From the Vineyard to the Bedside: A Clinical Nurse Leader's Journey

Clinical Nurse Leader is the first professional designation added to the American Nurses Association in the last 35 years. So, what is it?

In an effort to begin blogging about becoming a Clinical Nurse Leader (CNL), I should first share a tidbit about who I am. My name is Jessica Hatch. I am 24 years old, and I am not yet a CNL but on the progressive pathway toward this exciting designation.

Upon graduating from the University of New Hampshire - having obtained a B.S. in Nutritional Sciences with a minor in Healthcare Management and Policy - I dabbled for a number of years in viticulture and enology (aka grape growing and winemaking) in New England. Since the owner of the winery is a retired ER physician, his wife is a visiting nurse, and I was a student of nutrition, none of us had strayed too far from our respective health care fields. (What occurs in the wine cellar is biochemistry at its best; we had just extended our scientific knowledge into another interesting area of study.) As much as I enjoyed the wine world, I realized my true passion was to work with patients and that winemaking would instead become a hobby.

Nursing was always in the back of my mind, but I had never committed to the idea. Then I came across the Direct Entry Masters Program at UNH, which allows students of all undergraduate fields to become a Registered Nurse, and earn their CNL certification, in just two (very accelerated) years. The role was new to me, having only heard of it from an acquaintance studying in the program. But as I learned about the program, it was clear I could finally combine many aspects of my diverse educational background while growing into a prominent and needed leadership position as a nurse.

The hope is that, collectively, CNLs can guide all other professions to alter the path our stubborn healthcare system continues to follow. The role of the CNL is not to put innovative ideas that have never been considered into play, but instead to place a higher value on the key patient-care components that are often overlooked. A re-evaluation of pre-existing ideas that date back to Florence Nightingale and assigning more appropriate value to these ideas is a reoccurring theme throughout the literature that demands one thing: viewing the patient as a whole.

This will be accomplished through a redesigning of the system, incorporating the expertise of all disciplines to form a strong collaborative team that the CNL will guide. From pharmacists to school systems, social workers to surgeons, the CNL will empower all members of the team to transfer knowledge, constructively debate, collectively plan, and deliver care representative of the patient's values and goals. The hope is that ideal patient care is delivered.

It is important to note that the CNL works with other nurses, including Clinical Nurse Specialists, reports to the same nurse manager, involves all other disciplines to coordinate care, but at the same time, takes a leadership role.

This is what sets the CNL apart.

Through a strategically designed education and practice curriculum, the CNL is well prepared upon graduation to assume this role. (I believe a few years of work experience are also necessary.) Other staff members have been spread so thin that the CNL will be able to oversee direct patient-care, which should be the main concern. Still, the CNL will be sure to delegate appropriately and distribute equal loads across the partnership so there truly is a team effort in working with the patient. This is key to the success of the CNL, as it is clear other disciplines have become worn out due to overload. Furthermore, the CNL will reduce fragmented care, which results in errors - system errors, not staff errors.

I hope my introduction was interesting and helpful. In future posts, I will begin to shed more light on the role of the Clinical Nurse Leader. Stories from students, examples of practicing CNLs, and much more is on the way.

In the meantime, feel free to share your comments and questions!

- Jessica Hatch, Nursing Student, University of New Hampshire

Why I'm Becoming a Doctor

"Son, I shot her in the face."

Most people probably can't pinpoint the moment they chose their career. I can, though. It was the moment - in a quiet, sunny courtyard on a July - that I heard an old man utter those seven words to me. He probably didn't realize it, but it changed my life forever.

Let me start at the beginning.

My personal statement for my American Medical College Application Service (AMCAS) application was adequate. It talked about passion for medical school in three dimensions - academics, research, and service. I had a nice story about a personal experience with mental illness in my family, examples of my dedication to service work in the community free clinic, and a short but detailed description of my basic science research in neurosciences. All in all, I think it was pretty good. And more importantly, it served its purpose!

