Transitioning Registered Nurses
Utilizing the
Resource Nurse/Partners in Practice Model
FOR Med/Surg
Contingency Planning for Surge Capacity during
a Disaster Event
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Updated: 6/25/2020
Resilience
At HCA Healthcare, we’re no strangers to threats. We deal with them daily.
Infectious diseases, natural disasters, unspeakable emergencies.
Some say that managing life-threatening situations is part of business as usual for an advanced
healthcare network like HCA Healthcare. And it’s true.
That’s exactly what helped build a sharp set of best practices and a robust network of response
teams, which helped us, HCA Healthcare, mobilize quickly and scale accordingly in times of
need.
As this latest threat evolves, HCA Healthcare is collaborating with federal and local health
agencies, providing timely and practical updates that will help contribute to accurate reporting
and consistent guidelines. While our immediate priority remains the well-being of our patients
and people, we know that sharing insights can impact care far beyond the communities we
serve.
In the face of a threat, we don’t panic, we prepare.
Introduction
Our everyday lives and the way HCA Healthcare provides care is drastically changing due to the
spread of COVID-19. We are faced with an unprecedented health crisis. The worldwide scale is
daunting, and the challenge to our infrastructure, standard processes of care, and even
standards of care demands novel approaches. It is during these times that our colleagues have
shown their resilience and lead us through these difficult periods.
Our goal is to support our nursing colleagues as we prepare for potential patient surges,
predominately in our Critical Care Services. To support these critical areas, we will need to
reassign registered nurses to various nursing departments throughout the market to serve in a
partners-in-practice model.
To prepare for this surge in patients, HCA Healthcare Center for Clinical Advancement teams
have come together to provide information and education for you to serve in a primary nurse
role and support various nursing units that are facing challenges related to resource gaps in
patient care.
This booklet is not all inclusive, but does provide additional information to help you build on
your current nursing knowledge and skills.
Let’s begin our journey.
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Knowledge and Skills
We recognize that each Registered Nurse (RN) brings knowledge, experience and skills to the
clinical unit that you are assigned and you may already be very comfortable with some of the
knowledge and skills listed below. Review the list below and initial those skills that you can
perform independently.
Medical-Surgical/Progressive Care Knowledge and Skills
Skills Initials Skills Initials
Vital Signs/Vital Signs Monitoring
Equipment
Central Line Management/Dressing
Change
Telemetry Lead Placement Line Draw Blood Sampling
Assessment (General/Focused/
I&O)*
ADLs/CHG Bathing
Documentation
(Meditech/Downtime)
Fall Prevention & Gait Belt Use
Medication Administration
(General) *
Nasogastric Tube Maintenance
Medication Administration (High-
Risk) *
IV Pump Utilization
Oxygen Therapy PPE Utilization
Respiratory Therapies (Nebs, MDI,
IS, MDU, EZPAP, CPAP/BiPAP)
Suction Set-Up
Pain Assessment/Management Restraints *
PCA Management * Indwelling Urinary Catheter
Maintenance
Diabetes
Management/Glucometer
CIWA/COWS Management
PIV Insertion
*To be performed the first time with Preceptor or Charge RNs oversight.
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Preparatory Learning
First, we want to introduce you a variety of e-learning modules in HealthStream to help you
better understand some of the terminology, equipment, and various medical and nursing
interventions you may encounter. In order to access the majority of the content for your
preparatory learning, you will need to login to HealthStream. To login to HealthStream from
home: www.stdavids-institute.com or healthstream.com/hca Use your 3-4 ID and
Network password. If you have never logged in to HealthStream, please follow the directions on
the login page.
You must obtain authorization from your manager prior to doing HealthStream work at home.
You should be provided time during your workday to work on some HealthStream activities.
HealthStream Modules
o Head-To-Toe Assessment-EBSCO o Med Surg Quick Reference Tools-SDH o Basic Respiratory Care Nursing Skills-EBSCO o Incentive Spirometry Education at the Bedside-EBSCO o Urinary Catheter Care-EBSCO o Restraints Overview o Limb Restraints in Adults-EBSCO o Nasogastric Tube Care-EBSCO o Fall Prevention-EBSCO o CIWA Overview o Peripheral IV Insertion o Medication Management Basics o Inpatient Glycemic Control-SDH o Welch Allyn Spot Monitor Clinical Training Video
Orientation
Introductions are crucial to team success. Each individual brings with them certain
competencies and skills. In the introduction, each member should discuss what skills they can
assist with throughout the shift. Lead or Primary nurses should discuss the care needs for
patients within the unit with their Partner in Practice and how the work can be divided up to
ensure each patient receives the best care utilizing everyone’s talents on the team. During the
orientation phase, the lead or Primary nurse will review environment of care, which will include
the safety features of the unit.
