Nurses Driving Change - Through Evidence-Based Practice & Innovation 2017/2018 NURSING REPORT - Billings Clinic
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2017/2018 NURSING REPORT
Nurses
Driving Change
Through Evidence-Based
Practice & Innovation
> Click on page number to go
to that page
Contents
2 Leading the Way for
Change Through
Compassion and
Collaboration
3 Our Multidisciplinary
Approach for an
ECMO Program
4 Family Birth Center
Breathes “New Air” into
Pain Management
5 The SWAT Nurse’s
Many Hats
6 Alameda Model in the
Psychiatric Stabilization
Unit Makes a Positive
Impact for Patients
7 Billings Clinic’s Nurse
Residency Awarded
Accreditation with
Distinction
7 Nurse Residency
Program Has Significant
Impact on Retention
of Nurses
8 Nurse Residency
Champions of Evidence-
Based Practice
9 Nurses as Authors
12 Depression Outcomes
from a Fully Integrated
Obstetric Mental Health
Clinic: A 10-Year
Examination
13 Wound Ostomy
Nurse Navigator
14 Watchful Eye for Safety
with AvaSys Patient
Surveillance
15 Nursing Strategic Map,
2018-2021
16 Peppermint Essential Oil
to Control Nausea in
Hospitalized Patients
17 BSN Certification Rates
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Nurses Driving Change
Through Evidence-Based Practice & Innovation
Dear Staff, Colleagues and Friends,
Our vision to be a national leader in quality, safety, service and value has posed many wonderful opportunities for us. With this
vision in mind, Billings Clinic and the Nursing Division have taken on several new challenges and have accomplished much over
the past year. As a Magnet facility since 2006, we strive to constantly move forward with evidence-based improvements and
achieve high quality outcomes for our patient population.
You will read about new clinical initiatives that have been forged by nurses at Billings Clinic, all evidence-based and innovative in
the approach to provide our patients with the highest level of quality care.
Billings Clinic nurses are encouraged to bring information back from conference attendance, regional association meetings and
from journals that will enhance and improve the process and outcomes for our staff and patients. In this annual report, I am proud
to present stories of nurses introducing new technology in Critical Care and Labor, Delivery, Recovery and Post-Partum. The
addition of an evidence-based patient surveillance system was researched and installed to improve outcomes for falls prevention.
The Nurse Residency leadership team successfully navigated the accreditation process that resulted in PTAP Accreditation
with Distinction.
I am incredibly proud of working along side Billings Clinic direct-care teams and leadership as it seems that every day our staff
drive a new and improved process to continually provide advancing care to our patients.
My passion for nursing began as a Certified Nurse’s Aide and soon progressed to a Licensed Practical Nurse. After a short time, I
was able to obtain my RN BSN. After many years of serving as a Clinical Coordinator and a Nurse Manager in outpatient and
inpatient areas, I went back to obtain my Master of Science in Nursing. I then went on to serve as the Medical Surgical Nursing
Director prior to becoming the Chief Nursing Officer at Billings Clinic. I can fully appreciate the drive our nurses have to further
their education and professional careers through continuing education and process improvement initiatives.
I will never forget the incredible work by clinical staff who serve our patients and their families every day. Each day our team
makes a difference in many lives, helping them to face new challenges and fears. Nursing continues to be challenging everyday as
regulations change that impact financial, human resource and material needs. Our staff at Billings Clinic are problem solvers and
love a great challenge. We are truly better when we work together, and stories in this annual report are strong evidence.
Through staying engaged in evidence-based practice, Billings Clinic nurses stay on the leading edge of innovation which allows
them to control nursing practice at Billings Clinic by staying informed. I cannot thank this team enough. We have much to be
proud of.
Thank you to all the who contributed to this annual report.
Laurie L. Smith, MSN, RN, NEA-BC
CNO, Billings Clinic
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Leading the Way for Change Through
Compassion and Collaboration
As Billings Clinic employees, we are committed to provide the best service experience and outstanding quality care our patients
need and deserve. Across the continuum of care, from a clinic appointment to a hospital stay, our nurses are integral to providing
complete, safe, and evidence-based care for our patients.
Nurses are at the core of the collaborative and interdisciplinary team’s approach to the patients plan of care. Nurses solve
problems, and they challenge us to define, change and improve methods for the way we provide patient care. Our nurses serve as
a catalyst for change demonstrated through decreased infection rates, serving as preceptors to student nurses, ensuring the
safety of our medication practices, engaging in research for nursing best practices, all which results in benefits to the community
and region we call home.
On behalf of our organization, I want to extend my heartfelt appreciation for the dedication and care our nurses bring to our
organization. Through their diligence for providing the highest level of care regardless of complexity or simplicity of the
encounter, our nurses take pride in raising the bar required for exceeding our patients’ expectations and meeting the
requirements of a designated Magnet organization. To be the best takes humility, tenacity of purpose, courage, and a willingness
to measure the impact on those we serve. Thank you for exceeding patient expectations every day and for
always putting the patient first.
Robert K. Merchant, MD, FCCP
Interim Co-CEO, Billings Clinic
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Nurses Driving Change
Through Evidence-Based Practice & Innovation
Our Multidisciplinary Approach for an ECMO Program
A well-trained multidisciplinary team is needed to safely care for ECMO patients. Clearly defined
roles and collaboration allowed us to initiate and maintain an ECMO program with desirable
outcomes. We can provide local and regional support for patients in a large referral area.
Extracorporeal Membrane Oxygenation (ECMO) is a therapy that utilizes a machine’s artificial
lung to add oxygen to a patient’s blood and pumps it through their body like the heart. This
process takes place outside of the body. This also allows the ECMO team to lower the settings of
the ventilator, allowing the lungs to rest and heal.
