2011 Nursing Annual Report - UNM Hospitals - University of New ...

2 0 1 1 N u r s i n g A n n u a l R e p o r t
O u r N u r s i n g F u t u r e

ANNUAL NURSING REPORT 2011 — From CNO Sheena Ferguson
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Dear Nursing Colleagues,
Is anyone else as surprised as I am that we are already into 2012 and completing
our annual report for Calendar Year 2011 This annual report is an update of
another very successful year for nursing!
Let us review the contributions by our profession around the triad of education,
research, and practice. Again this year we’ve done much toward our goals, and
most exciting, our goals are in complete synchronization with the Institute of
Medicine: Future of Nursing recommendations!
In our efforts to enhance EDUCATION opportunities for staff:
“BSN in ‘10”: 80% of nurses will have their BSN by 2020. The numbers of our staff working to advance on
their next degree > we are above 58% with BSN or higher!!
Prepare nurses to lead: All of our UDs have a BSN or a bridge to MSN. The MSN is required for Unit
Directors by 2015. UNMH is exceeding Magnet expectations with this requirement. We have six UDs
completing their Master’s this past year; 10 of our staff completed their NP or other MSN this past year.
Double the number of nurses with a doctorate (PhD or DNP in Nursing): A UNMH co-hort is planned
to start the DNP in January 2013. We have three staff who were accepted into the PhD program!
Congratulations to Kim McKinley who completed her DNP in August! UNMH has two nurses in the BSN
to PhD program. Congratulations!
Participate in Lifelong Learning: We increased our Tuition Reimbursement budget to over $800K in
2011, with 2012 planned to increase to $1 million.
Create a National Workforce Database: Our internal database for tracking education and certification
Nurse Recognition Website is widely viewed around the country as being state-of-the art. Kudos to
Adrienne Fugett, Salem Islar and IT!
Mentor in our Community: Our High School program, to share what a career in Nursing offers, has been
featured in the local newspaper and several news channels. Our mentors are encouraging kids to think
early about science in school!
The staff working to advance our PRACTICE:
Nurses as Change Agents: Milagro Program for expecting moms with substance abuse issues: Funding
changes spurred partnerships with the county for a new location for the residential treatment component
of the program. The exciting news: as a new site for the clinic and increased collaboration with
family medicine developed, the number of women our program is able to serve has exploded — and that
helps the women and their babies. Easing the transition and facilitating the expansion was due in large
part to our own Eve Wohlert, RN, and thanks to Michelle Wafer, RN for the large role she played as well!
UNMH Goes Baby-Friendly: BFHI is a rigorous quality improvement, recognition and awards program
that acknowledges birthing facilities who successfully adopt care practices that support optimal infant
nutrition and mother-baby bonding. In 2011 we started on our first phase! Thanks to all of the Unit
Based Educators from NBN, MBU, WSC, L&D, and NBICU who led this effort for healthy babies.
Prepare Nurses to Lead: UNMH had 56 RN’s graduate from the Leadership Training Center!
Practicing at the Top of Our Scope of License: The Pathway to Excellence and Magnet Champions are
leading us to hard-wired Shared Governance! Each unit selecting their practice change! UNMH had 50
• continued, page 3