But not much of that was the real reason I was coming to medical school. I had the experiences that truly defined my interest in the profession, but I was too young to understand their impact on me. I now realize that the real reason I am studying/pursuing a career in medicine is because patients are people. How did I come to this realization?

The summer before my junior year in college, I had the opportunity to work as a Patient Safety Aide (PSA) in a local hospital. For those of you who don't know, a PSA is wonderful thing. We exist to serve. Our technical description is essentially to replace restraints. My unit was filled with rather sick geriatric patients, and as you may know, they sometimes get confused and try to get out of bed, take out their IVs, and generally cause a fuss. Instead of using restraints, the hospital put aspiring students in various units to move from bed to bed, check on patients, keep them company, and occasionally play some games with them. I also spent a lot of my time with the nurses, and I really was eager to help (when I wasn't reading novels, anyway - I think that was a Harry Potter summer for me). I would help clean up rooms, get things that nurses needed, and I wasn't really aware of much going on around me. You may think that I really got to connect with the patients, because I was spending so much time with them, but this is entirely untrue. Unfortunately, most of the patients weren't too communicative, and many of them were rather confused about where they were.

All in all, it was a very pleasant atmosphere and a nice summer. But it didn't particularly make me want to go into medicine. Actually, what I saw was pretty discouraging. Patients looked like bags of meat with all kinds of tubes sticking in them. Really, that's what I saw - near lifeless sacks of flesh that seemed to be entities of suffering far more than of living.

One sunny, July day, I engaged myself in one of our additional duties. Some thoughtful clinician had realized that patients don't really like to be cooped up in their rooms all day. I gathered the patient up into a wheelchair to take them outside.

It was a gorgeous day outside, the kind of sunny day that just feels great in scrubs that you've only been in for a couple of hours. I wheeled the patient to the garden and breathed in deeply, enjoying the flowers and bathing in the relaxation of the moment. It was just me and this garden, and it was rather peaceful. "This was a pretty good summer," I thought. "This'll look great on my med school app and I can probably write about some meaningful experience I basically make up about how I saw a doctor really connect with a patient and ... what was that noise?"

The patient had started talking. It wasn't too clear, and I had to walk around in front of the wheelchair and kneel down. I got a better look at him. He looked like he was 80, beaten badly from the inside out, with the bruises showing through his skin, but I knew he was in his early 60s. And he was talking to me.

"Sir? I can't really understand you."

A little coughing. The coughing had actually gotten quite a bit better, it seemed like.

"I was in the war."

"Sir? The war?"

"I was about your age. I was with my boys ... a little girl was walking up to us. It was disgusting there. She was maybe 6 years old. She was pretty. So pretty. Beautiful face. Adorable. She was one of them, wearing rags and looking tired and confused, but she was a beautiful little girl."

"Sir? A girl?"

What was this guy going on about? Maybe I should be worried - maybe he is becoming delirious or something. Maybe this is why they have me here, for when this happens and he starts to think he is back in the war, what if he tries to stand up and fight me or something. He probably thinks I'm the enemy!

"Son, I shot her in the face."

"... Excuse me?"

"She was carrying a grenade. They had sent her to us with a live grenade. I shot her in the face to save my men. She was so beautiful ... "

That is when it happened. Patients became people. That was the moment, crystal clear in front of my eyes to this day and forever. This man looked like hell and lived with incredible amounts of suffering, but he did not live the life I saw. He lived a life of profound regret for that one moment in his life that happened when he was as old as I was. He possessed a profound clarity despite the chocking fog of his illness, and he was not delirious or demented. And he was a person.

I think I told that story in an interview at my medical school, with a student. I don't know why I started to tell it, because I really didn't think it was a good story to tell at an interview. I told that story, and I barely understood it or its impact on me. Three years later, with some more maturity and a bit more experience with patients, the meaning of that story is only beginning to set in. Those suffering patients in that hospital were not sickened, lifeless, unanimated meat. They were human beings in the most deep and spiritual sense of the word, and they lived those ultimately human experiences. Love. Pain. Regret. The question of whether or not they did the right thing.