The ECMO program was brought to Billings Clinic with the help of Pam Zinnecker, MSN, RN,
CCRN-k, and Dr. Alexander Kraev. The Billings Clinic Foundation helped to purchase the ECMO
System and the nine months of training for Pam and eight other ICU nurses. Our ECMO
program coordinator, Pam Zinnecker, is the integral link to establishing and maintaining the
ECMO program.
ECMO specialists are ICU RNs who receive training and remain competent via quarterly
education/competency sessions and working with the program coordinator when caring for
the ECMO patient.
ECMO pump regulation and
In addition to educating the primary team, ancillary team members, including but not limited monitoring devices
to respiratory therapists, pharmacists, laboratory, dietary, physical and
occupational therapy are educated to their role regarding ECMO and care
of the patient on ECMO.
Staffing the ECMO patient is 1:1 or 1:2 depending on the overall acuity of
the patient. An ECMO specialist is always part of the staffing matrix,
following the orders and guidelines for patient management to optimize
ECMO therapy including anticoagulation, sweep, FIOs and volume
administration. Non-specialist ICU nurses caring for the patient on ECMO
have received education and complete annual competencies.
Perfusionists round daily to monitor the circuits and are available as a
bedside resource.
Our facility can support one patient on ECMO at a time, and we average ECMO presentation at International ELSO Conference
one patient per month. Due to limited resources, including nursing and (L-R): Amber Hellekson, RN, Specialist; Sherry Harper,
equipment, patients may require transfer to a larger facility after being Perfusionist; Pam Zinnecker, RN, Program Coordinator;
placed on ECMO at Billings Clinic. Mary Goldammer, RN, Specialist
We attribute our successes to the multidisciplinary team. In 2017, we
placed eight patients on Veno-Arterial (VA) ECMO, three patients on
Veno-Venous (VV) ECMO and two patients on Veno-Arterial-Venous
(VAV) ECMO. In 2018, we placed six patients on VA ECMO and four
patients on VV ECMO. Statistically, VA ECMO patients have a lower
survival rate than VV ECMO patients, and our success mirrors those
statistics. We have celebrated 10 success stories related to ECMO and
patients who are able to come off ECMO and proceed to discharge.
We have guided five patient families through the decision to move
toward comfort care rather than transfer to another facility. Overall, ECMO team celebrates with patient after discharge
we have improved our ability to choose patients for ECMO.
We were invited to present our ECMO story at the 2018 ELSO (Extracorporeal Life Support Organization) Conference. Pam
Zinnecker, MSN, RN, CCRN-K, Amber Hellekson, BSN, RN, CCRN, and Mary Goldammer, BSN, RN, CCRN, presented how we were
able to implement ECMO in a smaller facility using a multidisciplinary approach.
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Family Birth Center Breathes Ms. Halgren had her fourth child in July 2019 and
“New Air” into Pain Management utilized the Self-Administered Nitrous Oxide option.
Her birth experience as noted by her is below:
Childbirth Clinician Educator Jessica Halgren BSN, RN, LCCE, led
this organization on a journey to provide a new pain management “I had been teaching students in Billings Clinic childbirth
option for women in labor and giving birth. While Attending the classes about the use and benefits of Nitrous Oxide as pain
Rocky Mountain Childbirth Conference, she heard about the management in labor. When I found out I was expecting
our fourth child, I was excited that I would now have this
resurgence and promising use of Nitrous Oxide in laboring
option available to me as well.
women. Both the Association of Women’s Health, Obstetric and
Neonatal Nurses (AWHONN) and the American College of Nurse – As I was being admitted for labor, I let my nurse know that
I wanted to try the Nitrous Oxide… just to see what it was
Midwives (ACNM) have released statements supporting the use of
like. The contractions grew stronger and closer together. I
Nitrous Oxide.
was experiencing the “shakes,” and I felt tense. At that
“Nitrous Oxide should be a vital component in the provision of point, I requested to try the Nitrous Oxide. When a
quality maternity care, and the bedside labor nurse is the ideal contraction would begin, I took a couple deep breaths of
the Nitrous Oxide. Over the peak of the contraction, the
candidate to initiate N2O use.” – AWHONN Practice Brief 2018
dissociative effect really worked for me! I could still feel the
Nitrous Oxide has seen a resurgence over pain, but it seemed far away from me. My body was able
the last several years as an option for to relax, and I definitely felt more
in control.
women who may be looking for an
alternative to epidural anesthesia. A Between that relaxation, the
common pain management tool in the ability to move into productive
labor positions (enhanced with
1980s, nitrous oxide has seen a “rebirth.”
wireless monitoring), continuous
The program at Billings Clinic Family Birth support from my husband, and
Center gained momentum after Halgren utilizing other coping techniques
(like vocalization), my labor was
returned from the annual Rocky Mountain
able to progress, and before I
Childbirth Education Conference sharing
knew it, I was 8.5 cm! I was offered
her newly gained enthusiasm for this an epidural at that point, but I
self-administered option for women. The really felt confident that I could do
LDRP RN set up, educated, continues to it with the Nitrous Oxide. I was
monitor and document all aspects of this able to spontaneously push in
nurse driven protocol. response to a “strong urge,” one
that I had taught about but never
Program approvals, policy creation and felt before (due to the numbing
educational requirements were effects of epidurals I had used
accomplished in 12 months. Capital with my other deliveries). After my
expenditure for the equipment was approved, and Halgren daughter’s safe arrival, my ability to move was
uninhibited, which was a bonus.