ANNUAL NURSING REPORT 2011 — From the CNO
nominees from all five hospitals for the NM Nursing Excellence Awards. Congrats to category winners
were: Richard Noice (Med-Surg), Connie Hardy Tabet (Perioperative), Carey Carter (Emerging Leader),
Lorena Beeman (Education), and UNM Nursing Dean Dr. Nancy Ridenour (Distinguished Nurse),
Our CAP III nurses increased by 9% from 2010 to 2011 (729 to 792).
UNMH Nurse Residency received three-year accreditation!
Congrats Mary Blessing, Nicole Weimer, Donna Winn and Andrea De Chadenedes!
Require Residencies: Our Nurse Fellowship for Nurse Practitioners was developed by Gloria Doherty in
2011 (first candidates being accepted in 2012).
Several units made certification a unit goal:
Care Management • Emergency Department
6S Surgical SAC • GPU
Clinical Education: Kathy Willet: CEN, Dee Mulcahy: CPN
Nurses as Mentors: Carolyn Green received the Alumni Career Mentor
Award from her BSN program at Midland University in Fremont, Nebraska; and Susan Tobin was
nominated by her staff member Janelle Morris (also a mentoring hero) and received the UNM
CoN Outstanding Alumni award!
LoboWings: UNMH’s communication and team resource management program expanded significantly
with the help of our OPD colleagues. Bernadette Fernandez, your enthusiasm is contagious! OSIS, L&D,
Women’s Ultrasound and Ultrasound are all improving their culture for patient safety.
The staff working to advance our profession through shared RESEARCH:
Grow the Profession: Congrats Nicole Adams, RN on her manuscript on Suicide Assessment being
accepted for publication!
Our Transforming Care at the Bedside (TCAB) conference went citywide last year, and grew…again!
TCAB Highlights outstanding best practices.
National Presentations: Irene Zamora, “Epidural Pain Management” at the American Society for
Pain Management Nursing, and Joan Deis, “When the Brain Doesn’t Drain: Cerebral Venous Sinus
Thrombosis” at the American Association of Neuroscience Nurses annual educational meeting.
Fall Bundle: Rolled out by the Med-Surg Experts: clinically and professionally significant reduction in
patient falls!
Wow, that’s a lot for a year! But this is just a small number of the
people, teams, units, areas that are making UNMH a Pathway to
Excellence Organization — one where patient care is superb and
nurses thrive! I hope that all of you will contribute about your unit
or clinic next year.
All the Best,
Sheena
Sheena Ferguson, MSN, RN, CCRNr, CNS
Chief Nursing Officer, UNM Hospitals
smferguson@salud.unm.edu
In This Report
Page
Welcome from the CNO 2
People 4
Service 10
Quality 12
Finance 34
Growth 35
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ANNUAL NURSING REPORT 2011 — PEOPLE
People
2011 Nurse Star Performers
Standards in Action Winners are Star Performers
Given to employees who consistently “set the standard” in one of the Standards of Performance.
Name Area For Standard:
Miriam Bennet, RN Mother Baby Unit Customer Service
Rachael Brown, RN Orthopaedics Ownership
Veronica Lopez, RN 6S Professionalism
Stephanie Sanderson, RN MICU Professionalism
Doris Tinagero, RN CTH Dignity & Respect
Lisa Baca-Hoffman, RN Neuroscience Knowledge & Expertise
Kerri Brozena, RN ED Positive Attitude
Michele Mohler, RN Medical-Cardiac ICU Knowledge & Expertise
* Rosa Matonti, RN Digestive Health Center Knowledge & Expertise
Monica Vickery, RN Utilization Management Ownership
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ANNUAL NURSING REPORT 2011 — PEOPLE
2011 Nurse Employees of the Month
January 2011
PEOPLE: Anna Harmon-Keeney, RN,
Coronary Care Subacute
SERVICE: Melissa Base (Howard), RN,
Labor and Delivery
GROWTH: Danielle Ulibarri, RN, Pediatric Spec. Care
February 2011
SERVICE: Ruth de Rego, Nurse Practitioner, Retired
QUALITY: Kathryn Jackson, RN, Transplant
March 2011
PEOPLE: Jeanine Sukis, RN, Utilization Managment
GROWTH: Bethany Grow, RN, Labor and Delivery
May 2011
GROWTH: Linda Moore, RN Educator,
Clinical Education
June 2011
QUALITY: Kristen Fitzgerald, RN Supervisor,
CTH Rehab-Ortho
GROWTH: *Mary Blessing, Director and RN,
RN Residency Program
GROWTH: Laura Marsh,
RN Educator,
Clinical Education
September 2011
QUALITY: Pamela Lantz,
RN Specialist, Pediatric Cardiology
FINANCE: Max Parker, RN,
General Surgery 6-S
October 2011
PEOPLE: Meisha Smith, RN, General Med/SAC 4-W
SERVICE: Jackie Rhodes, RN Specialist,
Surgical Services Clinic
GROWTH: Amy Davis,
Advance Practice RN, IP Mid-Levels
November 2011
SERVICE: Rachel Theobald, RN Supervisor,
Mother Baby Unit
December 2011
SERVICE: Loryn Udell, RN,
Newborn ICU
July 2011
GROWTH: Coleen Seright, RN Supervisor, 6-S
August 2011
PEOPLE: Razvan Preda, RN Supervisor,
General Specialty Clinics, UNM PC
FINANCE: *Yoli Morales, Advance Practice RN,
UNM PC
* Also named as Employee of the Year!
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ANNUAL NURSING REPORT 2011 — PEOPLE
The Five Pillars of Excellence
UNMH has adopted “Five Pillars” as
a simple way to remember the Joint
Operating Plan (JOP). The pillars help
define the road map to pursue our
common purpose and mission. They give us:
People • Service • Quality • Finance • Growth
A way to focus our efforts
Help in prioritizing our main initiatives
Help in making decisions
Alignment so we are all moving in the same direction
Reminder of key points in the JOP
Pillars are for People, Service, Quality, Finance and Growth. You’ll find the following information to be
categorized into these pillars.
People
Working Mother Magazine Names UNM Hospitals to
Best Companies for Hourly Workers List
Part of an esteemed group of honorees, University of New Mexico Hospitals has again been named to
Working Mother’s second annual list of Best Companies for Hourly Workers. The only initiative of its
kind, Best Companies for Hourly Workers celebrates businesses working steadfastly to provide familyfriendly
benefits that promote health/wellness, education, flexibility and work-life balance. Best Companies
for Hourly Workers honorees must have a minimum of 50% hourly workers in order to submit their
data for this distinction. This is the second time UNM Hospitals has been named to this prestigious list.
With nearly half the U.S. workforce — 73 million Americans — punching in and out as hourly employees
every day, organizations such as UNM Hospitals are finding a competitive edge when they support hourly
workers. UNMH and 100% of this year’s Best Companies for Hourly Workers winners offer benefits such
as healthcare coverage, tuition reimbursement to workers pursuing degrees and paid job skills training
during working hours.
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ANNUAL NURSING REPORT 2011 — PEOPLE
Three Nurses Receive 2011
UNMH Employee of the Year Honors
Congratulations to
Rosa Matonti, RN, Quality (see more on page 21)
Yolanda Morales, RN, Finance
Mary Blessing, RN, Growth
Mary Blessing
receives her surprise
award from UNMH CEO
Steve McKernan.
Nursing Education Council —2011
The purpose of the Nursing Education Council is to
promote, facilitate, and plan professional development by
setting and maintaining educational practice standards. The Council addresses
identified educational issues and reviews and advises on staff development activities
based on nursing practice and education standards and regulatory requirements.
During 2011, the Nursing Education Council participated in several activities which demonstrated
progress toward achievement of goals. Several education referrals were made using a newly developed
form(specific topics listed below). After review, the Council recommended education plans based on
unique needs. A process for a standardized educational response to hospital-wide education was
written. The online competency process was examined. A recommendation for several patient safety
issues to be covered in annual unit clinical competencies was adopted by the Nurse Executive Council.
The Council charter was revised to include measures of success. The Nursing Education Council expects
to build on these successes during 2011.
Essential Online Competencies Remediation Proposal
CIWA • Leech Therapy
Res-Q-Pod • Inpatient Diabetes Education
Patient & Family Education of Central Lines • Stroke Education
Lighthouse Education • Ticket to Ride
UNMH Banquets
UNMH Congratulates Long-Term
Employees and Awardees with
Annual Banquets. Here some
nurses enjoyed banquets in 2011.
~ Janet Renn-Nelson (Co-Chair)
Joan Deis (Co-Chair)
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ANNUAL NURSING REPORT 2011 — PEOPLE
Nurse Residency Program
The Nurse Residency Program provides first year nurses with the tools required to adjust to the high
pressure of working as a hospital nurse. Newly graduated nurses often experience a difficult transition
from nursing school to real world practice. We offer a one-year, post-baccalaureate nurse residency
program and a six-month transition into practice program for new graduate associate degree nurses.
The post-baccalaureate program was created to assist the new graduates’ transition into their first
professional role. The program includes seminars based on a standardized curriculum, evidence-based
practice classes, clinical experiences under the guidance of a preceptor and access to nurse resident
educators who provide support and guidance in role development. Essential elements of the program
include a core curriculum used throughout the residency year.
New nurses who participate in the residency program benefit from the guidance and dedication of their
preceptors, unit-based educators and nurse residency educators throughout their first year. They
participate in structured educational experiences designed to develop competence in clinical practice
and professional growth. The conceptual framework of the program is based on Dreyfus’ model of skill
acquisition. This model provides the underlying conceptual framework for describing the development of
competency in clinical nursing practice as originally outlined by Patricia Benner in From Novice to Expert
and by Benner, Tanner and Chelsa in Expertise in Nursing Practice.
Benner identified five levels of competency in clinical practice: novice, beginner, competent, proficient
and expert. The post baccalaureate graduate nurse enters into practice at the beginner level with
theoretical knowledge but lacks the clinical and situational experience to apply intuition, clinical
judgment, and contextual knowledge of situations to nursing practice and care delivery. Graduate nurse
residents move to the next stage of practice, advanced beginner, when they can demonstrate acceptable
performance and have sufficient experience to begin to detect patterns of patient response.
The graduate nurse moves to competent level as he or she progress through the year. Competent nurses
are those who feel they have mastered the skill and have the ability to cope with the various possibilities
of care delivery. The goals of the program are to assist the new graduate nurse in the progression from
advanced beginner to competent professional nurse, develop effective decisionmaking
skills related to clinical judgment and performance, provide clinical leadership
at the bedside, strengthen commitment to nursing as a professional career choice,
incorporating research-based evidence into practice and formulation of an individual
development plan related to their clinical role.
In October 2010 we applied for accreditation through the Commission of Collegiate
Nursing Education and were granted accreditation in June 2011. We also offer a
transition program for new graduate Associate Degree Nurses. This program is
designed to supplement their competency-based orientation and support the
transition from student to RN. Components of the program include working within
the organizational structures, factors that influence care delivery, tools that support
opportunities to develop a proactive work environment and career advancement.
We strongly encourage associate degree nurses to begin their RN-BSN education after
they complete the first six months of employment. We support their education through
tuition reimbursement and the opportunity to participate in the Career Advancement
Program while attending school.
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Top to bottom:
Mary Blessing, RN,
Nicole Weimer, RN.
Not pictured:
Donna Winn, RN
and Andrea
de Chadenedes.