Orientation time may be limited, but as time allows we will provide hands-on-learning for
common skills, documentation, and work routines. If we are not able to provide any hands on
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training, there are huddle cards and videos that you will be able to access on your I-Mobile,
hospital Intranet site, or these may also be on the nursing unit for you to review.
When you arrive on your assigned nursing unit, you will be introduced to the team and
provided with an introduction to the nursing unit. This will include a document (shown on the
following page) that will provide you with items your preceptor or educator should orient you
to.
Below, you will see the Huddle Card for the Partner in Practice/Resource Nurse Model. Please
familiarize yourself with this information.
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This document below is what you should expect regarding conversations with the primary
nurses you will be supporting at the end of your shift.
Meditech Education
The clinical education team has developed training on how to utilize and document in Meditech
for the following scenarios:
Nurses in their current role who have not utilized Meditech
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Nurses who utilize Meditech in their current role and will need to document in another
care area, i.e., Med-Surg Nurse documenting in ICU or OR Nurse documenting in the ED.
Listed below are the Meditech courses, with a short description, that are located in
HealthStream:
HWS HCA WBT Meditech Nursing Documentation – this is the full course for teaching
nurses to document in Meditech utilizing Evidence Based Clinical Documentation.
COVID-19 Medical-Surgical Meditech Resource Toolkit – this course will provide a
nurse who has basic experience with Meditech, how to document in adult inpatient
units, such as Med-Surg, Telemetry, and Critical Care. There is a word document with
screenshot examples that can be printed.
HCA Healthcare Center for Clinical Advancement is excited to announce the launch of
a Meditech Assistance Hotline starting Friday, 4/3/20. This will be for staff and any
clinician who needs assistance with Meditech. This will be extremely useful for those
nurses who are moving to other nursing units.
Meditech Assistance Hotline
For Meditech assistance please call us at 1-800-737-8661 x1333 or 954-514-1333 and
select option 2 to contact an experienced Meditech instructor.
Hours:
Weekdays: 8AM – 5PM EST
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Just In Time Resources
In the Primary Nurse Practice model you are not going to have all the knowledge and skills as
you deploy to another practice area. That is ok! As a Registered Nurse, you understand you
need to ask questions. We want you to use your resources that you have available. We have
developed resources that include information and guidance to help provide excellent care. If
you cannot locate a resource please ask your educator, we are here to help you!
ONLINE RESOURCES AND REFERENCES:
Resource Name Description Location
Atlas HCA corporate intranet-HCA initiatives
and documents SDH intranet>Atlas Connect
CE Direct Free access to continuing education and
certification review courses SDH intranet>Clinical Tools; internet
access available
Clinical Pharmacology Drug reference, including medication interactions, compatibility, etc.
SDH intranet>Medical Resources
EBSCO Clinical Research Clinical research database-to access
specific articles or journals
SDH intranet>Medical Resources; internet access available
E-Demand Repository for facility/SDH forms
(consents, specific patient instructions, etc.)
SDH intranet>Admin Tools
HealthStream
SDH/HCA Learning Management System- repository for most mandatory and
elective learning; HealthStream Competency Center: electronic orientation and annual
competency assessment for all staff, as well as annual evaluations;
HealthStream CE Center: free access to continuing education and certification
review courses
SDH intranet>Admin Tools; internet access available
Dynamic Health SDH procedure manual, includes
instructions, checklists and references SDH intranet>Medical Resources
Policytech Electronic file for SDH policies SDH intranet>Policies
Institute for Learning (IFL) Course Registration-for any course
offered through the IFL
SDH intranet>Institute for Learning; internet access available www.stdavids-
institute.com
COVID Resources HCA Corporate education tools
available to support COVID education
SDH intranet>Atlas Home>HCA Center for Clinical Advancement>Education
Tools https://connect.medcity.net/web/cca/e
duresources
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HUDDLE CARDS/QR Codes – You are likely to see huddle cards or posters throughout
the nursing unit and on some equipment. For additional information about a specific
topic or to better understand equipment, please scan the QR code on the document.
Many of these documents will include videos.
VIRTUAL PRECEPTOR – we are introducing our Virtual Preceptor that is available
through I-Mobile. This will include numerous quick references on a number of topics.
These tools are designed for rapid review immediately prior to performing a task.
