Nurses Innovating in Practice

Catherine Francis, RN, CCRN, GNu’20

“[We wanted to make sure] families knew this wasn't just another patient, and we cared about them personally and were grieving with them,” Francis Says. Credit: Photo by Gene Smirnov

“Nurses innovate every day, in all settings. Innovation doesn’t just mean technology, a new discovery, or a defined advancement. The space is wide open to interpretation,” says School of Nursing Associate Dean for Practice Rosemary Polomano, PHD, RN, FAAN.

Sometimes innovation is about compassion and empathy, she says, pointing to Penn Presbyterian Medical Center (PPMC), where nurses organized to mail condolence cards to families of COVID patients who died. They ordered preprinted cards in bulk and with each, they enclosed a rhythm strip taken when there was a healthy heartbeat. A small note card explained the print-out: “May my heart always be a gentle reminder of the love I have for you.” (Identifiers on the strip were removed to preserve privacy.)

Catherine Francis, RN, CCRN, GNu’20, Clinical Nurse Educator for the Heart & Vascular Intensive Care Unit, and her colleagues behind the condolence card effort were navigating the unfamiliar landscape of caring for patients when families couldn’t visit. They wanted to make sure “families knew this wasn’t just another patient, and we cared about them personally and were grieving with them,” says Francis.

The heartfelt innovation demon - strates how nurses figure out ways to “break down barriers,” says James Ballinghoff, DNP, MBA, RN, NEA-BC, GRN’17, Chief Nursing Officer and Partner Perspectives “The partnership has been instrumental in our success. A lot of that really boils down to the collaboration between the academic and the practice setting, the sharing of resources, the intellectual capital, to be able to tap into resources like the nurse scientists at the School of Nursing to get guidance.” — JAMES BALLINGHOFF, CNO and Associate Executive Director, Penn Presbyterian Medical Center “ Associate Executive Director at PPMC, “so that patients and the community get the best possible care or we improve their health in the best possible way.”

Francis says she and her fellow nurses were continuously searching for opportunities to build trust with families and connect patients to their families and friends, all remotely. In one case that meant changing the socks every day of a patient who was a fan of fun footwear, after the family dropped off several pairs. For others, it meant playing a patient’s favorite song or repeating a distant loved one’s message in their ear.

“Yes, you are a nurse and you have a job to do, but the reason people become nurses is because of their compassion. It became second nature for the nurses to do everything they could so the patient wasn’t alone,” Francis says.

Once family members could visit PPMC again, the need to send the condolence cards fell away but, Francis says, she can see that a strong inclination to add extra-personal touches in patient care is here to stay.

PPMC was recently awarded its third Magnet Recognition from the American Nurses Credentialing Center. “Our surveyors commented that hear - ing what we did throughout the pandemic demonstrated to them that we not only survived but we thrived,” Ballinghoff says.

The hospital’s affiliation with the Penn Nursing, he says, is “instrumental in our success and how Penn Medicine led in this pandemic. The academic practice partnership creates a synergy where we can produce phenomenal work.”

Partner Perspectives

“The partnership has been instrumental in our success. A lot of that really boils down to the collaboration between the academic and the practice setting, the sharing of resources, the intellectual capital, to be able to tap into resources like the nurse scientists at the School of Nursing to get guidance.”

— JAMES BALLINGHOFF, CNO and Associate Executive Director, Penn Presbyterian Medical Center

Karen Sylvester, MSN, RN, CEN, GRN’23

“Out of COVID, there were so many heartbreaks, but there was some really good stuff. The innovation and the resilience of this team— I couldn't be prouder to work with them,” Sylvester says.

Shelia Kempf holds a picture in her mind: a Critical Care Unit nurse in full PPE inside a COVID patient’s room hold - ing a piece of paper to the door glass with a handwritten message begin - ning, “I am so sorry to be so disorga - nized, but can you get me … .”