I would be lucky to be that human, ever. And that is the real reason why I want to be a doctor. Because patients are people.

- Lakshman Swamy, MD/MBA Candidate, 2013, Boonshoft School of Medicine at Wright State University

Chapter Corner: The Importance of Sharing Knowledge

By itself, content is limiting. While the information from a book is useful, there is no incentive or opportunity to offer an opinion and receive a response. It is simply a one-way flow of information. It's the people we meet and speak to that hold the real knowledge. As social creatures, others' work and life experiences will resonate more with us when we ask questions and have the opportunity to respond directly, whether it is in person or through email. I know all of these things because I learned them firsthand.

I asked a colleague of mine if they knew anyone working with process improvement in healthcare, and they put me in contact with two professors at Emory University's School of Medicine. From these connections, I was put in touch with a director at a nearby hospital's center for clinical performance improvement, as well as the Chief Quality Officers at two other hospitals. I've learned a tremendous amount from my conversations with them.

My conversations with these people were the true driving force that sparked my interest in quality improvement in healthcare, and I try to drop a line to say "hi" every few weeks or months. I'm even working with the director at the clinical performance improvement center to establish a quality improvement project for the Atlanta IHI Open School students. It's experiences like these where I find value in establishing new relationships, especially with those so willing to give back to students.

Here are some other ideas on sharing knowledge:

• Take advantage of others' knowledge by talking to fellow students, teachers, leaders - anyone you can make time for (and can make time for you).
  
• Search on LinkedIn for professionals in the area who are involved in healthcare improvement (after all, wasn't LinkedIn made for networking?).
  
• Email leaders from other schools in your region, or across the country. See what others are doing and network to share ideas.
  
• Read the "Chapter Accomplishments" on the IHI Open School website and find ideas that interest you and your group.
  
• Contact schools to learn more about their methodologies and challenges to accomplishing their goals. (It's been my group's experience that IHI Open School chapter leaders are extremely receptive to sharing ideas.)
  
• Talk to others to share knowledge and to generate opportunities. People generally love to talk about themselves, and would be more than happy to meet or speak about their experiences (probably more willing to do so than you might think).
  
• Talk to professors and coworkers, and ask them about what they do and how they got there. Ask if they know others in quality or process improvement, and see if you could set up a time to chat with them for 15 minutes. This could lead to new partnerships with your chapter, quality improvement projects, mentorships, additional IHI Open School exposure, among other advantages. Once you've developed those relationships, maintain them by following up throughout the year.

I reached out to one of my public health professors to ask about her work in quality improvement and told her about my involvement with the IHI Open School. After some meetings and phone calls, we eventually established two quality and process improvement team projects for IHI students to be involved in, and we hope to find the right students to make these initiatives a success! It's my hope that I'll be able to give back the same way that these professionals did for me.

I've found it invaluable to have these discussions with others, and I encourage other chapters to do the same. It sounds simple, but it can be tough work to find and maintain these relationships. We will always have something new to learn from each other.

- Becky Ng, Public Health student, Emory University

Another Health Care Workshop? Five Reasons Why SQLA is Worth Experiencing

It's been almost six weeks since I left the IHI Open School Student Quality Leadership Academy (SQLA). Admittedly, I volunteered to put together a blog post weeks ago, but my hectic schedule as an outgoing student (classes, work, research projects, job interviews, networking, and summer visitors) kept stealing my attention.

As an emerging health professional, I have availed myself of numerous free networking events and educational seminars (and food). Eventually, after attending so many that fixated on the need for change in health care, I became jaded about how much these events actually contribute to inspiring innovation. But when I heard of SQLA, knowing IHI's great reputation for visionary leadership in health care improvement, I couldn't shake the feeling that this program was going to be different from the rest. Since attending, I have felt inspired to share my experiences with prospective attendees and, in the process, encourage you to apply for next year's Academy.