ANNUAL NURSING REPORT 2011— PEOPLE
UNM Hospitals Nominates 47 for 2011 NM Nursing Excellence Awards;
is Honored with Four Awardees
Awards are presented by the New Mexico Center for Nursing Excellence. The
program presents awards in 21 Nursing Excellence categories. UNM Hospitals
honored its nominees with a reception tea in October 2011. UNM Hospitals is
proud to announce that four of our nurses were honorees this year:
For Excellence in Education/Research/Academia: Lorena Beeman was honored.
For Excellence in Med/Surg: Richard Noice was honored.
For Excellence in Nurse Management/Emerging Leadership: Carey Carter was honored
For Excellence in Perioperative Nursing: Connie Hardy Tabet was honored.
UNMH is proud and honored to have these exceptional nurses as a part of our community! Nominees were
• Lorena Beeman
• Gayle Benintendi
• Mary Blessing
• Lindsey Breen
• Genevieve Cardona
• Carey Carter
• Joan Deis
• Jill Dykhuis
• Joanna
Essenmacher
• Kristin Fitzgerald
• John Fosler
• Yvonne Gabaldon
• Barbara Galvan
• Virginia George
• Sheryl Gordon
• Laura Grubb
• Geraldine Guerra
Sandoval
• Connie Hardy-Tabet
• Amber Ivey
• Denise Keller-
Merrell
• Jane King
• Kathy Kyler
• Andrew Leyba
• Kathy Lopez-
Bushnell
• Veronica Lopez
• Emily Maner
• Deborah Markee
• Linda Martin
• Amelia Martinez
• Rosa Matonti
• Gwynne McMurry
• Lisa McGuire
• Michelle Mescale
• Maureen Morain
• Richard Noice
• Eric Peterson
• Lori Ponge
• Razvan Preda
• Nichole Roesler
• Mary Root
• Teresa Royer
• Gloria Sharp
• Lauren Smith
• Yong Kathy Su
• Michelle Wafer
• Tiera Wissing
Pathways to Excellence
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ANNUAL NURSING REPORT 2011 — SERVICE
UNMH Receives Freedom Award
On April 7, 2011 about a dozen UNMH
employees visited the National Guard Armory in
Albuquerque to receive recognition from the
Employer Support of the Guard and
Reserve (ESGR). Steve Ross, RN wrote a
nomination for Steve McKernan, which was
chosen as one of New Mexico‘s awardees.
Service
That day, we were
also notified that UNMH had been
chosen as a semifinalist for the
national recognition — just 148 of the
4049 nominations have gone on to
this stage!
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UNMH Serves
Through St.
Baldrick’s Event
The Main Event for Albuquerque was held at the
BBRP plaza on May 7, 2011!
Many attended and participated in shaving their
heads to fund the most promising research to find
cures for childhood cancers and give survivors long
and healthy lives!
Each year 160,000 children are diagnosed with cancer worldwide. UNM Children’s Hospital is the
only cancer center for children in New Mexico. You can support the UNM Hospitals Main Event by
visitng http://www.stbaldricks.org/events/mypage/59/2012 and donating to a participant!

ANNUAL NURSING REPORT 2011 — SERVICE
Feria de Salud
UNMH Nursing staff participated in
the Feria de Salud (a day of free health
care) at National Hispanic Cultural
Center on April 18, 2011. Many came
for blood pressure checks and
information on their family’s health.
Many nurses participated
in this large community health
event in January.
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ANNUAL NURSING REPORT 2011 — QUALITY
Quality
What is National Database of Nursing Quality
Indicators (NDNQI) and How Does it Relate to the Magnet Recognition Program
Magnet requires data from many different areas within an institution;
however they do not specify which database a facility must use to
report this data. Some requirements exist for benchmarking — that is
why so many hospitals choose to join NDNQI. What is unique about
NDNQI is that they are the only national database that collects nursing
data at the unit level. This allows hospitals not only to compare themselves to other hospitals in regard to
nursing quality indicators, but also to other ‘like’ units in the nation participating in database.
Participating in NDNQI is completely voluntary and provides a hospital with an opportunity to be part of a
nursing database that specifically aims to help nurses refine their care and processes within their practice.
New facilities join regularly so this is a very dynamic database that allows nurses to closely monitor how
their nursing care compares to other facilities. This, in turn, provides multiple opportunities for better
quality and improved patient outcomes. What are the NDNQI Indicators Patient Falls; Patient Falls with
Injury; Pressure Ulcers: community-acquired, hospital-acquired, unit-acquired; Skill Mix; Nursing Hours
per Patient Day; RN Surveys: Job Satisfaction — Practice Environment; RN Education and Certification;
Pediatric Pain Assessment Cycle; Pediatric IV Infiltration Rate; Psychiatric Patient Assault Rate; Restraints
Prevalence; Nurse Turnover; and Healthcare-associated Infections:
VAP — ventilator-associated pneumonia; CLABSI — central line–associated blood stream infection; and
CAUTI — catheter-associated urinary tract infection.
What’s New in the ED for 2011
The Emergency Department is hard at it with some of the best AMI
Core Measures in the country. Pneumonia Core Measures are at 94%
and the staff members are currently working toward a Chest Pain
Center Accreditation.
The ED also offers monthly review courses for the CEN exam, and
constantly looks at new ways to improve communication including a
system called “Vocera Communication,” a hands-free ‘voice command’ communication wireless system.
2011 also ushered in a brand-new onsite adult urgent care center that is staffed by NPs and PAs.
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Way to go UNMH ED!