Kempf, PHD, NEA-BC, CNO, and VP of Patient Care Services at Penn Medicine Princeton Health, witnessed the scene as the pandemic was hitting New Jersey hard and nurses were en - couraged to save PPE and limit going in and out of negative pressure rooms when caring for a rapidly growing number of patients. “I said to Karen, ‘Are we doing something about that?’” Kemp recalls. “And she said, ‘I already got that covered.’”

Indeed, as soon as Karen Sylvester, MSN, RN, CEN, GRN’23, Director of Patient Care Services for Emergency and Critical Care, saw the nurses’ communication challenge in the Critical Care Unit, she grabbed a couple Motorola headsets from the emergen - cy department for an impromptu pilot. Sylvester told a couple nurses, “Here, try this. Put it on. This is how it works. Let’s do it. Let’s see how it goes.”

The headsets can be worn inside PPE and have an earpiece, mic, and a Karen Sylvester, MSN, RN, CEN, GRN’23 Partner Perspective “We have a very good relationship with the school in a number of arenas. Rosemary [Polomano] is an excellent resource for innovation, practice, and research. These past two years, we have really enhanced our research program at Princeton, with a number of IRB-approved and exempt research projects completed or underway. We have partial access to a nurse scientist from Penn who helps with statistics and consults with our staff nurse Research Council. There is a good collaboration back and forth, and my goal is to expand the relationship going forward. In addition, three of my directors have enrolled in the DNP in Executive Leadership program at Penn.” — SHEILA KEMPF, CNO, and VP of Patient Care Services, Penn Medicine Princeton Health circular button that’s easy to push when a nurse needs to talk with someone out - side. CCU nurses were paired up, with one in full protective gear entering the patient’s room and the other remaining outside to pass in equipment as neces - sary, verify dosages, and take notes.

With the staff quickly embracing the improvement, Sylvester placed a full order of headsets. The technology offered side benefits, such as minimizing equip - ment contamination, but she says the real driver of the innovation was improving nursing communication and safety.

“Not only did the headsets give nurses a partner who could be their runner and grab other items that they need - ed, but it also limited their exposure,” Sylvester says. “Out of COVID, there were so many heartbreaks, but there was some really good stuff. The inno - vation and the resilience of this team—I couldn’t be prouder to work with them.”

Going forward, Kempf believes that the way the pandemic accelerated in - novation will have a lasting impact on the profession. “The difference with COVID was the speed at which we had to get creative. We didn’t have time for a 10-month pilot. You could not be per - fect,” she says. “Nurses developed new models of care immediately, with exper - imentation, controlled risk-taking, and continuous refinement. You don’t have to have a project plan that takes months and months.”

Partner Perspective

“We have a very good relationship with the school in a number of arenas. Rosemary [Polomano] is an excellent resource for innovation, practice, and research. These past two years, we have really enhanced our research program at Princeton, with a number of IRB-approved and exempt research projects completed or underway. We have partial access to a nurse scientist from Penn who helps with statistics and consults with our staff nurse Research Council. There is a good collaboration back and forth, and my goal is to expand the relationship going forward. In addition, three of my directors have enrolled in the DNP in Executive Leadership program at Penn.”

— SHEILA KEMPF, CNO, and VP of Patient Care Services, Penn Medicine Princeton Health

Lisa Iozzo, BSN, RN, MEDSURG-BC, and Sandra Seiler, MSN, CRNP-BC

“When COVID started, there were a lot of questions about the proper ways to don and doff PPE. It was one of the major concerns of the bedside staff,” Iozzo says. Credit: Photo by Gene Smirnov

“Google is a verb. Why can’t ‘officer’ be added to the dictionary?” jokes Sandra Seiler MSN CRNP-BC.

To add a layer of protection for staff as they donned and doffed PPE when caring for COVID patients at Chester County Hospital, Seiler and Lisa Iozzo BSN RN MEDSURG-BC, implemented training for a new role: “Dofficer” is a blend of “officer” and “don/doff.”

Science shows that doffing PPE is a high-risk moment for virus exposure. Staff who trained as dofficers at CCH— eventually there were 62—served as a second set of eyes as colleagues put on and took off protective gear and made sure all safety protocols were followed.