conducted all educational sessions and competency validation for
the LDRP RN’s didactic content, hands-on demonstration and a While I recognize that this option does not work the same
written competency exam. for all patients or every delivery, I’m glad that it is available
as an option for women in labor at Billings Clinic. Birth is a
The option of nitrous as a self-administered pain management tool significant experience. If we, as health care providers, can
puts the control in the hands of the laboring woman. She help facilitate a positive experience for women and their
determines when to place it on her nose/mouth and how deeply families, that is significant as well. For me, it was
to inhale the 50/50 nitrous/O2 blend. As the photo depicts, she is unforgettable and empowering. Now, as a mother of four,
a reminder that I can do hard things is very helpful! I am
able to physically do something to impact the pain of her labor;
grateful my husband and I had the option to experience
self-administration of medication has repeatedly demonstrated
the birth of our daughter in this way.”
that lesser volumes are consumed when the patient manages – Jessica Halgren, BSN, RN, LCCE
the process.
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Nurses Driving Change
Through Evidence-Based Practice & Innovation
The SWAT Nurse’s Many Hats “When I was still on the floor, SWAT RNs were incredibly
Over the past few years, the Main Operating Room (MOR) and helpful! Whether it was starting an IV, passing meds or
Peri-anesthesia Care Unit (PACU) have experienced higher breaking a 1:1, they were always willing to help and
volumes of patients needing care after-hours. These higher saved us from drowning several times. I believe that role
volumes of occurrences necessitated a creative plan for has been incredibly beneficial.”
staffing to meet the regulatory standards of care in the PACU. – Lindsey Gustafson, BSN, RN, CMS-RN
American Society of Peri-anesthesia Nurses (ASPAN) standards “The SWAT role has done nothing but great things for
state, “Two registered nurses, one of whom is an RN night shift. They are so responsive to our needs. As a
competent in Phase I post-anesthesia nursing, are in the same charge RN, I am always requesting their assistance. They
room/unit where the patient is receiving Phase I level of care. have also helped me countless times when I am in
staffing. Whether it be with attaining IV access in
The same staffing requirements apply when patients are in the
difficult IV patients, passing medications when nurses
Peri-anesthesia Care Unit (PACU) after-hours as during regular
are swamped or helping with tasks that aren’t
business hours” (October 2017). The MOR nurses were utilized commonly performed on IPM, they are a good resource.
to fulfill the second nurse requirement but were logging shifts I think they have helped improve staff morale also. Just
of greater than 15 hours at times to meet this standard knowing they are available when we are drowning is a
for PACU. good feeling. At times, resources at night can be slim. I
have been a night shift nurse for almost 10 years. This
Clinical nurses collaborated with nursing leadership from the role is one of the best things Billings Clinic has done to
PACU and Nursing Resources on a solution for meeting a help the night shift staff. Thank you SWAT team!
variety of demands within the organization. Rising inpatient – Emily Mitchell, RN, IPM
staffing challenges as well as the after-hours flex in volumes
for PACU were taxing on Nursing Resources to provide enough
coverage to fill the needs. Billings Clinic approved additional
SWAT RN was
personnel support for Nursing Resources to provide the
affectionately named for
second nurse requirement to meet ASPAN Phase I recovery
the nurse’s ability to come
standards as well as quick and immediate support to the
into a situation and
inpatient nursing units during off-hours performing a variety
stabilize, whether in PACU
of tasks to meet the demands of changing patient needs and
or on the floors.
conditions. It was affectionately named the SWAT RN, for the
nurse’s ability to come into a situation and stabilize, whether in
PACU or on the floors.
The SWAT RN began coverage in August 2018, and staff input
has been instrumental in the successful adoption of this role.
In addition to the coverage for PACU, the SWAT RNs have
provided support to the inpatient units when admissions
have neared capacity for staff and have been a resource for
the insertion of IVs when the Vascular Access Team is
unavailable. They help alleviate stress for staff of units
where numerous admissions have come rapidly, as
an extra set of hands, to balance workload and
admission tasks, while also assisting patients with
the delivery of time sensitive care.
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Alameda Model in the Psychiatric Stabilization Unit
Makes a Positive Impact for Patients
In 2016, Billings Clinic began a lean six sigma process to address a number of issues being experienced by patients with
psychiatric chief complaints in our Emergency Department. Length of stay in the ED for this group of patients was approaching
nine hours. Our admission rate for this patient group was 57% or higher because our psychiatrists had two choices: admit or
discharge, and it was safer to admit. Our 30-day readmission rate was 19% and had been for years. We knew that patients were not
having a positive experience in the Emergency Department due to the nature of their illness. Finally, we knew we needed to find a
solution that focused on the patient experience.
A design was found that had evidence supporting better patient outcomes that was championed by Dr. Scott Zeller who said
“Patient boarding for long hours in emergency departments is a nationwide health care issue. Federal and state efforts to solve it have
revolved around increasing numbers of inpatient psychiatric beds. The Alameda Model focuses on immediate treatment at the
outpatient level of care, with a goal of avoiding hospitalization altogether. It bypasses medical emergency rooms completely in
two-thirds of cases, further reducing issues of regional ER overcrowding. These are national health care reform goals.” Based on finding
the ideal design for Billings Clinic, a multidisciplinary yellow belt team was formed which included nurses, social workers, mental
health workers, facilities staff, and was headed by a lean six sigma black belt. The team worked on unit design objectives based on
data from current state and consultations with Dr. Zeller and his team in California, and with the help of direct caregivers in the
department of psychiatry, a unit size and design were agreed upon. There were key design components agreed to by the team:
reduce admissions, decrease re-admissions, improve patient experience, improve wait time, meet demand of increased growth,
improve patient access, and reduce the number of psych patients in the ED and improve throughput.