Upon reflecting on the lectures and activities from the SQLA weekend, there are five reasons why I would recommend taking part in SQLA to all students in any field of health care (I personally am a clinical social worker and MPH candidate in Health Policy & Management):

1. Exposure to Diverse Perspectives: At our table alone, we had two international students, a nursing undergraduate, a physician, several advanced med students, a Masters-level nurse, and a public health social worker (yours truly), representing great diversity in geography, race/ethnicity, age, and education. Each member contributed thoughtful examples and insight from his or her actual experiences, covering an even broader spectrum of sub-specializations (mine is behavioral health). This rich confluence of experiences was very enlightening, introducing me to the perspectives of professionals in other health care areas with whom I have literally never interacted, and may not have for much longer if not for SQLA. For too long there has been an unfortunate dearth of cross-disciplinary collaboration among our segregated health schools, and SQLA breaks down these barriers.

2. Unbeatable Expertise: All of the weekend's presenters were seasoned veterans of health care leadership and innovation. Each one holds or has held very senior positions in national policy advising and/or academic medical centers. This year's presenters were predominantly current or past leaders from Beth Israel Deaconess Medical Center in Boston - one of the most respected, innovative health care organizations in New England. The only one without at least 20 years of professional health care experience was Dr. John Halamka, who is merely the youngest chief officer in the history of BIDC, had served as a key health information technology (HIT) advisor to the Obama Administration, and was recently contracted by Japan to assist development of a new HIT system across their Northern region following this year's devastating earthquake and tsunami. To say his knowledge and perspective are expansive is a serious understatement, and each presenter was of equally strong caliber.

3. Gaining Essential Management Skills: Take a walk in the woods to build rapport with your opponents and identify shared values. Use interest-based negotiation methods to manage and overcome conflicts. Implement "double-loop learning" to learn from and prevent future conflict situations. Carefully choose when to identify people instead of numbers when quantifying problems. Learn how leadership vision and operations management can foster an environment that minimizes conflict. The "Transition Curve" framework offers a method for managers to conceptualize and facilitate change processes with minimal staff resistance. Before embarking on a difficult conversation, ask those involved about their understanding of a situation, and let this guide your approach and language. These are just several of many examples to evidence that SQLA actually covers concrete management techniques that any of us can apply to improve our team's performance, morale, and ability to adopt innovations.

4. Assessing Personal Strengths and Needs: Through exposure to new management concepts, personal anecdotes from presenters, and group and individual exercises, the weekend at the Leadership Academy gave me the time and tools I needed to identify where I may struggle and succeed as a new manager in the health care industry. This self-understanding will be handy for upcoming job interviews, and also in identifying positions where I'm most likely to succeed.

5. Having Fun! Of course, after days full of challenging sessions, self-evaluation, and passionate presentations on health innovation, we were able to unwind. Harvard Square (and the rest of nearby downtown Boston!) offers a plentiful assortment of interesting activities and quality spots to pass the time with good people and entertainment. This year featured a public dance party in front of Cambridge City Hall, which closed down the largest roadway through town and featured thousands of locals partaking in a good old fashioned outdoor celebration. After three years in the same social and professional circles, networking, story-swapping, and joke-telling with 100 new, equally passionate students was rejuvenating. The city offers an eventful, lively locale for this gathering, which is pivotal because our work, no matter how valuable or urgent, cannot become our entire life. So once the lessons have been learned, there is much-deserved time to get out and play! So come early, stay late, and enjoy the marvelous landscape, history, culture and nightlife of Boston. Good things should come to those who wait (and bravely work on the daunting challenge of health care improvement)!

- Sandy Cohen, MSW, Boston University School of Public Health

Chapter Corner: Happy Hour in Atlanta!