“When COVID started, there were a lot of questions about the proper ways to don and doff PPE. It was one of the major concerns of the bedside staff,” Iozzo says. “The dofficers were available to go to floors as needed, to make sure it was being done properly to prevent any type of contamination. The staff were very grateful for the additional resource available to them.”

Seiler and Iozzo, both Nursing Professional Development Specialists at CCH, developed classes to train dofficers and quickly put together a video shot on a smartphone—all while following social distancing guidelines.

“We actually got the infectious disease doctor and the nurse that works there to be part of the videos so that people would understand how important it was in removing this protective equipment,” Seiler says.

COVID forced staff to adopt new ways of working, so innovative training didn’t stop with dofficers.

“We trained people to do a million different jobs. If you were in physical therapy, you learned how to do a foley,” Seiler says. “We taught doctors how to put IV lines in. We did weeks and weeks of cross-training.”

The dofficer program was inspired by a similar effort at another Penn Medicine hospital, according to Angela Coladonato, DNP, RN, NEA-BC, CCH’s SVP Nursing and CNO, highlighting one of the many ways that the Penn Nursing academic practice partnerships are beneficial. “We have that tight relationship with the school, and anything that’s innovative and new gets filtered through the CNO Council or the academic partnership and all hospitals are privy to it and can implement it,” she says. “That’s one of the true benefits of the system, instead of reinventing the wheel, utilizing what works at one place in another.” Iozzo also sees the difference the partnership with the School of Nursing makes when it comes to developing the workforce of the future.

“As educators and nurse residency coordinators, we see the struggles and challenges of new-to-practice nurses,” Iozzo says. “We are constantly in touch with clinical instructors, so we can better gear our program and orientation needs to the new graduate nurses.”

Partner Perspective

“Many of the CNOs are assistant deans for clinical practice at the University. Many of us have done guest lecturing at the School of Nursing. I did my doctoral project on how emotional intelligence is a key leadership skill. I was asked to speak to undergraduates and graduate students, and I did a video. All of us bring what we are experts at and share with the school. And Rosemary Polomano sits on our CNO Council … and through that we bring back information that we can implement at our organizations. The School of Nursing is very involved in planning our annual research conference. It’s a great thing for nursing, to promote nursing research.”

— ANGELA COLADONATO, SV,P Nursing and CNO, Chester County Hospital

Aliza Narva, RN, L’05, Nu’10, GNu’14

Credit: Portraits by GENE SMIRNOV

As she watched frontline staff step up to take on new responsibilities to ensure the best treatment possible for COVID patients at the Hospital of the University of Pennsylvania (HUP), Director of Ethics Aliza Narva, RN, L’05, Nu’10, GNu’14 turned to science.

“The first thing I learned in ethics was that good facts are the basis of good ethics. I think in a time of great fear and great uncertainty, to try to keep going back to the facts and what we know is really important,” Narva says.

With an ethical rounding mindset, she led an effort to address questions about caring for COVID patients and supporting the entire HUP staff as they faced stress-amplifying unknowns about the disease. She put together educational tools, wrote blog posts, held regularly scheduled meetings to talk through concerns with teams, recorded sessions for on-demand viewing, and made herself available for one-on-one conversations.

Her goal, Narva says, was to make sure everyone had an “understanding of obligations to ourselves with PPE, and potential exposure to this scary new virus, to figure out how do we provide the standard of care to our patients, and how do we interact in a civil and respectful way with our colleagues when everything feels tumultuous.”

The ethics rounding proved useful amid the national unrest of summer 2020, too. Narva incorporated themes of social justice and equity in health care into the ongoing conversations.

“Aliza’s structure for discussing ethics pertaining to treating COVID patients was useful after the killing of George Floyd as frontline staff grappled with national calls for social justice and the role of race and racism in their practice areas,” says HUP Chief Nurse Executive Colleen Mattion, DNP, MBA, RN, CNOR.

When Penn Medicine established the Action for Cultural Transformation to create an institutional roadmap to an anti-racist culture, Narva and a colleague had to interview staff about their experiences with race and racism in the workplace. But they didn’t stop once they reported their findings.