All this information was included into the process of getting a unit designed that allowed psychiatry to become the primary place
that psychiatric emergency patients were seen and treated. The unit was completed and ready for occupancy in April of 2018, and
patients began flowing from the Emergency Department to the unit we called the Psychiatric Stabilization Unit (PSU).
Immediately, our lengths of stay in the Emergency Department began to decline. Patient experience began to improve, and
nearly all of the design goals began to be met. The unit is designed without individual rooms, which allows patients the
opportunity for social interaction with other patients and immediate access to staff. The unit has meals delivered three times a
day, and food is placed in easily accessible refrigerators that allow the patients access to food and drink when they want it and are
not reliant on the nursing staff to meet those basic needs. The unit is designed as an observation unit with an expected length of
stay under 24 hours to allow for
development of treatment plans and
connection with community services.
Our results have been extraordinary.
Since opening, we have seen nearly 5,000
patients and have had less than 10
instances of seclusion or restraint. We have
seen our admission rate on the psychiatric
inpatient unit drop by one-third and our
30-day readmission rate drop by one-third.
The average LOS for our patients in the ED
has dropped to 3.7 hours. Hours on capacity
has dropped to under 20% from a high of
89%. We are able to provide a patient
experience that provides social interaction,
daylight, time for treatment plan
development, and most importantly, the
right care at the right time.
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Nurses Driving Change
Through Evidence-Based Practice & Innovation
Billings Clinic’s Nurse Residency
Awarded Accreditation with Distinction
In April 2018, the Billings Clinic Nurse Residency Program was awarded Accreditation with
Distinction as a practice transition program, the highest recognition awarded by the American
Nurses Credentialing Center’s Accreditation Program. The Nurse Residency Program is a
year-long program and is designed to provide each new graduate nurse with the skills and
knowledge necessary to deliver competent, safe and effective patient-centered care. Quality
outcome measures achieved by residents in transition to practice programs and new graduate
nurse retention overwhelmingly demonstrate the benefit of having a nurse residency.
Accreditation with distinction recognizes that the Nurse Residency Program at Billings Clinic is
meeting national standards for nursing excellence and quality. The accreditation designation will help to recruit and retain
high-caliber nurses and further validates that the education and experiences provided by our Nurse Residency Program will
enhance the nurse as he/she advances on their professional path towards proficiency and expertise.
Nurse Residency Program Has Significant
Impact on Retention of Nurses
Since the Nurse Residency Program’s inaugural year in 2016, 205 new
graduate nurses have launched their professional nursing careers at
Billings Clinic. The Nurse Residency Program uses a robust, evidence-
based curriculum to provide each new graduate nurse with the tools
and skills they need to build competence and confidence to become an
integral member of the health care team. New graduate nurse retention
and turnover rates are measured by transition to practice programs
across the country and continue to support the need and benefit of
structured programs to help new nurses acquire the knowledge and
skills to deliver safe and quality care.
Since 2016, data trends in new graduate nurse retention rates at Billings
Clinic demonstrate an increase in retention rates that are exceeding the
national average. Results from a 10-year longitudinal study of new
graduate nurses called the RN Work Project found that 17.5% leave their
first nursing job within the first year (Kovner, Brewer, Fatehi & Jun, 2014).
First-year nurse retention at Billings Clinic for 2018 approximated 90%.
Improvement in new graduate nurse retention has helped the Billings
Clinic financial bottom line. Cost savings of over half a million dollars
over three years has been appreciated through lower nurse turnover
and replacement costs.
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Nurse Residency Champions of Evidence-Based Practice
Nurse residents are at the forefront of scholarly inquiry at Billings Clinic through
their participation in research and development of an evidence-based project
during their first year of residency. This experiential approach to generating and
sharing new knowledge has helped our nurse residents to solve clinical
problems and inform best practice changes at Billings Clinic which have
contributed to enhanced patient outcomes. Residents not only apply the skills
they learn during this process but grow in their professional role as lifelong
learners and patient advocates who champion scientific inquiry to integrate best
available evidence into practice at the bedside. Nurse residents practice ostomy care in the
At the conclusion of year one of the program, nurse residents present their EBP Simulation and Experiential Learning Lab
projects symposium-style to hospital leaders and educators at their graduation
ceremony. Members of the Nursing Research Council (NRC) and the
Collaborative Science & Innovation team at Billings Clinic collaborate with the
nurse residents to refine and advance their project ideas and help disseminate
their work.
Examples of nurse residency evidence-based projects that have resulted in
practice changes at Billings Clinic include implementation of an Optifoam Island
dressing with embedded antimicrobial silver ions to minimize dressing related
skin damage, reduce pain, and foster earlier patient mobilization in total joint
patients; and research on microbial biofilm which helped further define nursing
practice and policy to minimize catheter-associated UTIs. Cohort 7A graduated February 2019!
Nurse Resident Title of EBP Poster Nurse Resident Title of EBP Poster
Beth Besel NPO After Midnight: Is it Best Practice for Jasey Leavitt Compliance with Intermittent Pneumatic
Patient Safety? Compression Devices
Carlee Bunkers Implementation of a Polyurethane Intravenous Felicity Linger Clotting Management in Traumas
Catheter to Reduce Risks of Phlebitis Dayna Madtson Fall Risk Assessment in the Emergency
Heather Carrier Sharps Injuries in the Operating Room Department
David Cifaldi Perioperative Pain Management in Mikaela Mostad Bringing Home the Bacteria
Trauma Patients Julia Nelson Showering with Peritoneal Dialysis Catheters
Grace Collins Biofilm Formation on Foley Catheters Katie Nessan Nitrous Oxide in Kids
Becky Crabtree Day/Night Shifts: Recommendation to Ashley Parnell Diagnosing Influenza
Flip-Flop Between?
