1. Field, Mary MBA, BSN, RN, CPHON

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The certified nursing assistant (CNA) population at Seattle Children's Hospital represents a valued member of our nursing care team. Over the past 5 years, we have altered our inpatient model of care to include a robust CNA model. Our nursing practice model is rooted in evidence-based care; however, there is little published literature to support CNA best practices. Over the past few years, the Nursing Professional Development department has done a tremendous amount of work applying standard work and evidence-based practice to our RN shift handoff; however, the CNA process remained unchanged. Historically, practice on each unit varied. CNAs on the Cancer Care Unit would prewrite their oncoming replacement's handoff sheet without referencing any reliable resources; most of the information was obtained via word of mouth, historical handoff sheets, or assumed individual knowledge. This allowed CNAs to pass along outdated and inaccurate information. Some of the erroneous information passed along included point of care testing orders, ambulation precautions, vital sign parameters, and patient preferences. Although no serious safety events occurred, the CNA group self-identified this as an extremely risky handoff procedure.


To address this problem, the nursing leadership team established a CNA handoff taskforce composed of two nursing managers, one unit-based nursing educator, and three unit-based CNAs. We were tasked by our unit director to improve the handoff process with both a cost and time neutral solution, as well as to demonstrate clear improvement metrics. We felt strongly that CNA handoff should be concise, accurate, and improve patient care, and we were certain with some creativity we could achieve these goals. The director of the Nursing Professional Development department encouraged this work and asked the Cancer Care Unit to disseminate their findings post go live.


The CNA taskforce met and started the brainstorming session by evaluating the current handoff sheet. We quickly identified the following problems: (a) Information contained did not match the needs of the CNA group, (b) the layout was visually busy and did not allow one's eyes to naturally flow to the most important information, and (c) cadence of information did not follow any natural flow.


During our 4-hour brainstorming session, the CNA team members recommended we train CNAs to individually take report by looking up their patients on the electronic health record and then following up 1:1 with the bedside RN. The task force felt that, by using the electronic health record as the source of truth, only accurate and timely information would be reviewed during report. In addition, we completely remodeled the CNA handoff sheet to match the flow of information on the computer and leveraged color coding for highly important information.


The CNA task force trialed these updates and found that report was both faster and more thorough. In addition, a postimplementation survey indicated that CNAs were extremely happy with this change and felt they were providing more informed clinical care. Most impressively, our unit rates of chlorhexidine wipes, mouth care, and patient ambulation all increased as a result! The success on our unit was so clear our Nursing Professional Development department helped disseminate these practice changes on the other acute care nursing units throughout the hospital.


As a nursing leader, I learned a valuable lesson from this experience: Ideas for improvement are most effective when they come from those that do the work. The more I can empower and support clinical staff to do their best work, the better care our patients will receive! Ultimately, it was the partnership between nursing managers, the unit-based educator, and the entire CNA staff that made this practice change successful! Although this practice change was homegrown on the Cancer Care Unit, it is the Department of Nursing Professional Development that ultimately helped apply this change at a systems level. I anticipate the partnership of CNA staff with our nursing professional development peers will generate many more progressive changes throughout the hospital!