APPENDIX
The appendix will provide you additional information that you will find helpful. Listed below
are the various topics that you can find located in this section:
Reassigning nurses to other nursing units using the Donna Wright Model
Monitoring Patient Vital Signs
Common Medications given in Med/Surg
Reassignment of Nurses – Based on Donna Wright Model
When nurses are floated from one nursing unit to another the issue of competency arises. We
need to frankly ask does this nurse have the skills, knowledge, and abilities to function in this
capacity? Experiencing a surge of patients can make it difficult to cross-train or put nurses
through a complete orientation. If this occurs, how can we facilitate a successful floating
process? According to Donna Wright, when asking nurses who float and those who receive float
nurses, there are three themes that are consistently heard. These themes, which are actually
competencies for the nurses that are reassigned to another care area, include:
Learning on the Fly
Marketing yourself in a positive way
Understanding crisis management options
Learning on the Fly
The learning on the fly competency has two parts to it. First I need to know what I do not
know, and be able to speak up about it. The second essential aspect of learning on the fly
includes:
I am not sure about this procedure….I am going to look it up.
I am going to ask someone how to do this.
I will use the resources that are available to guide my actions.
Obviously, this is not going to work for every procedure and task that we do, but many times
the learning on the fly skill is used successfully. To demonstrate learning on the fly, a nurse is
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floated to a medical-surgical floor that does dialysis. The nurse has never worked in dialysis
before and does not know how to do dialysis. The charge nurse may ask an experienced nurse
to set up the dialysis and identify the basic things to assess when monitoring a patient on
dialysis. The charge nurse can pair the inexperienced nurse with a seasoned nurse to answer
further questions to support the patient’s care. The most important thing is to propose ways
you can be useful while remaining open to learning new things.
Marketing Yourself in a Positive Way
As a Registered Nurse you have lot of knowledge, skill and experience that you can bring to any
situation. As RNs, we need to market ourselves and let those you are working with understand
what skills and experience you can bring to the team. Sometimes we may want to say I was told
to come here, I have never worked here before, I am not familiar or comfortable with working
in this area or specialty, and I do not know how to do any of those things. However, when you
are reassigned to another nursing unit we recommend that you make these two statements to
the team or the charge nurse instead:
My name is ________ I am floating to your unit for this shift, I am here to help you.
I have the following skills that I can offer to you today, and you can determine how they
best fit your needs. I can do ___________, and so on.
When nurses have the ability to market themselves positively, the results and the shift are
much better. The success of the shift and the reassignment experience do not lie in the clinical
skills, but instead in the can do attitude the person brings.
Understanding Crisis Management Options
Most of the time when a nurse is reassigned to another area, that area is under stress,
stretched, or moving into crisis mode because they do not have enough staff to meet the
needs. They need help to function, so they reach out for support. The nurse being reassigned
can provide care and/or service assistance to help the team get the routine work done, but can
also offer something else: a fresh perspective or insight that the group may have trouble
seeing. Here is an example:
The skill of understanding crisis management options can work in any area, not just in nursing.
The team is able to change the normal workflow temporarily to match the crisis situation and
still produce the desired results.
This is an excerpt from Donna Wrights, Competency Assessment Field Guide for Implementation
and Application, 2015, Creative Healthcare Management. Prior to COVID-19, HCA Healthcare
began to transition to the Donna Wright Competency Assessment Model. We will resume the
implementation later in 2020.
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Monitoring Patient Vital Signs in the Medical/Surgical Setting
Normal Vital Signs
Temperature:
97.6-99.9F (36.4-37.7C)
Respiratory Rate:
12-20 Breaths per minute
Heart Rate:
60-100 BPM
Blood Pressure:
Systolic (top number)
o Normal=90-140
o Abnormal is anything greater than 140 or less than 90
Diastolic (bottom number)
o Normal 60-90
o Abnormal is anything greater than 90 or less than 60
Oxygen Saturation:
Report any value of 89% or less to the Physician
Report any significant drop in saturation
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Common Medications in Med-Surg Cardiovascular Class/Indication Tips
Furosemide (Lasix) Diuretic/Removes excess fluid
Monitor electrolytes Don’t give later in the eve, if they do
not have an indwelling catheter in place
Lisinopril (Prinivil, Zestril)
Lotensin
Captopril