Saije Pollard Reaching Optimal Health Through
Deborah Cranford Screening Used for Mental Health Patients PEMF Therapy
Rachelle Darragh Can Immersive Virtual Reality Be Effective for Yvonne Ransom Central Line Associated Bloodstream
Pain Reduction? Infection
Sarah Dietz Hazardous Drugs: Protect Yourself Stormy Richards Turmeric Supplements for Post-Operative
Laura Duppong Effective Pain Assessments Increasing Safety Pain Control
and Satisfaction Marina Rokke Preventing Pressure Injuries Through a
Jenna Ferris Color-coded Food Trays for the Diabetic Patient Turning and Positioning System
Erinn Fjetland For the Love of God, Let Me Sleep! Taylor Rose Aromatherapy Use with Dementia
Joel H. Folkers Enclosure System Providing Fall Prevention & Jeremy Salazar Misuse of the Emergency Department
Patient Safety Shay Shelhammer Analgesia for Cesarean Section Patients
Kendra Fournier Aromatherapy in the Psychiatric Setting Cortney Smith Liquid Plasma in Trauma Situations
Amethyst Jade Ganson Cobalt Toxicity in Total Hip Arthroplasty Patients Jamie P. Stahl Quiet Time on a Neurosurgical Floor
Madeleine Hammond Diabetic Nurse Educator: Treat the Root of Karen A. Stucky Pain Assessment Tools: NRS vs CAPA
the Problem
Kathryn Taillie Certified Nurse Midwives (CNMs) in the
Asha Heggen Vital Sign Monitoring on the Night Shift Family Birth Center
Lauren Hendrix Crisis Stabilization Units for Psych Emergencies Lacie Thomas Patient Education and Emmi
Adam Hertig Correcting End-of/Start-of-Shift Transfer Ryan Tierney B/P Monitoring After Lymph Node Removal
Complications
Courtney Unruh Missed Orders in the Emergency Department
Lauren Jones Improving Patient Outcomes Through Bedside
Neurological Checks Paige Wagner Combating Nurse Burnout with Volunteers
Kelsey Jovick Caring For Patients Undergoing Alcohol Jodi Waller Nurse Staffing Matrices: Do I Have Too Many
Withdrawal Patients to Provide Safe Care?
Heather Kelly Periarticular Joint Infiltration Brittany Wetstein Implementation of Pediatric Home Oxygen
Danelle Wooley Pain Management in the Emergency Setting
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Nurses Driving Change
Through Evidence-Based Practice & Innovation
Nurses as Authors
Author(s) Type of Title Publication/Meeting Date of
Publication/ Publication Presentation
Jeannine Brant, PhD; Poster Shared Decision-making Preferences and Pain American Society of Clinical November 16, 2018
Debbie Wujcik; Presentation Characterization in Patients with Cancer Oncology (ASCO) 2018 Palliative and
Carrie Stricker; Supportive Care in Oncology
William Dudley Symposium; San Diego CA
Diane Thomas Hurd, Poster The Need for Speed – Triple Chronotherapy, 2018 Neuroscience Education November 9, 2018
PMHNP-BC Presentation A Rapid Adjunctive Intervention in the Acute Institute (NEI) Congress
Treatment of Depression and Suicidality in the
Adolescent Population
Diane Hurd, PMHNP; Journal Prospective, Open Trial of Adjunctive Triple Journal of Child and Adolescent November 2, 2018;
Mariela Herrera, MD; Chronotherapy for the Acute Treatment of Psychopharmacology Published Online: 2
Jeannine Brant, PhD; Depression in Adolescent Inpatients Nov 2018 https://
Nicholas Coombs, doi.org/10.1089/
MS; Eric Arzubi, MD cap.2018.0063
Jeannine M. Podium From Abstract to Poster: Presenting Your Work Journal of the Advanced Practitioner November 1, 2018
Brant, PhD Presentation with Clarity and Impact in Oncology (JADPRO) Live 2018
Conference; Hollywood, Florida
Ya-Huei Li, PhD; Journal The Stepped-Wedge Trial Design: Paving the Journal of the Advanced Practitioner Volume 9; No. 7,
Elizabeth Mullette, Way for Cancer Care Delivery Research in Oncology November/
RN, MSN; Jeannine M. December 2018,
Brant, PhD, APRN, Pages 722-727
AOCN, FAAN
Susan S. Tavernie, Journal Context Matters for Nurses Leading Pain Pain Management Nursing Volume 19, Issue 5,
PhD; Jia-Wen Guo, Improvement in U.S. Hospitals October 2018, Pages
PhD; Jacqueline 474-486
Eaton, PhD; Jeannine
M. Brant, PhD; Patricia
Berry, PhD; Susan L.
Beck, PhD
Diane Thomas Hurd, Podium The Need for Speed – Triple Chronotherapy, American Psychiatric Nurses October 24-27, 2018
PMHNP-BC Presentation A Rapid Adjunctive Intervention in the Acute Association 32nd Annual
Treatment of Depression and Suicidality in the Conference; Columbus, Ohio
Adolescent Population
Jeannine M. Poster Barriers and Solutions to Conducting Patient 2018 American Society of Clinical September 28-29,
Brant, PhD Presentation Reported Outcomes (PRO) Research in Patients Oncology (ASCO) Quality Care 2018
with Pain Symposium; Phoenix, AZ
Brant, J. M.; Stringer, Journal Predictors of Oversedation in American Journal of Health September 15, 2018;
L.; Peterson, L.; Hospitalized Patients System Pharmacists 75(18):1378-1385
Herbert, S.;
Coombs, N.
