, comprehensive, high-quality, cost-effective, and efficient care; the NP afforded more time for patients and family members to ask questions and the NP was readily available when clinical statuses changed.

In a typical day, the NP would be present on the unit for the changing of shifts. This allowed RNs to review their night shift concerns, discuss abnormal labs, etc… The NP would then organize the patient census and become updated on new admissions. The fellow would then round with each of the six surgeons and observe their assessment and history taking. After rounds, the surgeon and NP would discuss clinical status and the goals of care. This provided an opportune time for knowledge translation from surgeon to NP. The fellow would then meet with the intraprofessional team at the allotted time for 'rounds' to discuss status, plans for discharge and supports needed. The fellow translated the aforementioned findings to enhance care plans and stimulate effective discharges. After the team rounds were complete, the fellow performed her own assessment on the identified patients. This afforded patients more time to ask questions they may have forgotten to ask the surgeon, and to voice any concerns. For the surgeons that could not round until later in the day, having the fellow assess patients added assurance that they were well managed. The NP could assess suitability for discharge, provide teachings, write the necessary scripts, coordinate with the discharge pharmacist and other disciplines involved, and dictate the inpatient stay.

Patient satisfaction with the NP was captured in a survey and also in interactions. This was expressed also in meaningful cards, one such from a patient with a prolonged stay.  

"I just wanted to take a moment and thank you for the time and attention you gave to me during my stay at Southlake. You truly are remarkable at what you do, and I feel extremely grateful to have had you by my side during one of the most difficult points in my life. Thank you from the bottom of my heart for everything you did for me, you will never be forgotten."

Efficient, accurate, and timely communication is required for quality health care and is strongly linked to health care staff job satisfaction (Gausvik, et al., 2015). Developing ways to improve communication is key to increasing quality of care, and interdisciplinary care teams allow for improved communication among health care professionals (Gausvik, et al., 2015). 

These were outcomes experienced by staff and are best summarized in the survey results. Please see each link to review the outcomes.

Staff satisfaction with the Nurse Practitioner: (select responses below, see the link for the entirety) https://www.surveymonkey.com/stories/SM-389PQJV8/

• The Nurse Practitioner was a GREAT asset to our floor. It was most beneficial that she was on our floor and very easily accessible. I found it very beneficial to have someone to quickly run questions/concerns by and/or get orders for small things instead of having to page the doctor and hope they call back in a reasonable amount of time. It was great having someone on the floor that could writer an order for, for example, Gravol rather than waiting for a doctor to answer a page. It saved a lot of time both for the nurses on staff and the doctors, and not to mention puts patient centered care first.
• Having the nurse practitioner on the unit for 8 hours has improved communicating important updates with the patient including new vitals, symptoms, lab values as well as an improvement on understanding the patient's overall plan of care. Another benefit has been the ability to order meds, get orders signed and diagnostics done in a more timely manner as she is on the unit for the majority of the day. I believe it has improved overall patient care and efficiency.
• Beth was always readily available and open to communication and discussion, she really made me feel part of the team.
• She is an invaluable resource on the unit and with her as a member of the circle of care, continuity of care improves. Her presence on the unit allows quicker assessment and intervention when a patient's status changes, resulting in better care provided.

The fellowship experience

The opportunity of being chosen for the ACPF Fellowship was an invaluable experience. I felt privileged to have the support to learn and potentially carve out this new and exciting role. Working with the mentors and established NPs in the hospital allowed me to comprehend how a successful role could be built and sustained. Having already established relationships with the staff and understanding the issues faced by each discipline enhanced my capacity to care for patients and improve staff satisfaction. I felt that this role helped bridge the gap in communication and relation between the surgeons and the nursing staff and stands to further evolve.

I have many moments that I will continue to reflect on. The most seminal was bearing witness to the compassion and bedside manner of the surgeons'. I felt privileged to be part of the team who provided such dedicated care. One moment in particular occurred near the completion of the fellowship. One surgeon whom initially thought the role of the NP may 'be redundant to that of a charge RN', was able to actualize the SOP and complementary role of the NP.  We had many discussions throughout the fellowship on SOP and what I could and could not do. Over time, the value was witnessed in the actions and time given by myself. There were patients with complications, prolonged stays and even death. One case in particular, was a patient experiencing a sharp decline. I had already established a relationship with a family member and was able to take the time to discuss the goals of care, have the patient's wishes documented and ensure a comfortable death. The family member was gracious for the team approach that was facilitated and that she was present. During the last week of the fellowship the surgeon said, 'whatever I can do to help make this permanent, let me know. It was great having you.'

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