Enalapril (Vasotec)
Quinapril (Accupril) Clonidine (Catapres) (po or
transdermal)
Ace Inhibitor/ Decreases BP
Anti- hypertensive/ Decreases BP
Avoid in patients with renal compromise
Monitor BP
Angioedema (side effect)
Diltiazem (Cardizem)
Amlodipine
Nicardipine Nifedipine (Adalat,
Procardia)
Captopril
Calcium Channel Blocker/ decreases BP
Anti-hypertensive decreases BP
Anti-arrhythmia/ used in atrial fibrillation
Monitor BP
Some are long acting preparations to be given only once per day (CR, XR, XL)
Atorvastatin (Lipitor) Simvastatin
Lovastatin
Rasuvastatin
Pravastatin
Statin/Decreases cholesterol/LDL/HDL
Monitor Liver Function
Clopidogrel (Plavix)
Tigagrelor (Brilinta)
Prasugrel (Effient)
Dipyridamole Dipridamole/aspirin
(Aggrenox)
Ticlopidin (Ticlid)
Anti –Platelets/Blood Thinner
Monitor for any signs of bleeding
Labetalol (Normadyne, Trandate
Metoprolol (Lopressor, Toprol XL)
Atenolol (Tenormin)
Carvedilol (Coreg)
Nadolol (Corgard)
Beta- Blockers/ decreases BP and heart rate
Monitor BP
Monitor Heart rate
Warfarin (Coumadin) Blood Thinner Monitor INR lab values
Typically given in the evening Monitor for signs of bleeding
(Blood in urine, excessive bruising)
Avoid foods high in Vitamin K
Reversal agents: Vitamin K and FFP
Clonidine (Catapres) (po or transdermal)
Anti-hypertensive Can be oral or transdermal preparations
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Common High-Risk Medications Given on the Med-Surg Unit (Heparin, Insulin, TPN, PCA)
Medication Name
Indication/Drug Classification
Route of Administration Nursing Tips
Heparin Anticoagulant (Blood Thinner) DVT Prophylaxis
Sub-cutaneous Sub-Cutaneous: Give in the Abdomen 1. Pinch a 2 inch fold of abdominal
skin 2. Cleanse with alcohol swap 3. Let dry 4. Inject slowly into skin fold 5. Release skin and monitor for
bleeding (may need a band aid if oozing at the site)
6. Avoid area near the umbilicus or areas of previous injection sites
Heparin Anticoagulant (Blood Thinner) TX of PE, DVT, or CV disease
Continuous IV infusion Review orders carefully: Various orders sets available based on reason for use: Low Intensity Protocol High Intensity Protocol Acute MI Non MI
1. Baseline labs prior to starting infusion (per facility)
2. Monitor lab results q 6 hours (see orders) to make adjustments to infusion rate per order set
3. Follow order set per facility: typically need 2 lab values WNL before proceeding to daily lab testing
4. Per facility requires a co-signature in Meditech
5. Document Lab phone results in Process Interventions: Manage/Refer/Contact/Notify
6. Monitor patients for any signs of bleeding and notify provider as indicated. (Blood in urine, excessive bruising)
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Medication Name
Indication/Drug Classification
Route of Administration
Nursing Tips
Insulin: Long-Acting Short-Acting Rapid-Acting
Anti-Diabetic agent
Sub-cutaneous Injections site options: Abdomen, outer lateral upper arm, thigh
1. Pinch a 2 inch fold of skin 2. Cleanse with alcohol swap 3. Let dry 4. Inject slowly into skin fold 5. Release skin and monitor for bleeding
(may need a band aid if oozing at the site) Avoid areas of previous injection sites
Long-acting: Detemir (Levemir) Glargine
Follow order:
Typically given at HS, can be BID dosing.
Take blood glucose prior to administration
Do not mix with other insulins
Short-Acting Regular
Follow Sliding Scale order set: Various Sliding Scale order sets: Review
carefully: some involve basal dosing as well as scheduled dosing and various adjusting based on the Blood Glucose result
Blood glucose prior to administration
Give within 30 minutes of meal
Rapid-Acting Lispro/Aspart Has a more rapid onset and shorter duration than Regular Insulin
Follow Sliding Scale order set: Review carefully: some involve basal dosing as well as scheduled dosing and various adjusting based on the Blood Glucose result
Take Blood Glucose prior to administration
Give in close proximity of meal Do not mix with other insulins
Combination NPH/Reg Lispro/Prot Novolog 70/30
Follow orders: Take Blood Glucose prior to administration
Blood Glucose can be a lab draw or a finger stick
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Medication Name
Indication/Drug Classification
Route of Administration Nursing Tips
TPN Total Parental Nutrition
Nutrition Intravenous
MUST BE ADMINISTERED IN A CENTRAL LINE (PICC is a central line)
0.22 micron filter is required
Follow order instructions carefully: Typically has a starting dose and then increases per order and a wean if discontinued
Do not stop abruptly
Must be co -signed prior to administration
Dietician involved in dosing adjustments based on labs
Blood glucose monitoring per order
Needs a dedicated line (DO NOT administer other medications into the line)
Lipids Fat emulsion Intravenous Follow order set instructions carefully:
Typically given on certain day(s) of the week in conjunction with TPN
Per facility may have a solution with TPN and Lipids in one bag
Refer to policy regarding filtration of lipids.
Check with Primary RN
If you have any questions, please reach out to the St. David’s HealthCare Institute for Learning at 512-544-0100 or via e-mail at SDHP.DL IFL Clinical Education
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