Jeannine M. Podium Integration of Patient-Reported Outcomes: Rochester, NY NCORP August 2018
Brant, PhD Presentation Research and Practice
Brant, J. M.; Book Chapter Cancer Pain Cancer Nursing: Principles July 10, 2018
Stringer, L. H. and Practice
Ya-Huei Li, PhD; Poster A Predictive Model to Identify International Society for May 23, 2018
Jeannine Brant, PhD Presentation Opioid-induced Respiratory Depression Pharmacoeconomics and Outcomes
among Hospitalized Patients Research 23rd Annual International
Meeting, Baltimore MD
Sarah Tracy, BSN, RN, Poster The Grab-and-Go Resiliency Kit ONS 43rd Annual Congress, May 20, 2018
OCN; Leah Presentation Washington, DC
Scaramuzzo, MSN,
RN-BC, AOCN;
Jeannine M. Brant,
PhD, APRN, AOCN,
FAAN
Continued on page 10
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Nurses as Authors
Author(s) Type of Title Publication/Meeting Date of
Publication/ Publication Presentation
Leah A. Scaramuzzo, Poster Zero CLABSI: It Takes a Village to Make It ONS 43rd Annual Congress, May 20, 2018
MSN, RN-BC, AOCN; Presentation Happen Washington, DC
Amy Walton, BSN, RN,
OCN; Jeannine M.
Brant, PhD, APRN,
AOCN, FAAN
Shannon Crable RN, Poster Stem Cell Infusion Guidelines and Practices ONS 43rd Annual Congress, May 19, 2018
OCN; Leah A. Presentation Washington, DC
Scaramuzzo, MSN,
RN-BC, AOCN;
Jeannine M. Brant,
PhD, APRN, AOCN,
FAAN
Tauna Jeffery, RN; Poster Cancer Care Delivery Research: The Importance ONS 43rd Annual Congress, May 18, 2018
Jeannine Brant, PhD Presentation of Oncology Nursing Engagement Washington, DC
Brianna D. Biggins, Poster Oncology Nurse Informaticist: Driving ONS 43rd Annual Congress, May 18, 2018
BSN, RN, OCN; Leah Presentation Evidence-Based Practice Through Washington, DC
A. Scaramuzzo, MSN, Documentation
RN-BC, AOCN;
Jeannine M. Brant,
PhD, APRN, AOCN,
FAAN
Jeannine Brant, PhD Podium Opioids: They’re Not Always the Answer ONS 43rd Annual Congress, May 18, 2018
Presentation Washington, DC
Betty Mullette, MSN; Podium The Alzheimer’s/Dementia State Plan… Montana Gerontology Society April 27, 2018
Jan Smith Presentation Not Just a Book on a Shelf! 36th Annual Conference –
Pathways: Aging in the 21st Century,
Bozeman, MT
Ciemins, E. L.; Coon, Journal An Intent-to-Treat Analysis of a British Medical Journal, Open April 21, 2018
P. J.; Coombs, N. C.; Simultaneous Multi-Site Telehealth Diabetes Research & Care
Holloway, B.; Mullette, Diabetes Prevention Program
E. J.; Dudley, W. N.
Ciemins, E. L.; Arora, Journal Improving Blood Pressure Control Using Telemedicine and e-Health March 1, 2018
A.; Coombs, N.C.; Smart Technology
Holloway, B.; Mullette,
E. J.; Garland, R.;
Walsh Bishop-Green,
S.; Penso, J.; Coon, P. J.
Cheryl Miller, RN, Podium Making the Impossible Possible International Meeting on Simulation January 13-17, 2018
BC, MSN Presentation in Healthcare (IMSH 2018) Los
Angeles, CA
Pam Zinnecker, Poster PTSD Journal Project Society of Critical Care Medicine. December 2017
MSNEd, BAN, RN, Presentation Critical Care Quality Summit
CCRN-K
Tafelmeyer, J.; Wicks, Journal Incorporating Nurse Input and Evidence Tafelmeyer, J., Wicks, R., Brant, J., & December 1, 2017
R.; Brant, J.; Smith, L. into a Newly Designed Unit to Improve Smith, L. (2017). Incorporating Nurse
Patient and Nursing Outcomes Input and Evidence into a Newly
Designed Unit to Improve Patient
and Nursing Outcomes. J Nurs Adm,
47(12), 603-609. doi:10.1097/
NNA.0000000000000554
Brant, J. M.; Journal Precision Medicine: Accelerating the Clin J Oncol Nurs December 1, 2017
Mayer, D. K. Science to Revolutionize Cancer Care
10> Back to Contents
Nurses Driving Change
Through Evidence-Based Practice & Innovation
Author(s) Type of Title Publication/Meeting Date of
Publication/ Publication Presentation
Jeannine M. Podium The Growing Landscape of Palliative Care SWOG, Chicago, IL November 1, 2017
Brant, PhD Presentation
Cheryl Miller, RN, Podium A Relational Coordination Theory Informed 3rd International Systems and October 27-28, 2017
BC, MSN Presentation Nurse Residency Program Complexity in Health Conference at
George Washington Conference,
Auburn, VA Campus
Brant, J. M.; Mohr, C.; Journal Nurses’ Knowledge and Attitudes about Pain: Pain Management Nursing August 1, 2017
Coombs, N. C.; Finn, Personal and Professional Characteristics and
S.; Wilmarth, E. Patient Reported Pain Satisfaction
Brant, J. M., Newton, Journal Pain Management in the Middle East: Oncol Nurs Forum July 1, 2017
S., Maurer, M. A. Building Capacity with Global Partners
Rodriguez, N. M.; Book Chapter Thinking Differently in Global Health in ASCO Educational Book July 2017
Brant, J. M.; Oncology Using a Diagonal Approach:
Pendharkar, D.; Harnessing Similarities, Improving Education,
Arreola-Ornelas, H.; and Empowering an Alternative
Bhadelia, A.; de Lima Oncology Workforce
Lopes, G., Jr.; Knaul,
F. M.
Core Curriculum Authors
11> Back to Contents
Depression Outcomes from a Fully Integrated Obstetric
Mental Health Clinic: A 10-Year Examination
In 2007, an Advanced Practice Registered Nurse (APRN) at Billings Clinic, Diane Goedde, MSN, APRN, RNC, collaborated with Diane
Arkave, MSW, LCSW, and Astri Zidack, EdD, LCPC, to develop an integrated Obstetric Mental Health Clinic (OBMHC) to manage
psychiatric disorders in the perinatal population. This year (2019) marks the clinic’s 12th consecutive year of service. Ms. Goedde
attended a national mental health meeting where she
discussed her model during a networking session. The purpose of this study was to examine depression
Others encouraged her to examine outcomes and outcomes in women receiving psychiatric services from
disseminate findings of the model so that others could a psychiatric nurse practitioner between 2007 and 2017
benefit from the work done. The team approached the at a fully integrated OBMHC and to explore patient and
Nurse Scientist Jeannine M. Brant, PhD, APRN, AOCN, health care team perceptions of OBMHC experiences.
FAAN, and together, the team conducted a retrospective
database study. Co-investigators included two additional co-investigators from the Collaborative Science and Innovation
Department (CSI) who joined the team: Betty Mullette, RN, MSN, Research Nurse and Ya Huei Li, PhD, Statistician.
The purpose of this study was to examine depression outcomes in women receiving psychiatric services from a psychiatric nurse
practitioner between 2007 and 2017 at a fully integrated OBMHC and to explore patient and health care team perceptions of
OBMHC experiences.
The study received full board approval by the IRB of Billings on March 20, 2017.
Summary of Findings
The sample included 192 women (195 pregnancies). Approximately 72% experienced less depression by the first follow-up visit.
Patients taking three or more psychiatric medications attended more OBMHC visits. Trend analysis indicated women with the
highest levels of depression had the best response to the intervention. Qualitative patient interviews reveled high satisfaction
with the clinic; three qualitative themes emerged: Safe Place, Mental/Emotional Stability, and Integrated Personalized Approach.
All obstetric team members (n = 11) perceived the clinic to be helpful and noted improved access to mental health care.
Clinical Nurse Dissemination to External Audience
Following study conclusion, Diane Goedde, MSN, APRN, RNC, Diane Arkave, MSW, LCSW, and Astri Zidack, EdD, LCPC, along with
the research team scheduled writing sessions to prepare a manuscript for publication. The team discussed potential journals for
dissemination, and Ms. Goedde chose the Journal of the American Psychiatric Nurses Association (JAPNA), recognizing that this
journal’s audience would benefit most from the study findings. Sections of the manuscript were divided among team members
who worked collaboratively to complete the manuscript. It was submitted in March 2019. The team received a decision letter on
May 15, 2019 which encouraged the team to revise the manuscript. The team again met to discuss revisions and made revisions
together as a team during writing sessions. The team resubmitted the manuscript and received a request from the JAPNA editorial
team to make additional revisions. The team again met and made requested revisions and resubmitted the manuscript on
September 9, 2019.
The clinical nurse investigators noted three significant contributions of their work:
• The study adds to the body of literature on OB Mental Health Clinics (OBMHC) and treatment of perinatal psychiatric
disorders (PNPD) in pregnancy
• Clinical nurses at Billings Clinic had the opportunity to participate in research and then disseminate findings in a
peer-reviewed journal
• The research study illustrates a successful model that can be replicated to manage perinatal depression and benefit the
obstetric team
12> Back to Contents
Nurses Driving Change
Through Evidence-Based Practice & Innovation
Wound Ostomy Nurse Navigator
Janice McFarland, RN, manager of General Surgery, along with a physician cohort, recognized the need for enhanced care,
treatment, education and “normalization” of the processes involved for patients undergoing new surgical ostomy placement. They
began by looking at volumes of new colostomy patients, wound and ostomy nurse turnover rates and availability or lack of
appropriate resources. The team felt there was inadequate patient teaching, inconsistent care and no after-treatment support.
Anecdotal information also pointed to the fact that several post-colectomy patients presented to the Emergency Department (ED)
due to lack of appropriate resources, access to supplies and/or training.
The team discovered that they were doing approximately 270 colon cases per year, which was a volume that they felt more than
validated the need to provide additional care for these patients. The goal was to provide exceptional care for these patients across
the continuum.
Ms. McFarland presented a proposal to hire
a combined Ostomy and Enhanced
Recovery After Surgery (ERAS) nurse to fill
this gap. Although the initial pro forma did
not look like this position would pay for
itself, our Chief Nursing Officer (CNO) felt
the enhanced care more than justified the
financial outlay and advocated to get the
position approved. We then began a
vigorous nation-wide recruitment effort
and interviewed several well-qualified
nurses. We hired Michael Sealy BSN, RN, to
fulfill the valuable role designed for
enhancing patient care and outcomes.
