In order to tackle with the growing pressure on the healthcare system in Hong Kong, it is important for all nurse leaders to develop leadership competencies and build up high performing teams regardless of their level of responsibilities and working background. From 9th to 20th October 2017, a group of six nurses attended the clinical observational training in leadership organized by The Johns Hopkins Hospital in Baltimore, United State. This was the first time to involve a group of nurses from different positions and working background participating in an overseas leadership training program. The Johns Hopkins Hospital is the first Magnet Hospital recognized by American Nurses Credentialing Center for its excellence in nursing care. During this 2-week training, we were arranged to visit different clinical areas including Department of Medicine, Perioperative Services and Preoperative Evaluation Center, Comprehensive Transplant Unit, Adult Emergency Department and Pediatric Emergency Department. Besides, we also attended 3-day Nursing Leadership Academy and one-day Patient Safety Summit. Although the healthcare system in United State is different from Hong Kong, we are now facing similar challenges such as increasing demand for healthcare service and insufficient nursing manpower. Through this overseas visit, we had the opportunity to meet many experienced nursing leaders in The Johns Hopkins Hospital and learned how to engage staff, create high performing teams, promote evidence-based practice, and manage transition and conflicts effectively. As a team, we not only shared the visit journey in various clinical areas in The Johns Hopkins Hospital with each other, but also had fruitful discussion about the challenges we are facing in our own clinical settings from different perspectives. And as a novice at leadership, I cherished what I have learnt from the visit and all groupmates.
 

The Corporate Oversea Leadership Program provides a good opportunity to build up the competence of clinical leader and also broaden our perspectives in oversea health care service delivery. The UC San Diego hospital we visited, was bestowed the Magnet recognized health care organization for quality patient care, nursing excellence and innovation in nursing practice.
The Magnet Hospital is based on strengths in five key areas as structural empowerment, transformational leadership, exemplary professional practice, new knowledge innovations and improvements and empirical outcomes. The transformational leadership plays a proactive role in the healthcare management that inspiring followers to change perceptions and motivations to work towards the common goals of the organization and creating a sense of commitment.
The regular executive patient safety rounds and Nurse Collaborative Round among nurses and the leaders in the UC San Diego hospital can facilitate the mutual learning and sharing of the best practice to enhance safety of patient and quality of care. The periodic clinical nurse workshops act as a good platform to encourage staff to gain recognition through conducting research to develop new models and evidence based nursing care. The just culture is facilitated in the UC San Diego hospital for open communication focused on the improvement of care instead of blaming or criticism.
The clinical service development and enhancement in individual hospital as well as the cluster based service in Hospital Authority in HK will also be led by competent leader. The roles of the clinical leader in the healthcare unit are to promote the teamwork among staff and motivate staff to function at a high level of performance. The new generation of clinical leaders needed to be equipped and nurtured with significant training and support to enhance the continuum and standard of care.
The synergy in nursing chain can be best demonstrated in our groups of participants for this leadership program in different ranks from RN, APN, DOM and GMN. This nursing chain reaction is powerful as it provides a great platform to learn and share the management skills from different positions and specialty nursing.
 

Background
Aortic stenosis (AS) is the most prevalent native valve disease in the elderly with a prevalence of 4.6% in adults 75 years of age. Patients with symptomatic severe AS have high risks of sudden death and their 2-year survival rate is only 30-40%. Surgical AVR is the standard of care but Transcatheter Aortic Valve Implantation (TAVI) is an innovative and alternative treatment option for the elderlies. A multi-disciplinary heart team approach has been recommended as Class I indication for managing patients with severe AS according to AHA and ESC guidelines. The “Heart Team” is used to describe the entire multidisciplinary team involved in the care of these high-risk, elderly patients in pre-procedural planning, intra-operative procedural details and post-procedural care It includes cardiologists, cardiac surgeons, radiologists, cardiac anesthesiologists and cardiac nurses.
Being a member of the Heart Team, nurses play a crucial role in the whole patient’s journey. The nurse’s competencies and expertise can provide administrative and clinical leadership within the Heart Team. Cardiac nurses help to screen and evaluate potential candidates, ensure they receive necessary assessment by echocardiogram, CT scan and angiogram to decide on suitability. Besides, the patients and family have to be well-informed for such high risk procedure pre-operatively. Intra-operatively, nurses have to prepare the valve going to be implanted and as an assistant as well after receiving appropriate training. After the procedure, cardiac nurses have to monitor the patient’s recovery and prepare the patient and family for discharge. After discharge, nurses have to keep track on patients’ follow up schedule and ensure ongoing monitoring of the health condition for each patient. Other than clinical duties, cardiac nurses have to organize heart team meetings and keep everyone abreast of the cases. Last but not least, keeping a good data registry with regular audit is very important as well.
Conclusions
In the early era of TAVI, most attention has been drawn to how successful the procedure was done by the physicians. In fact, multi-disciplinary team approach is the key to success. Cardiac nurse as the core member of the Heart Team, not only help to organize and facilitate communication among different disciplines but also integrate best practices for best patient outcomes. Hopefully, this group of high-risk patients can regain their lives with reasonable quality and good outcomes.
 

Electrophysiological recording (IONM) during neurosurgical, orthopedic, and vascular surgery are gradually becoming part of standard medical practice, mainly because it provides information regarding the functional integrity of the nervous system. The merits of IONM have been extensively reported in the literatures worldwide, in terms of its high sensitivity, specificity and prognostic value in surgical outcome.
Currently, multimodal methodology include monitoring of electroencephalogram (EEG)/ electrocorticography (ECoG), evoked potentials (EPs), electromyography (EMG), nerve conduction velocity (NCV), and spinal reflex are employed together in many types of major neurosurgical procedures. It serves to avert damage (e.g. ischaemia and mechanical injury) of neural tissues that are at risk during surgical maneuvers, and to identify specific neural structures and landmark (e.g. central sulcus mapping, motor & speech cortex mapping, cranial & spinal nerves functional mapping and integrity check etc). Continuous measurement of electrophysiological signal changes allows one to objectively assess, detect and quantify the variations of the functional integrity of neural structures over time. The real-time information also enables the assessment of efficacy of surgeon’s corrective effort upon the alert of potential damage and effectiveness of surgical intervention.
In Hong Kong, IONM programme has been developing in each neurosurgical centre since 1996. Staffing of the monitoring team usually include Neurosurgery Nurse Consultant (NC) or Advanced practice nurse (APN) with related training at local or overseas, and under supervision of reading surgeon during the course of monitoring. Most of the local practice guidelines are adopted from overseas professional Neurodiagnostic Society (e.g. the American Electroencephalographic Society, American Clinical Neurophysiology Society), in terms of monitoring technique, equipment, personnel competency, and documentation etc. In our review, the overall outcome of those critical neurosurgical procedures with IONM is comparable with the results from literatures.
The coming direction of our service will be the emphasis on advanced training, technology & skill update, research, and professional development of monitoring staff, as well as, extended applications covering wider variety of surgery.