ANNUAL NURSING REPORT 2011 — QUALITY
Compared to the 50th Percentile (Median) for Academic Medical Centers (AMC), UNMH was:
First Quarter: Lower Than
Second Quarter: Higher Than
Third Quarter: Higher Than
Fourth Quarter: Lower Than
The ICU units use a blood stream infection (BSI) checklist during the insertion of a central line. Use of the
checklist is good but can be improved for consistency of excellent patient care. Documentation occurs in
the patient’s electronic medical record (EMR). All supplies are bundled so they are readily available when
the procedure begins. UNMH is participating in the New Mexico state (BSI) collaborative in order to
decrease infections and learn best practices. One area of opportunity is to determine the best practice
when cleaning the ports prior to use.
Did You Know
Each year at Bring Your Child to Work Day the Operating Room
staff create a hands-on scenario for student attendees to get a
taste of what it’s like to prep for and perform an operation
The kids dress in gowns, masks, caps, shoe covers and gloves,
and then participate in a Time Out protocol before their
surgical experience! The kids love it.
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ANNUAL NURSING REPORT 2011— QUALITY
Injury Falls per 1,000 Patient Days
50th Percentile (median) comparison
2011
AMC
UNMH
1Q
'10
2Q
'10
3Q
'10
4Q
'10
1Q
'11
2Q
'11
3Q
'11
4Q
'11
Compared to the 50th Percentile (Median) for
Academic Medical Centers (AMC), UNMH was:
First Quarter: Higher Than
Second Quarter: Higher Than
Third Quarter: Higher Than
Fourth Quarter: Higher Than
Compared to the 50th Percentile (Median) for
Academic Medical Centers (AMC), UNMH was:
RN Education
Total RNs
50th Percentile (median) comparison
2011
First Quarter: Higher Than
Second Quarter: Higher Than
Third Quarter: Higher Than
Fourth Quarter: Higher Than
AMC
UNMH
1Q
'10
2Q
'10
3Q
'10
4Q
'10
1Q
'11
2Q
'11
3Q
'11
4Q
'11
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ANNUAL NURSING REPORT 2011— QUALITY
We are HIGHER THAN the Median for all four quarters compared to all other
AMC’S that participate in the NDNQI!
UNMH Identified Best Practices
Core Measures
Door to catheter
Asthma
Restraints
Cleanliness of Facilities
Environment of Care and Emergency Management
Plans
Patient Rights-New Patient Centered Consent
Medication Reconciliation Process
Advanced Directives
Leaders
Commitment to mission at all levels
Strategic plan shared with community
Frontline Staff
Ownership of goals/mission
Electronic Medical Record
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ANNUAL NURSING REPORT 2011 — QUALITY
Ventilator Associated Pneumonias per 1,000 Ventilator Days
50th Percentile (median) comparison
2011
AMC
UNMH
1Q
'10
2Q
'10
3Q
'10
4Q
'10
1Q
'11
2Q
'11
3Q
'11
4Q
'11
Compared to the 50th Percentile (Median) for Ventilator
Associated Pneumonia (VAPS), UNMH was:
First Quarter:
Second Quarter:
Third Quarter:
Fourth Quarter:
Lower Than
Same
Same
Same
At UNMH, we follow the national ventilator associated pneumonia (VAP) care bundle. This includes such
practices as elevating the head of the bed 30 degrees, routine oral care with chorohexadine, turning the
patient every two hours, decreasing the number of times the ventilator circuit is disconnected which
reduces the opportunities for infections to begin, using the VAP checklist in the EMR for documentation,
and “sedation vacation” for the patient to assess for the earliest opportunity to extubate the patient.
Using our Nursing Recognition Website, with well over 95%
of our nurses reporting, we have a 40% certification rate!
Way to go UNMH Nurses!
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ANNUAL NURSING REPORT 2011 — QUALITY
Total Falls per 1,000 Patient Days
50th Percentile (median) comparison
2011
AMC
UNMH
1Q
'10
2Q
'10
3Q
'10
4Q
'10
1Q
'11
2Q
'11
3Q
'11
4Q
'11
Compared to the 50th Percentile (Median) for Injury Falls, UNMH was:
First Quarter: Higher Than
Second Quarter: Higher Than
Third Quarter: Lower Than
Fourth Quarter: Lower Than
UNMH formed a Falls Task Force via the Medical/ Surgical shared governance group to evaluate and
standardize the fall with injury definition. Prior to this task force there was inconsistency with reporting
falls with injury. Through increased education, there was increased awareness, which resulted in increased
correct reporting. We are having patients self-report falls by providing this education to them.
A new fall scale has been implemented and associated interventions are in process of being changed.
Documentation will occur in the EMR once that module is built and added.
In the Excellence Spotlight: Stephanie Sanderson,
RN, MSN, CCRN, CCNS
Stephanie Sanderson, RN, MSN, CCRN, CCNS received the prestigious
Estelle Rosenblum award from Sigma Theta Tau International in April 2011
for Excellence in Nursing Ediucation. Congratulations Stephanie — we’re
proud of you and glad to count you as a coworker at UNMH!
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ANNUAL NURSING REPORT 2011 — QUALITY
Fall Prevention Workshop
On August 2, 2011 many caregivers attended an educational activity
that presented significant findings, implications, outcomes, and
process recommendations suggested by the literature on patient falls
in acute care hospitals. These findings were validated by a multispecialty
nursing unit pilot in the Medical/Surgical area of UNMH.
Staff gained knowledge and skill to assess a patient’s fall risk and
implement prevention strategies, and learned about a successful
quality improvement
project that resulted in
improved patient
outcomes.
DAISY Awards Coming to UNMH
UNMH announced in late 2011 that we would be participating in the
Daisy Award Program in 2012! The program was started in 1999 by
the family of a patient, Patrick Barnes. Patrick died of Idiopathic
Thrombocytopenic Purpura (ITP) at the age of 33. DAISY stands for
'Diseases Attacking the Immune System.'
The Barnes family wanted a way to remember their loved one, but also to
recognize the amazing compassionate care that bedside nurses give every
day, in addition to their clinical expertise. This is a national award program
for nurses and UNMH is glad to be a part of it. Visit http://
daisyfoundation.org/ for more information.
In the Excellence Spotlight: Sue Tobin, RN
Sue Tobin, Unit Director for Pediatric Clinic and Peds Infusion, was
selected in 2011 as the UNM College of Nursing New Alumni award
recipient! Sue was honored at the Homecoming Dinner in
September 2011. Congrats Sue — well done!
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ANNUAL NURSING REPORT 2011 — QUALITY
UNMH Presents the Surgical Experience
For the first time in June 2011, UNMH offered a three-day course for
high schoolers to show them what it was like to work in an operating
room. Students from around the state attended the surgical experience,
a ― soup-to-nuts review of life in the OR. Students heard about being a
surgeon; learned about other roles in the OR; and had demonstrations
and presentations on anesthesia, radiology and pharmacy. They gowned
up and scrubbed in, learned to suture and watched and participated in surgical
simulations in the BATCAVE. The event was part lecture and part hands-on.
Local TV station KRQE was on hand to capture the class happenings and promote
the event on their newscast on June 10. Thanks to Sheena Ferguson, Cynde Tagg,
Lorena Beeman, Mary Blessing, Connie Fassler, Kathy Lopez-Bushnell, Laurie Mason,
Doug Gadomski, Luke Esquibel, Jane Potter, Myra Zucker, Jerry Beeman, Rosalia
Ciddio, Dr. David Pitcher, staff from the cardiac cath lab, and others who
participated in this
terrific opportunity
for the youth in our
community.
Laurie Mason, RN,
explains double
gloving.
Training Top 125
UNM Hospitals has again been honored by Training magazine as
one of the top 125 training organizations in the country that excels
at human capital development, and training and development.
The annual Training Top 125 list is the only report that ranks
companies’ excellence in employer-sponsored training and
development programs. This recognition is testament to the quality
of — and importance the organization places on — the education
offered to employees at UNM Hospitals.
Five educational services divisions — Computer Learning and Technologies, Clinical Education,
Frontline Education, Behavioral Health Education, and Organizational & Professional Development —
provide valuable, useful information in classes and trainings to UNM Hospitals employees.
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ANNUAL NURSING REPORT 2011 — QUALITY
UNMH Quality Outcomes Department
Professionals Helping Professionals
for Better Quality Outcomes
Thanks to ED Teresa Royer and her team of dedicated
professionals whose continuous efforts to improve
quality help our staff provide exceptional care.
In the Excellence Spotlight: Lorena Beeman, BSN, RN, MS, CCVT
Heart failure program education,
Inpatient patient education center
2011 New Mexico Nursing Excellence Award for Nursing
Education/Research/Academia
2012 Gamma Sigma Chapter, Sigma Theta Tau
International Honor Society award for
Excellence in Nursing Practice
Chair of UNMH Nursing Research Council
Chair of the Gamma Sigma Governance Committee and
Financial Chair
Program Planning Member for local chapter of AACN
Education Committee Chair for the Society of Critical Care Medicine-New Mexico Chapter
Director Fundamentals of Critical Care Medicine (sponsored by the Society of Critical
Medicine)
Member of the New Mexico Center for Nursing Excellence Board, Education Committee,
Action Coalition Committee focusing on Nursing Education and Clinical Partners, and Action
Coalition Committee focusing on Life-long Learning in Nursing
On Panel for the Nursing Publication Workshop
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UNMH Reacches Four Stars in UHC Scorecard
Congratulations to UNM Hospitals and the attainment of
4-Star status (out of 5 possible) in the 2011 University
Healthsystem Consortium (UHC) Quality & Accountability
Performance Scorecard.
ANNUAL NURSING REPORT 2011 — QUALITY
The 4-Star recognition by UHC places UNMH in the top 33% of
academic health centers in the nation, based on six domains of
quality and patient safety. The scorecard is based on mortality,
core measures, readmission rates, complication rates, patient satisfaction, equity and efficiency. Top scores
in UNMH mortality rates, readmission and complication rates led the way. Did you know that UNMH is a Top
10 performer in readmission rates and "door to balloon" time for heart attack patients
The 4-Star recognition comes after four years of steady improvement since UNMH began their Patient Safety
journey in 2006. Improvements in the documentation of care and the adherence to protocols fueled the
increase in scores in all areas. Keeping our patients safe is hard work, so once again, congratulations to all
the providers, nurses and staff who have made UNM Hospitals one of safest and respected teaching hospitals
in the nation.
Dr. Kendall Rogers
and Rosa Matonti
presented this poster
at the International
Hospital Diabetes
Meeting in San
Diego, October 2010.
It was also presented
at the TCAB
conference in
October 2010. Rosa
and the staff of 4W
have been invaluable
in creating a much
smoother process of
blood glucose
measurement,
insulin administration, and meal delivery. This was a lot of hard work for all involved, but the patient
outcomes speak for themselves! This project will continue to make great patient improvements for our
diabetic population. The National Association of Public Hospitals & Health Systems went on to award Rosa &
4W with and Honorable Mention Recipient for the 2011 NAPH Safety Award! Thanks 4West and all involved!
It was in part because of this work that Rosa Matonti, RN was named Employee of
the Year at UNMH in 2011 (see more on page 7).
21