His initial job expectations were to provide
counseling prior to ostomy placement
regarding the life-changes that would affect
the patient, provide education regarding
ostomy products, how to obtain them and
how to troubleshoot issues. His goal was to
be a consistent resource and offer Michael Sealy, BSN, RN, providing education on ostomy device selection with patient
continuity of care for these patients
beginning in the outpatient phase, meeting with them as inpatients and being involved in post-op visits. As Mr. Sealy has
continued to develop the role, he has been able to optimize the total care for the ostomy patient by being present at the surgeon
visit when the initial discussion occurs, be present at the bedside in the pre-operative arena prior to surgery and marks the
surgical site with the surgeon and the patient for optimal ostomy placement, provides support for the patient, family and staff in
their post-operative inpatient encounter to reinforce the initial teaching and proper ostomy care, ensures the patients have the
correct supplies for discharge and provides resources to them for how to get supplies once they are home. He has provided his
office and personal cell phone number to patients so he can provide answers to questions as they arise. In addition, Mr. Sealy has
become a resource to the emergency department when ostomy patients present due to issues related to their device.
Through the interprofessional collaborative approach to the ostomy patients’ care and coordination, Ms. McFarland provided Mr.
Sealy with the opportunity to enhance the lives of patients across the spectrum of health care services.
13> Back to Contents
Watchful Eye for Safety with AvaSys Patient Surveillance
Patient safety is at the forefront of every decision at Billings Clinic. The patient fall reduction program has been taxed with
increasing needs for resources that do not overburden the staff. An intense review of processes and equipment left few options
for providing continuous 1:1 support for patients to prevent falls. An interdisciplinary falls prevention team, known as RUF
(Reducing Unit Falls), comprised of both direct and indirect caregivers, including RNs, CNAs, Physical and Occupational Therapist,
and nursing leadership reviews inpatient falls monthly and determined a need for an “out of the box” approach to patient safety.
After extensive research into continuous video monitoring options, the AvaSure Patient
Surveillance platform (AvaSys) was purchased and implemented in all inpatient nursing units in
March 2018. As part of the implementation plan and to ensure broad education and real time
support to clinical areas where AvaSys would be used, a multidisciplinary team of Clinical
Champions were identified. The Clinical Champions were all provided hands-on training with the
equipment, monitoring guidelines, device set up and troubleshooting, and communication
expectations of staff to the video monitor clerks.
Taylor Muessig, telesitter
AvaSys telesitters provide 24/7/365 continuous
visual and audio monitoring for patients
identified as appropriate for this technology
solution. Patients are monitored with a mobile
non-recording camera that provides immediate
supervision and surveillance for optimal patient
safety. The implementation has improved the
caregiver experience by improving workflow and
empowering care teams, as well as reducing 1:1
sitter cost utilized for patients at risk for falling
while under our care.
AvaSys telesitters provide patient and family-
centered care that is seamless, safe, and provides
Portable AvaSys System comfort. For the organization, Billings Clinic has
aides in falls reduction
enhanced how care is provided to help patients
achieve better outcomes. Falls have declined by
52.6% on IPM alone.
14> Back to Contents
Nurses Driving Change
Through Evidence-Based Practice & Innovation
Nursing Strategic Map, 2018-2021
15> Back to Contents
Peppermint Essential Oil to Control Nausea
in Hospitalized Patients
Four clinical nurses from the cardiovascular unit – Cassandra Jensen, RN, BSN, Amanda Jones, RN, BSN, Carla Mohr, RN, BSN, and
Nicole Mohr, RN, BSN – recognized that nausea and vomiting was not always controlled by standard drug therapy. Carla Mohr
stated, “Patients would still have nausea after I gave them something, and we wouldn’t have any other option!” The team had
heard a lot about aromatherapy and its potential impact on nausea and desired to incorporate peppermint aromatherapy into the
antiemetic regimen for hospitalized patients. A literature review revealed that few studies have carefully examined this issue. Most
studies were small, and the Nursing Research Council (NRC) at Billings Clinic felt that more research needed to be done in this
area. Therefore, the NRC encouraged the team to design a research study that would allow patients to use peppermint
aromatherapy as an option to help control nausea. The clinical nurses also engaged three additional co-investigators from the
Collaborative Science and Innovation Department: Betty Mullette, RN, MSN, research nurse, Ya Huei Li, PhD, statistician, and
Jeannine M. Brant, PhD, APRN, AOCN, FAAN, nurse scientist.
Patients who were receiving care in the cardiovascular or medical surgical
areas of the hospital were invited to participate in the study if they
experienced nausea during hospitalization. When nausea set in, patients could
choose either peppermint essential oil aromatherapy only or an antiemetic
medication with aromatherapy. Clinical nurses then asked the patient about
their level of nausea right at the start of the nausea episode and 30 minutes
after receiving the aromatherapy or combination of antiemetic and
aromatherapy. Patients who used only the aromatherapy had a 3.5-drop in
their nausea score, and interestingly, those who used both the antiemetic and
aromatherapy had a 1.8-point drop. Only 37% of patients had used
aromatherapy prior to the study, indicating patients were open to trying this
option; 60% of patients used aromatherapy only for their nausea episode,
meaning that they did not require a drug
to treat their nausea.
The clinical nurse investigators noted
three significant contributions
of their work:
• The study adds to the
body of literature on
aromatherapy use in
hospitalized patients
• Clinical nurses at Billings Clinic
had opportunity to participate in
research
• The research study led to a change in
nursing practice, and patients now have
the option to try and manage their nausea
with essential peppermint oil aromatherapy
16> Back to Contents
Nurses Driving Change
Through Evidence-Based Practice & Innovation
BSN Certification RatesNurses
Driving
Change
Through
Evidence-Based
Practice &
Innovation
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