Nursing Bundle

After working for a straight twelve hours on graveyard shift last Monday I still have to stay for another two hours after my shift when it finished at 7 am for a mandatory facility's educational update on the Nursing Bundle.

A Nursing Bundle is a body of science which is based on best practice. It is a structured way to improve processes of care. It is also proven to improve patient outcomes. It is a small, clear-cut, set of practices which requires a complete consistency. And there are elements necessary to accomplish it.

It is a way of improving our patient's satisfaction by improving interaction to patients. It involves four components which are an hourly rounding, bedside shift report, individualized patient care, and discharge planning.

Hourly rounding is the practice whereby nurses and other support staff check their patients on a one to two hour basis and to meet patient needs and perform particular behaviors. It involves checking the three P's which are pain, potty, and positioning. It is a mechanism to standardize the patient expectations.

Some also use PPD which stands for pain, plan of care (what's going to happen next), and duration (of laboratory results, diagnostics like x-rays, consults, etc.).

Some address the SKIP needs which stands for (a) supply needs like diaper, pads, water, (b) komfort [k is being used instead og c for better memorization] needs like blanket, cot for significant others, pain control etc. (c) information needs like feeding the baby, car seat, lab results, and (d) personal needs like toileting and shower.

It is geared towards better clinical outcomes, improve patient safety, attaining higher patient satisfaction by decreasing anxiety (by letting the patients know that the nurses are spending time with them and checking their conditions and needs), and increasing trust and give a sense of comfort to the patient. It also aims a higher employee satisfaction by providing staff with control and management of their time and reduced use of call lights by the patients.

The hourly rounding is being done at the same time when the nurses are going into the room for another purpose. As the nurses bundle their care the patients will also bundle their requests. When making rounds the nurse must scan the room while talking with the patient and making sure that the following things are within reach like the bedside table, call light, phone, full water pitcher, and garbage container. The nurse must also ensure that the bed rails are up as appropriately as possible and must tidy up the room every time the rounds are being made.

When doing this the nurse gives the patient and family visual evidence that they have been checked on. Also it dispels any patient's anxiety. And accessible information of the patient's condition are available to the nurse and the family.

After doing the hourly rounding the nurse must ensure that the patient has no additional unmet needs and lets the patient and family know when the nurse will be back thereby reducing the patient's and family's anxiety. So it is always inportant to encourage patient to also "bundle" their request.

The second element of the Nursing Bundle is Individualizing Patient Care through the use of a small board inside the patient's room. The board differentiate between the "daily routines" and personal preferences" of the patient. The nurse should not use no abbreviations to identify patient's needs and it should write down entries in a language that the patient understands.

The individualized patient care should be reflected on the care board which includes daily routines, patient's personal preferences, pain management and a visual reminder of the hourly rounds. It also reviews the plan of care for the shift with the patient. It lets patient know specifically what is going to happen for that shift. The plan of care must be written on the Care Board. It should be specific, functional, educational, and progressive.

The Care Board identifies from the patient's perspective (not the nurse) what is important to them, their likes and dislikes. It also identifies how to reduce the patient's anxiety and demonstrates sensitivity to their needs. It also identifies how to make them have an excellent patient experience and must be done upon admission and through out the patient's stay.

The Plan of Care will alert all staff of the patient's pain tolerance, keeps patient and family informed and involved in the care, promotes collaboration of care, provides patient and family education, improves patient hospital experience, gives patient and family a visual evidence that someone  has checked for them every one to two hours, and accessible information that the patient's condition being made sure are the same as the other.

The third component of the Nursing Bundle is the Bedside Shift Report. This third element improves the accuracy of patient's identification as stated in the Annual Joint Commission's National Patient Safety Goals. It also improves the effectiveness of communication among caregivers and accurately and completely reconcile medications across the continuum of care. It will also reduce the risk of patient harm resulting from falls and prevent health related or care-associated pressure ulcers.

Bedside Reporting promotes patient empowerment, involvement, and uses patient as an additional resource for information. It will also identify the patient's perception of safe and professional hands-off and promotes better rapport with the staff and will lessen the occurence of anxiety. It also better a working relationships with nurses on other shifts, better relationships with patients and families, and promotes more time at the bedside thereby reducing overtime.

The Bedside Report uses the format of SBART. S for Situation which includes complaint, diagnosis, treatment plans, patient's wants and needs. B for Background which includes vital signs, mental and code status, list of meds and labs. A for Assessment which includes current caregiver's assessment of the situation. R for Recommendations which identifies pending results and what needs to be done for the next shift. And lastly T for Thanks which tells the patient that you appreciate them for allowing you to care for them.

During this process the nurse must observe the following techniques. The nurse should not use third person, she should not talk as if the patient is not there, must use a patient friendly language, must use language line (like the Cyrafone) or interpreters and whenever possible must communicate at eye level.

The last element of the Nursing Bundle is the use of Discharge Phone Calls. According to research; "Many patients do not understand the care they receive in the emergency department, nor they understand the discharge instructions." This is very scary and only suggests that most of hospital admissions happen because of such misunderstanding and lack of education.

So this fourth element of the Nursing Bundle will fill well by rewarding and recognizing the staff, providing staff with closure, and provides nurses with a direct and positive patient feedback. It also opens an opportunity to identify areas for improvement and encourage the patient to fill out the survey.

Attending this conference review had made me learn to follow and apply these four elements in all my interactions with my patients and their significant others. These four elements that comprise the Nursing Bundle is always geared towards a better nursing and patient care excellence.

During this post review conference it also updated and taught us to promote a more patient and family centered care rather than a patient or family focused care to make everybody get involved in a collaborative approach to the care and decision-making for the care of the patient.

As I wrote down all what I've learned from this post review let me leave you this inspirational passage to all nurses who are always hands-on with delivering the patient care:

In a hospital life and death are on the edge of  happening every day and pain is ever present.
In your hospital how many people will die today and how many  will be born?
Today is the last day on earth for some of your patients, and they are spending that last day with you.
And today is the first day on earth for some people, and they are spending that day with you as well.
"What could be more sacred than to be with people on their first day of life, or their last day on earth? What could be more meaningful than to be present with them when they may be in their greatest pain or highest joy?" So, always make a good impression.

This is how nursing is all about and is intended to be and this is what I've been doing everyday ever since I graduated from nursing school. In short this is my calling and I love what I am called to do. There is always joy in serving for the people who needs my care and it always fatten my heart everytime I could be of help.

Every picture of service is always worth a thousand words. What I am doing comes deep from my heart and it is of pure intention. I love what I do and I will always do what I love. I am always inspired about it and I will continue to do it to the last of my breath. Thank you and good luck in your service for the patient.