ANNUAL NURSING REPORT 2011 — QUALITY
Structural Empowerment — Nurse Recognition Website
Using our new Nurse Recognition Website, we have approximately 1,938 nurses who have entered their
professional credentials to this website. Last year at this time we had over 1,280 nurses reporting. That
is statistically significant to report the following information:
BSN Rate: As of December 2011, we are at 49% with 95% of our nurses reporting on our Nurse
Recognition website!
MSN Rate: 8.2%
BSN & Certification Rate: 22% (up from 19%)
Certification Rate: 40%
Published Rate: 3%
Presentation Rate: 5% This includes nurses who have
presented at a state or national conference.
Community Service Rate: 8%
Percentage of Nurses Belonging to a Professional Organization: 20%
Belonging to a professional organization is a great way to stay current in nursing issues as well as
contribute to our profession, and learn from our nursing peers! This is completed degrees only, not
those who are in school with a pending degree completion date.
The UNMH Magnet website contains information about our
Magnet journey, our Pathway to Excellence designation,
and many other shared governance and nursing topics.
22
Visit https://hospitals.health.unm.edu/intranet/mrp/index.shtml for more.

Nursing Recognition Website
In November 2010, UNMH rolled out the Nursing
Recognition Website. We have come a long way
with this website. With the new ANCC Magnet
requirement for all Nurse Leaders to have a
minimum BSN by 2013, capturing this information
will be of utmost importance for any newly
designating hospital, as well as for currently
designated Magnet hospitals.
ANNUAL NURSING REPORT 2011— QUALITY
Over the last year, several hospitals, both Magnet
designated, and those on the journey, have
contacted our hospital to find out how we created
this simple, yet powerful database. This has proven
to be a best practice whereby we can accurately
capture professional achievements while offering the nurses a professional recognition venue.
STRUCTURAL EMPOWERMENT:
Recognizing our Professional
Achievements, realizing our
autonomous nursing practice,
and a determined focus on the
growth of our Shared
Governance — this is the
future of nursing at UNMH!
In the past, whenever our CNO wanted to get some statistical
information regarding how many BSNs any one unit had, how
many were in school, who was certified, etc., the units were doing
a lot of last minute work to get in touch with their staff in order to
update this information. Unfortunately, we knew that the collected
information likely was not reflecting the complete certification
status, and/or the education status, but we were also missing
opportunities to recognize our nursing peers who have published,
presented or were active in community service.
So far, more than 1,900 nurses have entered professional information! Plans for 2012 include capturing
much of our required documentation for CAP whereby the nurse can upload specific documents, and later
create a PDF and/or printed report for proof of CAP requirements. The opportunity to recognize one
another on an intranet venue has resulted in a great sense of pride for the nurses at UNMH who saw a
missed opportunity for recognition. Way to go UNMH Nurses!
Internal Link: https://hospitals.health.unm.edu/intranet7/apps/nurse_achievements/index.cfm. External
Link (accessible from home): https://hospitals.unm.edu/intranet7/apps/nurse_achievements/index.cfm.
Nursing Publication Workshop
On May 13, 2011 UNMH sponsored a Nursing Publication
Workshop with keynote speaker Dr. Sharon Lewis, a world
renowned nurse researcher and author.
Many nurses got the opportunity to learn about publishing in
professional journals and the process for submission.
23

ANNUAL NURSING REPORT 2011 — QUALITY
PDSA Status Summary — Carrie Tingley Inpatient Unit– 2010 –2011
PDSA Status Summary Outcome
The pediatric rehabilitation
population experienced a fall
prevalence rate of 2.34 per
1,000 patient days for 2010.
The breakout for this year
looked at monitored patients
versus un-monitored patients
who fell.
In December 2009 a video
monitoring system, which
consisted of digital cameras
mounted in five designated
patient rooms, and a centrally
located monitor was purchased
and installed.
The objectives of this video
monitoring system were to
afford continuous visual
observation of patients by
remote staff; as well as determine
the need for dedicated
room sitters. Implementation
of the video monitoring system
has been a success.
Continue to monitor
fall rate by breaking
out monitored versus
unmonitored data.
Consider adding
additional cameras
on unit.
Present and educate
other UNMH Nursing
Departments on the
benefits of the video
monitoring system
versus sitter usage.
Publish data since
there is little research
completed in this
area.
# PATIENTS FALLS FALL RATE
TOTAL 4,055 9 2.22
MONITORED 1,066 2 1.88
UNMONITORED 2,989 7 2.34
Cost savings related to sitter usage is equivalent
to 6.7 FTEs resulting in a savings of $328K.
Fall Rate reduction comparing monitored versus
unmonitored area is a 31% reduction.
CTH Inpatient Video Surveillance Data Update for 2011
Actual fall rate for 2010 = 2.39%
2 falls monitored
7 falls unmonitored
Actual Fall Rate for 2011 January-December = 1.44%
1 fall monitored
5 falls unmonitored
0.92% for monitored area
1.62% for unmonitored area
1.44% for total
Reduction in Sitter Usage for Fiscal Year 2011
24
Sitter Usage = .8 FTE utilized for patients who were a threat to
themselves or others.
Sitter Usage Cost = $16,320
Saving from project initiation = $316,480

