Beyond an interesting “read”

Nurse authors call on educators to incorporate IOM findings into education, practice.

Hollywood news took a decidedly different turn late last year when a famous actor’s newborn twins reportedly were administered the wrong dosage of heparin while hospitalized in Los Angeles. Equally well documented in the popular press were accounts of patient deaths attributed to methicillin-resistant Staphylococcus aureus (MRSA) and the rise of other worrisome hospital-acquired infections. In a time when the public has a growing consciousness—and demand—for quality care, the news may have caused consumers to question whether healthcare professionals are doing all they can to ensure a safe patient environment.

Yet for many years, the Institute of Medicine (IOM) has addressed both medication errors and hospital-acquired infections in ongoing reports that provide evidence-based information and advice about health and science policy to healthcare professionals, lawmakers, and other segments of society.

And for nurse educator Mary Gallagher Gordon, MSN, RN, CNE, the accounts of the heparin error and the upswing in MRSA cases represented two real-life, real-time teaching moments. “I always try to weave in recent news events and IOM reports throughout my nursing informatics course,” says Gordon, a clinical assistant professor at Drexel University in Philadelphia. “It’s important to get nursing students thinking about patient safety right from the start.”

Gordon uses the ground-breaking 1999 IOM report, To Err is Human: Building a Safer Health System, which recommends taking a systems approach to eliminating potentially fatal errors, during the first week of class when students also are learning the five rights of medication administration and documentation in their nursing fundamentals course.

Last year, the heparin story happened to break around the time Gordon was discussing healthcare systems. “I used the IOM report to portray how medical errors are often a result of a systems problem, not necessarily the result of a particular person’s error,” says Gordon, a Pennsylvania State Nurses Association member. “I also worked with students to perform a root cause analysis based on the news accounts.”

Established in 1970, the IOM has produced reports that focus on all sides of the healthcare equation—from the system to the professionals to the patients.

In addition to To Err is Human, other reports include Health Professions Education: A Bridge to Quality, which recommends that all healthcare professionals meet five core competencies: the ability to work in interdisciplinary teams, employ information technology, use evidence-based practices, apply quality improvement, and deliver patient-centered care. Another is Keeping Patients Safe: Transforming the Work Environment of Nurses, a follow-up to To Err that raises issues like nurse staffing, work hours and fatigue, and their link to care.

Although using IOM reports in the classroom may not yet represent a trend, it certainly is a movement that is picking up steam. Two nurses who are leading the way are Anita Finkelman, MSN, RN, a nurse consultant and assistant professor at the University of Oklahoma (OU) College of Nursing, and Carole Kenner, DNS, RNC, FAAN, dean and professor of OU’s nursing program. They feel so strongly about incorporating these reports into education to create better-prepared nurses and better patient outcomes that they wrote a book, published by ANA Nursesbooks, called Teaching IOM: Implications of the Institute of Medicine Reports for Nursing Education.

The what and why

Kenner and Finkelman believe the IOM reports contain information that is vital to ensuring safe, quality patient care, and therefore should be part of the educational and practice experience of every future and current nurse. They acknowledge that many healthcare facilities already have embraced a range of quality-focused programs, such as ANA’s National Database of Nursing Quality Indicators™. And given proposed regulatory changes, facility administrators’ increased emphasis on ensuring quality is only expected to grow.

“To me, it seems obvious that nursing education also needs to teach what is in these reports,” says Finkelman, an Ohio Nurses Association member. “Yet I’ve discovered that some nurse educators don’t know the content of the IOM reports or even what the IOM is.

That means students have not been immersed in many of the IOM’s recommended competencies, such as providing patient-centered care, that will allow them to perform better in the workplace. “New nurses are expected to work a miracle the first day they are on the job,” Finkelman says. “They suddenly have to communicate with a doctor when they’ve had no real experience with working in interdisciplinary teams.”

Adds Kenner, “Why are we the only profession that expects our young to hit the ground running, while other health professionals have internships to help their graduates transition into practice? There shouldn’t be such a wide gap between education and practice.”

Making a case

Looking at medication errors alone, the IOM reports reveal a wealth of information that can be incorporated into the nursing classroom and clinical rotations. When To Err was released, it noted that as many as 98,000 people die each year in hospitals as a result of preventable medication and other medical errors.

In that report and others, the IOM details many recommendations that can help reduce medication errors, including utilizing technological safeguards such as bar coding on medication labels, reducing interruptions during the medication process, and eliminating the practice of giving drugs similar-sounding names.

But it’s not just a matter of knowing what’s in the reports; it’s a matter of internalizing the recommended competencies and putting them into practice. Finkelman and Kenner recommend that nurse educators employ case studies to help incorporate the IOM content, as well as to strengthen student nurses’ clinical reasoning. “As toddlers, we don’t learn one piece of information at a time,” says Kenner, an Oklahoma Nurses Association member. “We should be teaching nursing in a way that allows students to see the bigger picture.”

Finkelman says she had the opportunity to sit in with second-year medical students who were engaged in team-based learning. Although they had no clinical experience, they were given case studies that required clinical knowledge. “The students told me that they found this way of learning challenging but not difficult,” Finkelman says. “We don’t do this enough in nursing and that hampers students’ ability to pull together all the pieces that are needed to ensure quality care.”

Using MRSA as an example, Finkelman says that nurse educators most likely would take that topic and deliver a traditional lecture on pathology. Instead they should create a discussion about all of MRSA’s implications – from the importance of hand washing to the policy that could lead to a hospital losing its reimbursement if a patient acquires the infection while in its facility. “We have to get away from just regurgitating the facts to students,” Finkelman says.

Looking at another IOM recommendation—working in interdisciplinary teams—Kenner and Finkelman say that healthcare students should begin working in interdisciplinary teams while they are still in school. There are schools that bring together students from all healthcare professions to discuss case studies. This interdisciplinary learning approach helps forge working relationships that will benefit students in the practice setting—and eventually patients.

Yet another important aspect that the nurses believe should be part of the nursing curriculum based on the IOM reports is better use of technological advances—not only to reduce errors but also to improve the flow of communication and to provide coordinated care. Gordon’s institution, Drexel University, already has taken that recommendation to heart. In 2002, it began requiring student nurses to use personal digital assistants (PDAs) in both the classroom and in clinicals.

On the horizon

The Nurse Educators Chapter of the Arizona Nurses Association (AzNA) recently polled its roughly 110 members to determine topics of interest for its fall educational session. The number one topic on the minds of educators from both academia and healthcare facilities was determining strategies to teach IOM competencies, according to Anne McNamara, PhD, RN, dean of Grand Canyon University’s College of Nursing and treasurer of ANA’s Board of Directors.

Aware of the book that Finkelman and Kenner wrote, the AzNA planning committee has invited the authors to share their strategies at the October 17th association event in Phoenix. “The IOM recommendations are all about saving lives, improving patient outcomes, and providing safe, quality care,” McNamara says. “We want to look at how to enmesh those IOM competencies into our nursing curriculum and into hospitals’ policies and procedures.”

And although Gordon always incorporated some IOM findings into her classes, she says the strategies outlined in the book have helped her develop more ways to build students’ IOM competencies. “It’s not like it requires adding extra content into courses,” Gordon contends. “It is how you present the information and create discussions. Students like that format, and they learn a lot.”

For more information on Teaching IOM: Implications of the Institute of Medicine Reports for Nursing Education and its companion CD, go to www.NursesBooks.org.

Susan Trossman is the senior reporter in ANA’s Communications Department.

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