Northwell Health to nurses: ’Constantly question practice’

Nurse Leader Insider, October 1, 2019

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By Jennifer Thew, RN

As chief nursing officers work in a healthcare industry that's awash in a sea of change due to evolving reimbursement models, consumerism, and M&A activities, they understand that the nursing profession must also make changes within this environment.

To some, reshaping nursing and healthcare delivery is daunting. But for others like Kerri Scanlon, MSN, RN, FAAN, deputy chief nurse executive at Northwell Health and chief nurse executive at North Shore University Hospital, and Lily Thomas, PhD, RN, FAAN, vice president, system nursing research at Northwell Health Institute for Nursing, this opportunity is invigorating.

"I'm very excited to see, over the next number of years, what the profession of nursing brings to the table in terms of healthcare," Scanlon says. "I'm so honored to be in this profession because we are going to see [nurses] be able to create what the next version of healthcare will look like."

To propel the nursing profession and patient care forward, Scanlon, Thomas, and Northwell's other leaders, have committed to creating a culture of inquiry at the organization.

"In a culture of inquiry, we want to remain open to multiple ways of knowing the answer [to questions about improving care delivery and patient outcomes]. Right now, we predominantly rely on evidence-based practice and research, and we have a commitment to uncover and disseminate the knowledge that is embedded in practice." Thomas says. "And we have a commitment to clinical scholarship. We don't just accept things because it's the way we've always done it."

In a recent interview with HealthLeaders, Scanlon and Thomas discuss how a culture of inquiry that values clinical research can make a difference for an organization, nurses, and patients.

The transcript has been lightly edited for brevity and clarity.
HealthLeaders: What is a culture of inquiry?

Thomas: We started this work believing that the best opportunity to build nursing practice is at the bedside. So, that's where we started with the culture of inquiry. Our vision for nursing research was to establish the spirit of inquiry as a professional value, standard, and behavior for all nurses.

So that meant, we needed a culture to support that. A culture of inquiry meant nurses would constantly be questioning things regarding practice, with the goal of improving care delivery and patient outcomes. So, it's a culture where we promote questioning.

In fact, you (the nurse) should question what you're seeing regarding the patient's response to treatment. Is it working for your patients?  Or should something be different in that patient experience?

Don't accept everything just because it's a standard. That's how we grow.
HealthLeaders: What qualities do you look for among the nurses you hire, both at the bedside and in leadership, to help support the culture of inquiry?

Scanlon: Bringing in the right people is key. You really want to have those who truly understand research and understand evidence-based practice. What we're finding is many of the new graduates are already exposed to this during their education.

For example, we run a program called the Golden Ticket Event each year across Northwell Health System's 23 hospitals. What we're doing with that event is we're recruiting the top-level talent (top 10% in their nursing class) across the region.

Last year at that event, we had nurses asking, 'How do I join the research committee?' As a leader, that's what you want.

I happen to know a number of graduates we've just hired have already published in peer-reviewed journals. They've gone through the experience of formulating and doing qualitative or quantitative research.

They are coming into this profession, I believe, wanting to be involved and they are always asking the questions, 'Why am I doing this? Why am I doing that?' That's the type of nurse you want, someone that is asking those questions. So, we are looking for individuals that are not happy with the status quo [and have the attitude]: 'There's got to be a better way to do something.'
HealthLeaders: Can you give me an example of how the culture of inquiry translates to bedside nursing?

Thomas: At our flagship hospital, one of the nurses in the palliative care unit had turned a patient, and noticed changes on the skin, which was pressure injury, and [the nurse] became very upset. She went to her manager and said, 'I did everything possible for the patient and this is what I'm seeing.'

From there, Kathy Trombley, the manager at that time, and the nurse went to the literature and found mention of the Kennedy terminal ulcer. They thought maybe this [situation] is something signifying the end of life. So, they called the wound care nurse, Mary Brennan, and they called me, and I said, 'Let's start studying this systematically.'

We put a protocol together, went to IRB, and studied the skin condition and how it was similar or different from pressure injuries. And then [we studied] what was the relationship between it and the time of death. We found a correlation between appearance of these skin changes and the time of death. We named the phenomenon Trombley Brennan-Terminal Tissue Injury. It's one kind of a prognosticator of death; our studies showed that 75% of our patients with TBTTI died in 72 hours. We validated it. It's a phenomenal finding.

This is an example of what can happen when we support a spirit of inquiry.

Then taking this concept further, we had a patient whose son had to leave [her] to go back to work. He was really struggling with that. The nurse noticed the appearance of the Trombley Brennan-Terminal Tissue Injury and called the son. He was able to get back literally within hours before his mother's passing.

Also, my mother-in-law was here as a patient, and there's 11 siblings in my husband's family. I noticed the skin changes and immediately called the nurse who came in and noted it. I called my husband and said, 'You need to get your family together. [Her death is] going to occur in a number of hours.' And, sure enough, she passed.
HealthLeaders: What are the outcomes and benefits you have seen as a result of your culture of inquiry?

Thomas: We've had improvement in terms of patient outcomes, but also, whenever evidence-based practice is implemented, it's been documented that it improves nurse autonomy, nurse satisfaction, and nurse engagement. It's also promoting professionalism because the nurses can take action to improve practice.

Scanlon: What we've done is effectuated a model where the frontline caregivers are supported under champions. The champions have been educated and updated on evidence and they become the resources for the frontline staff. The RN engagement has climbed year over year, and 'opportunity to develop' is one of the highest-scoring items that we see across our NDNQI data. That's when you start to really move things to where people see nursing as a profession, not as a job.

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.

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