Nurse's Perspective on Shadowing

Meet Jessica Carlson a former nurse and current Improvement Specialist at the UPMC Innovation Center (IC). Using the Patient Centered Value System (PCVS), shadowing and team building, the IC partners with patients, families, caregivers, and hospital administrators to bridge the gap between current practices and ideal experiences. 

See how Jess has made the change from full-time patient-facing care to patient centered improvement and learn about the projects she and the IC team have tackled that have resulted in real, impactful change.

What is your healthcare background? 

I worked as a staff nurse for 9 years on an Orthopedic/Trauma/Burn step-down unit. I also spent 4 semesters as an adjunct faculty member for the Community College of Allegheny County, leading nursing students through clinical rotations and skills labs. In both my full-time hospital position and my time teaching nursing students, I had many opportunities to care for patients on various hospital units including Neuro/Trauma, Surgical Oncology, General Med/Surg, Cardio/Thoracic step-down, and General, Brain Injury and Spinal Cord Rehabs.

Currently, I work as an Improvement Specialist for the UPMC Innovation Center where we develop tools and technologies that improve patient and family experiences and outcomes. 

How did you get into shadowing and improvement work?

During my bedside nursing years, I decided to go to graduate school because the timing was right and I wanted to take advantage of the opportunities I had (flexible schedule and tuition assistance). I really had no intention of leaving bedside nursing. However, throughout grad school, I started learning about quality improvement, and I realized that so much change begins with frontline caregivers. By the end of my program, I knew I had a skill set that would let me serve patients at a much higher level than I could with direct care.

I found my current position and felt it was the perfect opportunity to serve the interests of patients and families and also maintain my identity and ties to nursing. My work with the UPMC Innovation Center always starts with shadowing patients, families, and employees. I love being embedded in real care experiences. I love talking to patients and families and letting them know we are interested in their perspective. And I love building rapport with the caregivers on the frontlines because I was there once, too, and I know first-hand that they feel overlooked and undervalued. It can be challenging to empower people who, historically, feel that they aren’t listened to. But when their voice results in an improvement, it’s inspiring.

With regard to shadowing itself, did you find it difficult to get started?

I had no trouble jumping right into shadowing. My background in bedside nursing means that I am very comfortable interacting with patients, families and medical professionals. However, I tell everyone you don’t need medical experience to be comfortable with, or successful at, shadowing. All you need is a professional demeanor and an open mind. I’ve had the opportunity to shadow many care areas in which I’ve never worked (OR, for instance). Those experiences can be challenging as they’re fast-paced and I’m working hard to decipher much of what is going on, but I find that I’m a better observer when I start shadowing without any preconceived notions of what should be happening. 

What about shadowing and improvement science or co-design interested you as a nurse?

What I didn’t know in my early years of nursing is that all nurses engage in improvement science every day. Nurses are problem-solvers who try, and try, and try again. When a dressing falls off your patient’s foot every time he stands up to walk, you invent, and re-invent, and re-invent that dressing until it stays in place and protects that wound. The real work of nursing IS improvement science, we just haven’t been trained to call it that.

Shadowing interested me because nurses are always looking for evidence. We always want to know that what we’re working on is supported by truth and need. Shadowing gives us that evidence, especially when we’re trying to improve something that we’ve only heard anecdotally. When every nurse on the unit tells you, “We waste so much time looking for remote monitors. We never have enough,” you can shadow a few times and get the qualitative and quantitative evidence you need to change that process. You’ll shadow and see several different nurses searching for supplies, you’ll time how long it takes them to locate those supplies, and you’ll observe the patients’ reactions when that nurse is gone from their room for extended periods of time. Shadowing is an easy way to quickly collect the evidence you need to support improvement projects. 

Do you think it's possible for nurses on the ground to use shadowing to improve their jobs/ their patients' experience?

Yes, absolutely. When a patient has a concern, or when you feel like you’re always running into the same barrier, you shadow to see what’s happening before that point. When patients are always arriving on the unit in pain, you can shadow the area they’re coming from to see what’s going on. When a patient falls are on the rise, you can shadow your area to see what processes are in place (or are missing) to prevent them.

Nurses are happier in their work when they have ownership in what is happening. Shadowing a care area gives you the true picture of the current state. When you have that current state, that evidence of what is truly happening, you can take ownership and work toward improvement. Your patients, your fellow employees, and your administration appreciate your dedication to quality care and you feel a connection to the service that you are providing.

Can you describe a project that you worked on that had the most impact on you personally?

I worked on a unit-based project that addressed the Venous Thromboembolism (VTE) rate. This particular unit accounted for more than a third of the total VTEs in the entire hospital. Shadowing showed that several processes were in place to prevent VTEs (medication and mechanical prophylaxis), but most of the processes were used inconsistently. We worked with pharmacy and the nursing staff to identify areas for improvement with heparin administration and the use of sequential compression devices (SCD). Pharmacy started routinely scheduling prophylactic heparin at times more satisfactory for patients (6 am versus 2 am – no one likes to be woken up for a shot at 2 am!). This increased patient compliance and reduced the number of doses refused by patients. The nurses and Patient Care Technicians started a process of checking SCDs twice a day and recording the number of hours a patient wore his SCDs every day. They also worked on an education plan for PT and OT so that after therapy sessions, SCDs were reapplied while the patient was at rest.

In the first year after implementation of the pharmacy changes and daily audits of SCD compliance, the VTE rate dropped significantly (to almost zero)! This project had a lot of impact on me because it showed the power of simple, incremental changes. We started with a problem. We examined the current state and found that solutions were there, but weren’t being fully utilized. Then we pulled together to work on several, small areas for improvement. Each change went through a few iterations before we found what worked best for patients, nurses, and pharmacy. But the end result was a sharp decrease in a serious but preventable complication for patients. It was a powerful example of how any nurse can own and improve experiences and outcomes.

------

To learn more about how to integrate shadowing into your nursing program or for information on staff training, visit https://discoverdrd.com/innovation-center or email info@goshadow.org.