“We’ve actually kept those conversations going, not necessarily to gather data for the institution, but because we recognize that, like the ethics rounds, just having the conversation and helping people frame things with an ethical framework is really helpful,” Narva says. “Being able to be curious about our colleagues and our patients and the impact of our care is really helpful.”

Partner Perspective

“The academic-practice partnership has proven to be an invaluable bidirectional relationship, particularly with regard to research and innovation. As an example, Dr. Rebecca Trotta (Nu’98, GNu’01, GR’10) established a research team including a HUP nurse, Ms. Rachel Senker, and Dr. Barbara Riegel to embark on a study to improve selfcare and symptom perception among advanced heart failure patients with left ventricular assist devices. This work is unfolding under the auspices of our Abramson Family Center for Nursing Excellence, which was unveiled in May 2021 under Dr. Trotta’s leadership. Dr. Trotta also works closely with Dr. Terry Richmond to ensure we capitalize on new opportunities for research and innovation that would not otherwise be possible if it were not for this amazing partnership.”

— COLLEEN MATTIONI, Chief Nurse Executive, Hospital of the University of Pennsylvania

Brynn Moore, BSN, RN, COCN, CPUP

“COVID increased anxiety, but we made things smoother and reliable, and in the face of COVID, that gave us an edge to satisfy our patients,” Moore Says.

Sparsley stocked grocery store shelves were a common sight in 2020, but a critical shortage that predated the pandemic in - spired urology nurses at Clinical Practices of the University of Pennsylvania to innovate. Their efforts meant that when COVID did directly affect ambulatory care, they were able to focus on guiding patients through mask mandates and going through appointments alone.

In early 2019, to compensate for production shortfalls and an increased demand for BCG, an intravesical immunotherapy agent, the American Urologic Association advised treating bladder cancer patients in split doses. At CPUP, they started scheduling their outpatients throughout the week, in pairs or groups of three. But if one patient was late or had a complication, others were left waiting or had treatments canceled.

“Every procedure morning was really emotionally taxing,” says Brynn Moore, BSN, RN, COCN, CPUP, Ambulatory Nurse III. Patients, nurses, schedulers, and the pharmacy were all frustrated. (The BCG dose has to be administered within two hours of mixing.) “That caused us to rethink. We can’t increase our supply, there’s nothing we can do about that. How can we make it so that these groups have a little bit more flexibility when something unforeseen comes up? We wanted to avoid the medication going to waste, too.”

Moore says the urology nurses came up with the idea to try an all-hands-on deck model, with all patients scheduled for treatment on a single day. That way, if one patient ran into issues, the staff could more easily change up the duo/ trio treatment groups. With the new approach, cancellations went down. Patient wait times decreased. There were fewer wasted doses. In fact, even though the BCG shortage persists, the practice eventually stocked up on enough for high-risk patients to receive full doses. “Our patients are consumers, and we are in a city where there are other options. COVID increased anxiety but we made things smoother and reliable, and in the face of COVID, that gave us an edge to satisfy our patients,” says Moore, adding that she values their leadership being open to the innovation from the start. One of those leaders, Associate Executive Director of Clinical Operations and CNO Barbara Prior, NE-BC GNu’03 brings a Penn Nursing background to creating a workplace where she says nurses are encouraged to continually evaluate processes and care delivery. “I feel like my education and my continued partnership with the School of Nursing has really taught me how to be an innovative leader,” Prior says.

Partner Perspective

“Our partnership with Penn has been instrumental in taking their senior students to do rotations, and then most of them we’re able to recruit and hire. In addition to that, I work with Rosemary Polomano a lot on research. If there are any research projects going on, we try to connect them to someone at the school, to help the nurses lead research. We partner a lot with HUP. We [promote] educational forums. It provides that continuing education for our nurses who have an interest in research.”

— BARBARA PRIOR, Associate Executive Director of Clinical Operations and CNO, Clinical Practices of the University of Pennsylvania