This is the newest installment in a series of posts written by chapter leaders and members. The goal, simply, is to share best practices and creative ideas with other chapters around the globe.

I love happy hours. But I love them even more when they are an excuse to spread the word about the IHI Open School.

My group, the Atlanta IHI Open School Chapter, is made up of students from Emory University and the Georgia Institute of Technology. We kicked off recruitment for 2011 on July 7th with an IHI Open School information session. We followed this up with a happy hour the following Saturday.

Why did we do a happy hour? We think social events like these build solidarity between group members from different schools. These are opportunities for our current and prospective members to meet other students outside of our particular programs. Events like the happy hour will help develop friendships and create an added incentive to participate in IHI Open School activities throughout the school year. We had a turnout of about 10 at our happy hour session, despite the pouring rain. The vice president of Health Students Taking Action Together (HealthSTAT) was also in attendance, and she and our president have discussed plans of co-sponsoring events throughout the year.

Even better, our summer information session turnout was great with over 20 attendees, including a handful of healthcare professionals. At our meeting we included snacks and distributed a fact sheet that summarized the IHI Open School, our goals for the year, and proposed upcoming events.

Here are three questions - and answers - we think might be helpful for other Chapters:

What did we include in our information session agenda?
1. A Denver Health patient safety video
2. Introductions around the room
3. Small groups to briefly share any personal stories of patient harm or unjust culture
4. A short presentation made by our chapter president describing what IHI is, the Open School, and what we've done so far
5. An overview of what we have planned for the year, including:
- Monthly "lunch and learns"
- IHI modules to be integrated into school curriculum
- Upcoming quality improvement projects
6. Don Berwick's Introduction to Open School video
7. A survey asking about interest in events and involvement

Why start recruitment in the summer?
We want students to start thinking about the IHI Open School and talk to their friends about it. We feel the interest-we just have to get the word out! We also want students to start preparing for any quality projects they might be interested in by taking the IHI quality modules as early as possible to prepare.

How did we advertise our event?
We asked our schools and departments to forward our event email and flyer to the current and incoming class, as well as posted flyers around schools. We also emailed any connections we had with faculty and professionals to pass on the word to any interested individuals.

We're trying to foster a supportive environment where we can build relationships and share ideas. Social events like the happy hour can help facilitate this, in addition to our group meetings and learning events. What are your thoughts?

- Becky Ng, Public Health student, Emory University

Chapter Corner: Five Rules of (Student) Engagement

This is the first in a new series of posts written by chapter leaders. The goal, simply, is to share best practices and creative ideas with other chapters around the globe.

One of the biggest challenges that we face as a group at UMass (in Worcester, MA) is encouraging people to come to our events and classes. The topics and the speakers may be fantastic, but the audience consists of only about 10 students. It is difficult to engage students in anything outside of the board exams even if the material will be important in their careers. We worked hard to increase student interest and attendance at events this past year. Things did not always work out for us, but the following are some of the strategies that we used to bring students in:

1. Make it personal for the students. Take a story that will really hit home and organize a speaker or a class around that one story. For example, we had a death at UMass Medical Center on the telemetry floor. The story was all over the local news broadcasts and many students were discussing the case, especially saying that they were embarrassed to represent UMass. We took a different spin and invited the physician who was working to solve the problem to come and speak. He talked about what UMass was doing to prevent future incidents of alert fatigue and really excited the students to get involved in solving the problems instead of gossiping about them.

2. Early preparation is critical! We had one event that had great speakers and a really interesting topic, but we had the worst luck getting a room. The day before the event a room finally opens up, and we emailed out to all of the students with the room assignment. The morning of the event room reservations calls us and switches the room. So we email again saying, "Last minute room change!!" Later that day, mere hours before our event, we get switched to yet another room. So we send out another room change email, but at this point, it is just about time to get started. In the end, we had fewer than 10 students in attendance. Lesson learned? Get all your ducks in a line quickly and early so you can accurately advertise long before the event.