TCAB 2011—TRANSFORMING CARE AT THE BEDSIDE
ANNUAL NURSING REPORT 2011 — QUALITY
Another great TCAB conference for 2011! Again
we took it statewide, and had over 160
participants. Our Keynote Speaker was Sandy
Summers MSN, MPH, RN, owner and founder of
“TruthaboutNursing.com.” Sandy has dedicated
her time to creating awareness in the public eye
about our inaccurate and oftentimes harmful
portrayals of nurses in the media, and in
Hollywood. She makes a great case for how this
misperception affects our ability to attract nurses,
but it also undermines those of us in the
profession, if we don’t take our profession
seriously. Check our her website for more info!
The 2011 TCAB conference was held at the Crown
Plaza Hotel. We had 6 presentations this year, and
all are posted on our Magnet intranet link under
“Nursing Research.”
Topics included staff development at the bedside,
conversing with the whole patient, conscious and
unconscious, as well as a presentation from the
CNO of Lovelace sharing their success with patient
satisfaction by creating patient welcome packets.
TCAB reminds nurses to “own their outcomes.”
This is how we can improve patient care and
increase nurse satisfaction.
The better we become as nurses,
at owning our patient outcomes,
the better understanding we
gain for our goals in Shared
Governance and autonomous
nursing practice. This is vital for better patient
outcomes and for decreasing our RN Turnover.
In the Excellence Spotlight:
Terri Gibson, MSN, RN
Terri conducted a
community program called
the NM Super Fit Family
Challenge, an eight-week
course for families to learn
about and experience the
gift of health together.
Participants shared a light
meal each week and learned
how to create low-cost,
healthy meals and activity sessions at home.
Way to take it to the community, Terri!
25

ANNUAL NURSING REPORT 2011 — QUALITY
Magnet Journey — Important Announcement for Upcoming Designation
In January 2011, UNMH began their Magnet data
collection. We collected, and continue to collect
impressive best outcomes for several units. However,
as you are all aware, there are some important
elemental requirements whereby an organization
may find they need to delay their application
process. This is no reflection on anything
that anyone has not done, and it is important to
remember that achieving and maintaining Magnet
status is a process. Constant evaluation is important.
One of those requirements includes new nursing
leadership criteria for 2013. The new criteria require
that all nurse leaders have a minimum BSN
degree in 2013. This is a new and non-negotiable
requirement, even for currently designated Magnet
hospitals. However, because our nursing leadership
will exceed this requirement with 100%
MSN accomplishment in 2015, we have shifted our
anticipated Magnet application date to April 2015.
No other Magnet facilities have this high of a requirement
for their nursing leaders, so this is
something we will definitely showcase. We will
also need to create a more substantive Nurse Peer
Review Program for direct care nurses.
according to ANCC/Magnet, it is really hard to see that any organization
has truly implemented a peer review program throughout,
for all levels of nursing. One of the Sources of Elements in Magnet
states that “EP20—Nurses Improve Professionally through Selfappraisals
and Peer Reviews.” Our Nursing Quality & Peer Review
Council meets part of this criteria, now we just need to consider
adding a peer review process through our unit-based Shared Governance
councils. For example, as a unit-based shared governance
council you could focus on your quality outcomes, patient
satisfaction results, NDNQI, etc., and set goals for improvement as
a SG council, then peer review one another while striving for these
goals. Look for Peer Review classes to start in early 2013 based
on the ANCC Magnet requirements for peer review in nursing.
We have the data to re-designate for Pathway to Excellence in
March of 2013, and that is a worthy re-designation for us to accomplish.
(See next page)
In the early ‘80’s the ANA agreed that as a profession
we needed to incorporate peer review at all
levels. However over the years
26

Pathway to Excellence Designation: Journey Onward to Magnet!
How does PTE Re-Designation Propel Us Forward for Patient Excellence & to
Our Magnet Journey
ANNUAL NURSING REPORT 2011 — QUALITY
As we mentioned on the previous page, shifting our Magnet application to April of 2015,
and re-designating for Pathway to Excellence (PTE) in March 2013, is an incredibly worthy
path for UNMH to pursue.
We have the data to re-designate for our existing Pathway to Excellence (PTE) award based on the
extraordinary information we have collected on our Magnet Journey. Our PTE re-designation is due the
same time as our original anticipated Magnet application date, March 2013. This will allow us to continue
with the momentum that we have created, and continue to make the nursing practice changes and growth
we all seek. The extra time will further allow us to roll-out and refine our nursing Peer Review at the
nursing staff level, through the Shared Governance structure.
If we believe that a determined focus on our practice can help us constantly improve our patient outcomes,
as well as create New Knowledge, Innovations & Improvements (the research component of Magnet), we
can truly transform our units, and our practice, to be the hospital with the best patient care — with the
evidence to back it up!
Continuing to build up our unit-based Shared Governance is an important goal to focus on while we gear
up to re-designate for PTE. Many of the nurses have shared that although they support a journey of
excellence, and the goals that both Magnet and PTE strive to achieve and maintain for nursing practice,
many nurses feel we aren’t quite ready, but will be, if we keep up this momentum. Many direct-care nurses
and nursing leaders have shared that through continued growth with Shared Governance and Peer Review,
we can address more of the culture changes and outcome improvements that are important to all of us, no
matter our role at UNMH.
Pathway re-designation is an achievement that will ask more of us at every level, just like Magnet, but the
returns and rewards will be evident with decreased RN turnover, more job satisfaction and better patient
outcomes. Both PTE and Magnet offer a great blueprints for achieving these outcomes, but only if we all
embrace these journeys of excellence!
Questions Contact the Magnet
Program Manager, Adrienne Fugett at
afugett@salud.unm.edu.
27

ANNUAL NURSING REPORT 2011 — QUALITY
CLINICAL EDUCATION Annual Nursing Report - 2011
The mission, vision, and core values of the Clinical Education (CE) department are consistent with
those of the institution and nursing division. The primary goal of the CE staff is to provide high quality,
relevant education to improve patient outcomes while containing costs. Clinical Education has 14
gifted nurse educators and two skilled support staff. Eight nurses are Master’s prepared; several
possess specialty certifications and one is board certified in Nursing Professional Development. Eleven
are enrolled in school pursuing nursing-related degrees.
Some of the members of the Clinical Education
Deppartment
28
The educators in Clinical Education use Benner’s
model of staff development to design educational
programs. Basic and advanced education was offered
for a wide variety of courses developed to address
the learning needs of novice and experienced staff:
life support, pediatrics, women’s health, newborn,
ambulatory, neuroscience, trauma, emergency,
medical-surgical, oncology, pain, end-of-life, cardiac rhythms, certification preparation, precepting,
supervising, educating, and delegating. Many Unit-Based Educators, Clinical Nurse Specialists,
Specialty Nurses and others make a significant contribution to our educational programs.
In 2011, Clinical Education staff and guest instructors provided 1049 offerings, 182 types of classes,
attended by 13,949. Seventy-five new Continuing Nursing Education applications were written and
23,595.7 contact hours were awarded. Self-study modules were completed by 5039. Nurses and
unlicensed assistive personnel who attended new hire classes numbered 314 and 284, respectively.
Eleven academic programs placed 1815 nursing and medical assistant students for clinical experiences.
Our most significant successes from the past year are described.
An electronic survey of Clinical Education’s services was conducted and identified learning needs
were incorporated into the department’s strategic educational plan.
The Nurse Technician course was redesigned to better meet staff needs and increase participants.
Basic trauma education for critical care and emergency nurses was reinstituted.
Course offerings are more widely disseminated through our updated website and via hospital-wide
electronic communications.
Benchmark Quality Indicators were developed and reported for the first full year and include the
number of educational opportunities provided, teaching hours, and the measurement of selfreported
learning by course participants.
Several educators achieved special recognition. Irene Zamora presented on “Epidural Pain
Management” at the American Society for Pain Management Nursing and Joan Deis lectured on
“When the Brain Doesn’t Drain: Cerebral Venous Sinus Thrombosis” at the American Association of
Neuroscience Nursing annual national educational meeting. Joan also presented “The Effect of Staff
• continued, page 29