3. Get creative with your advertising. This example doesn't come from our IHI Chapter, but one of the global health groups on campus sponsored an HIV/AIDS awareness event. To advertise, they gave out small goodie bags in class. These contained two condoms and enough M+M candies to represent a day's worth of antiretroviral medications. They also included a short written piece with some facts about HIV and an invitation to their event. Even if people didn't attend the event, they were exposed to the problem and the ideas they were promoting.

4. Bring in the big guns! Include professors and administrators in the planning, and definitely send them an invitation. It adds legitimacy to events that you are organizing. We ran a panel event on interprofessional communication, and we had the dean of the school of nursing in attendance. She really encouraged nursing students to attend. We had great turnout from the school of nursing, especially relative to medical and graduate students.

5. Schedule informal events around your class breaks. We started a series of "lunch and learn" events during the lunch breaks in our class schedules. These were short events, usually about 45 minutes, where students would pack a lunch and we would lead a discussion of a case study or recent article. The Open School web resources are fantastic for this sort of forum and attendance was good because people were sitting around campus anyways.

These were some of the strategies that really helped us this year, but we still have a long way to go in engaging students in QI and patient safety. Sadly free food tends to be the best motivator, and we just don't have the budget to feed hungry grad students with every event.

What have other people done at their chapters?

- Aubrey Samost, medical student, University of Massachusetts

Lessons Learned from the IHI Open School Student Leadership Academy

On June 24 and 25, many healthcare students and professionals converged on Harvard Square in Cambridge, MA, for a two-day forum on leadership. I think I speak for more than just myself when I say the weekend was fantastic -- both highly entertaining and educational. Our moderator for the weekend was Dr. James Reinertsen, the former CEO of CareGroup and current president of The Reinertsen Group. Over the two busy days of the conference, somehow his energy never flagged, and he was able to keep us energized and engaged. At the end of the weekend, Dr. Reinertsen left us with a parting message on life-long learning and how there are three equally important components of it:

1. The continuous acquisition of knowledge


2. Personal experiences


3. Reflection on the first two parts

So, just for you Dr. Reinertsen, these are my reflections on the incredible amount that I learned and the wonderful experience I had during those two days in Harvard Square:

The easiest, but perhaps most complicated place to start is to ask, "What did I learn?" Through didactic sessions, I learned conflict management (I wasn't surprised to find that I'm an avoider) and how to take a walk in the woods (a negotiation technique, actually). Through the lectures and anecdotes from the invited speakers, I learned about how to lead through a crisis (like a massive computer system crash), how to lead without authority, and the benefit of a fancy job title. Through exercises, I learned how to effectively have awkward conversations (like dumping a guy or firing an employee) and how to assess the safety of a patient care unit by observing its teamwork. All of these skills I anticipate using throughout my career and life.

While the lectures were useful and enlightening, I would be greatly remiss if I didn't discuss everything I learned from the other participants, the other students. We were assigned seating right from the start to force us to meet people we might not have interacted with otherwise. I ended up sitting with one other medical student, a psychology student, two nursing students, and three healthcare administration students. This medley of backgrounds and people's unique experiences made the discussion very lively. It was eye-opening to hear everyone's perspective on a problem because they could be so different from my own. Looking back, it makes me really appreciate a drawing that Dr. Barry Dorn (one of the speakers) made of a cone in a box which highlighted an important lesson: Where you are looking from greatly influences what you see.

Needless to say, I learned a lot this past weekend, both from the speakers and from my peers. The lessons I learned are not found in textbooks or medical school lectures even though they are critical to our future work. I am extremely grateful that I had the opportunity to attend the Leadership Academy. The knowledge and experiences that I gained are definitely going to stick with me as I continue on my path toward becoming a physician.



- Aubrey Samost, University of Massachusetts