Development on Transforming Care at the Bedside” at the statewide
Transforming Care at the Bedside conference. Two educators,
Linda Moore and Laura Marsh, were honored as hospital
Employees of the Month.
Our greatest rewards came from course participants
who reported the value and applicability of their learning.
One staff nurse had attended a certification preparatory
course emailed the instructor, “I just wanted to thank you
for an awesome review course. I took the CNRN today
and PASSED…!” An evaluation comment after a lecture
on Shock was “The importance of base deficit was unclear
previously; being able to accurately monitor and
intervene based on this number (at least partially) will
improve patient outcomes.” A Basic Arrhythmia Course
participant wrote, “It is crucial for me to understand
causes & treatments for arrhythmias and be able to
recognize them in order to maintain safety and good
outcomes for my patients.”
Opportunities for the future are outlined.
ANNUAL NURSING REPORT 2011 — QUALITY
Provide quality education based on identified needs (pediatrics, geriatrics, orthopedics,
breast-feeding, and those related to regulatory compliance).
Build instructor pool for life support classes and establish a quality standard.
Develop web-based educational training including electronic process for summarizing course
evaluations.
Implement strategy for decreasing high “no show” class rate.
Continue to study outcomes of educational programs and report quality indicators measuring
educational value.
Update list of required orientation classes.
Certified Nurses at UNMH
Studies indicate that nurses who are certified are quicker at initiating early
interventions and have more control over their practice; better communication;
fewer adverse events and patient errors; more satisfaction and better pay.
Board certification of nurses plays an increasingly important role in the
assurance of high standards of care of patients and their loved ones.
UNMH celebrated Certified Nurses day on March 18, 2011 with about 45
staff members participating. Information on how to get certified was readily
available!
29

ANNUAL NURSING REPORT 2011— QUALITY
Exemplary Professional Practice: UNMH Nurse Residency Program
Evidence-Based Nursing Practice, Nicole Weimer, MSN, RN Nurse Residency Program
"The most important practical lesson than can be given to nurses is to teach them what to observe..."
~Florence Nightingale, 1859
The Nursing Research Council has been working hard on continuing to enhance, encourage, and
being a positive role model for evidence based practice and research at UNMH.
Nursing Research Rounds Presentations:
Use of the Pain Crosswalk Decreased Narcotic Overdoses Kim McKinley PhD RN
Translating evidence into practice Lorena Beeman MSN,RN
Reflexology CON students
Shaken Baby Syndrome CON students
COPE Christine Perez MSN, RN
Measuring Family Education and Satisfaction with care in the Adult ICU: A Randomized
Controlled Pilot Study Melanie Tidwell PhD OT
How to use Survey Says and other Survey Builders Nicole Weimer MSN, RN
Magnet Data Collection Terri Gibson MSN, RN
The use of Simulation and Evidence Based Practice Lorena Beeman MSN, RN
Diversity Pipeline Kathy Lopez Bushnell PhD, RN
Coping Algorithms in Labor Catherine Lukes BSN, RN
Does a Step-by-Step, Evidence Based program help to increase the number of completed
projects in the first year Nicole Weimer MSN, RN
Creating a Research Program Utilizing Simulation Resources Lorena Beeman MSN, RN
IOM report and what it means to nursing Kathy Lopez-Bushnell PhD, RN
Other Accomplishments:
Partnered with/or presented at the TCAB, Simulation Symposium, Publication workshop,
other conferences outside of UNMH.
Merged nursing research rounds and nursing research council for improved time management
Worked with many units on the PDSA's
Facilitated the nursing publication workshop
Created CEU classes for Evidence Based Nursing Practice education
Hosted the research poster session during Nurses Week
Developed a survey for UNMH nursing research needs/interests
Created Article Critique forms to be used in the institution for standardization
Collaborated with Hospital councils to improve practice.
30
• continued, page 31

ANNUAL NURSING REPORT 2011 — QUALITY
At Hospital Week in 2011 we held a hospital-wide poster board day. Everyone who came through to
look at posters and speak with the nurses got to vote on which posters were the best. CNO Sheena
Ferguson awarded three additional winners of her choice.
Award: CNO Award: Nurse as Scientist
NSI/Nurse Residency Project
Kathy Dolan
"IV Infiltration"
Award: CNO Award:
Nurse as Leader
5 ACC
Terri Gibson
"Super Fit Family
Challenge"
Award: Most Innovative for
Patient Care
NBICU/ICN
Christine Perez
"Back to Sleep Positioning:
NICU to Home"
Award: CNO Award: Nurse as Change Agent
CTH Inpatient
Sharon Guerra
"Reducing Patient Falls using a Video Monitoring
System"
Award: Greatest Impact on Practice Tie
4 East Trauma Surgical SAC
Martha Andazola and Afton Rigdon
"Improving Communication Hand-Offs"
Nurse Residency
"Academic Nurse Resident Retention Over Time"
Award: Best Process
Improvement Design
5 East/3 East
"Chemotherapy Safety
PDSA"
We finished 2011 by planning several roll-outs for
2012: Including a series of educational classes for all
employees on PICO, evidence-based practice, PDSA
and research. These are classes that you will be able
to walk away with something to work on, whether it
be your question, finding evidence, or starting on a
project to solve a mystery in your practice. The
educational classes will also be offered by webinar.
A nursing research and evidence-based practice
website will be on the nursing page so that you
can access everything we have to offer here at our
institution that has to do with Research from
classes, conferences, and handouts to web links,
and an online journal club, etc.
We are studying several evidence-based practice
and research models to decide which one is the
best for our institution.
~ Mary Blessing, RN MSN
Nicole Weimer, RN MSN
31

ANNUAL NURSING REPORT 2011 — QUALITY
Our 2011 Magnet Fair Success
The first-ever Magnet Fair was a great success!
A very special thanks to all who participated and
made this day and information presented possible!
With 90 people turning out for the fair, and
indicating a positive review of what took place, the
Magnet Champions at UNMH labeled the day a
success. Attendees were given a passport to be
stamped at each of the six tables. Everyone walking
by was encouraged to take the 30-minute tour and
then receive a limited edition pin. They were also
eligible for the prize drawings throughout the day.
Here are a few highlights from the day:
Honored Guests: Florence Nightingale & Sheena
Ferguson (CNO) both stopped by and enjoyed brief
tours of our various table displays and poster
presentations.
Table Topics/ Just a Few of Our Presenters:
TL– Transformational Leadership Information was
presented by various Executive Directors (EDs),
such as Crystal Frantz, Doris Tinagero, April
Verhoog, Pam Demarest, Maribeth Thornton,
Mike Chicarelli and others.
TL has to do with our CNO being a knowledgeable
transformational leader, with a strong vision and
well-articulated philosophy, to mention a few
things that go into
quality nursing leadership.
The result of good
transformational
leadership processes
means that “ ... nurses
throughout the
organization should perceive that their voices are
heard, their input valued, and their practice
supported.”
SE– Structural Empowerment Information was
presented by various representatives from different
units and departments, including Larry Cobb and
Helen Sisneros, of the Trauma Support Program,
presenting their colorful poster about their
community education program– “Think First.”
Lindsay Breen of the 4 West General Medicine unit
had a fun-looking poster about all the Nursing
Professional Development that is taking place
and being supported on that unit.
SE has to do with nurses throughout the
organization being involved in self-governance,
decision-making structures, and processes that help
to establish the standards of practice, and address
issues of concern at UNMH.
32
The first-ever Magnet Fair was held during
Hospital Week at UNMH in May 2011!

EP– Exemplary Professional Practice Posters and
information were presented by representatives
from different units and departments, including a
poster from Carol Vehar and her group at the Heart
Station, relating about the inter-disciplinary team
and teamwork that goes into their patient care.
Several nurses from PICU, including Tina Gonzales
and Kathy Bergs, addressed posters about Nurse
Self-Directed Learning and how they sought
information for the SOE– EP2. Celia Andrews &
Chris Foust spoke for their unit, the Trauma-
Surgical ICU (TSICU) about the poster showing the
best practice – “Nurse Voice at the Bedside during
Multidisciplinary Rounds.” Lisa George, RN,
represented Behavioral Health with a poster on
their Magnet data collection process. Other
posters included a poster form Rachel Rivera and
April Figueroa on Reducing Catheter Associated
Blood Stream Infections, and a Staffing Office,
Inpatient, PDSA poster.
EP has to do with how nurses “practice, collaborate,
communicate, and develop professionally to
provide the highest quality care for those served
by the organization” - such as patients, family, and
community. It is about our Care Delivery system
and our profession practice model, which is
currently being reviewed and updated.
NK– New Knowledge, Innovations and
Improvements Catherine Lukes, formerly RN
Supervisor of Labor & Delivery, spoke about their
poster on Coping with Labor. Barb Macmillan, RN,
Ruth Bear, RN and ML Johnson, RD from the Patient
Education Department presented a poster about
the work they are doing in their department related
to mentoring new Diabetes Educators.
NK is about UNMH conscientiously incorporating
and integrating “evidence-based practice and
ANNUAL NURSING REPORT 2011 — QUALITY
research” into our everyday “clinical and operational
processes.” Thus, nurses are able to explore and
implement safest and best practices for the
patients in their care and generate new knowledge
in the process.
EO– Empirical Outcomes The Nurse Residency
Program was represented at this table. This
program plays an integral role in assimilating new
nurses into the culture and practice of patient care
at UNMH.
EO is about UNMH establishing baselines for care
measures and developing the ability to track our
progress over time, including the use of national
benchmarks. “The empirical measurement of quality
outcomes related to nursing leadership and clinical
practice in Magnet organizations is imperative.”
SG– Shared Governance Although listed last, this
topic is one of supreme importance to our Magnet
Journey. Magnet Program Manager Adrienne
Fugett, RN BSN MBA, presented a poster on the importance
of Shared Governance. She had handouts
and answered questions about the process.
SG drives Magnet Recognition, and throughout our
written submission we will be required to discuss
how SG drives the nursing practice at UNMH.
~ Terri Gibson, MSN RN
33

ANNUAL NURSING REPORT 2011 — FINANCE
UNMH Nursing Research
Grants 2012
The following are grants for nursing research:
Daniels Foundation Grant, $75,000: The purpose of
the “Nursing Diversity Pipeline Youth Development
Program” is to increase the number of underserved
ethnic minority high school students into the
existing “Nursing Diversity Pipeline” program. This
program offers education in health careers, CPR,
First Aid and other health related subjects. This
program allows these students access to UNM
Hospital and its staff and encourages the youth of
New Mexico to enter into healthcare thereby
reducing health disparities in New Mexico.
DOH Grant. $25,000: The purpose of this program is
to ‘teach the teacher.’ The “Youth Development
Pathways” program allows nurses and other
educators from the UNM Hospitals to enter into
underserved rural areas, such as the Jemez Pueblo,
and teach local educators the skills necessary to
provide health and first responder type services to
their communities. The goal of this program is to
increase access to basic healthcare and emergency
services in rural areas by educating the rural youth
of New Mexico through the education of their
instructors.
Vision 2020 Grant, $5,000: The purpose of this
program is to measure the effect of an evidence
based program on health promotion practices in
overweight adolescents and their family members.
This is an eight week program that is offered in the
community and offers exercise, nutrition, a healthy
34
Finance
meal, goal setting, peer education for adolescents
and education for the whole family.
RWJF PIN-6 Grant, $150,000: The purpose of this
program is to capture the NM nursing workforce
data information and to establish a Hispanic Nursing
Association. A statewide survey has been
distributed to all nurses in New Mexico.
Other Nursing Research Projects:
Time allocation for frequent nursing tasks in a
metropolitan emergency department by Kate
Hicks, RN, BSN, CEN, Emergency Department
staff nurse
Comparison of Parenchymal and Ventricular
Intracranial Pressure Readings utilizing the
Hummingbird Synergy Ventricular System
(Innerspace, Inc.). by Tracey Berlin BSN, RN,
CCRN, CNRN
Neuro-Sacral Modulation in the Over Active
Bladder Patient: Continuous vs Cyclying
Program by Gwendy Beer, RN and Peggy
Gurule, RN
The Effect of End-of-Life Education on Moral
Distress of ICU Nurses by Stephanie Sanderson
RN, MSN and Nicole Adams, RN, MSN
The Therapeutic Effects of Mindful Movement
and Breathing Exercise on Reducing PTSD
Symptoms by Sang Kim and Kathy Lopez-
Bushnell, RN, EdD, MPH, MSN

ANNUAL NURSING REPORT 2011 — GROWTH
Community Meetings
Growth
Throughout 2011, UNMH administrators visited with
community members in meetings regarding growth
of UNMH facilities in the Albuquerque metro and
Bernalillo County areas.
The accessibility of health care in the city’s
neighborhoods is an important issue for UNMH.
Patient-centered facilities such as Southeast Heights
and Southwest Mesa Clinics have proven efficient and
welcomed models for UNMH to provide accessible care
to our patients.
Outpatient care, a large component of UNMH, relies on
nurses to provide comprehensive care to our community
population.
Clinical Neurosciences Center Opens
In December 2011 the UNM Clinical Neurosciences Center
began seeing patients. The state-of-the-art center opens
opportunities for adult and pediatric patients from the
community to receive care previously received only
out of the state.
35