Our Caring Culture-Your Nursing Destiny
This section will contain an ongoing case study illustrating some of the critical thinking and reflection of a nurse related to the weekly learning objectives. We will follow Nurse Daniel through his planning process involving a possible nursing practice change on his unit. The process he uses will parallel the process you will use in selecting a clinical topic, locating evidence through a systematic review, and applying the ACE Star Model of Knowledge Transformation (Stevens, 2013) in planning a change.
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Daniel has been an RN for 12 years and works on a Medical-Surgical unit at a community hospital. He is completing his BSN program in a few weeks and is being mentored by his supervisor, the current Unit Manager, who will soon be retiring. Daniel will be promoted to that leadership position shortly after graduating. Daniel is aware of challenges that are impacting patient outcome measures. Daniel is also cognizant of his own strengths and limitations and is currently developing a plan to address the unit patient issues, communicate effectively, and stay engaged with his peers, as well as maintaining his own positive health status.
Week 2: Lesson – Illustration
Daniel has identified a practice issue on his unit that he would like to address for better patient outcomes. The number of health-associated infections (HAI’s) have been increasing for patients with central lines on his unit. The current Unit Manager has alerted Daniel to the fact that infection rates of patients on the unit have increased by 35% in the past year. Daniel is unsure of the exact nature and cause of this increase but suspects there may be non-adherence to policies and/or procedural errors. As he reflects on this, he also becomes aware that when his role changes to the new Unit Manager, this issue will take on renewed importance and accountability. Deciding to be proactive, Daniel begins to search for a systematic review that could be used as part of an evidence summary for quality improvement with the HAI issue. He also plans to inquire about the unit data and other in-house information that might be pertinent. After discussing his plan with the Unit Manager, Daniel decides to use the Cochrane Database of Systematic Reviews to find an appropriate systematic review. His manager suggests he also use the ACE Star Model as a strategy for looking at the evidence and planning a possible change of practice.
After searching the Cochrane Database, Daniel located a systematic review that aligned with his topic issue. He has decided to use a PICOT format to further clarify what he is wanting to summarize and plan. As far as the scope of this practice issue, Daniel also found slight increases in the numbers of HAI on other units within the facility for patients with central lines. His thinking is that the nurses may be missing the signs of infection through irregular assessment and monitoring. Therefore, his PICOT contains the following:
· P=Patients over the age of 25 years with central lines
· I=Develop and implement an early detection system on his unit to compare with another unit
· C=The comparison of the 2 units related to the number of infections (HAI) on each unit
· O=The targeted outcome would be a decrease in central line infections
· T=The timeframe would be for a 6 month period of trial time
Daniel knows it will be important to justify his rationale for this type of trial, so he is preparing to summarize the discovered evidence. His Unit Manager has informed him that any trial involving a possible change of practice requires submission of evidence from the literature and presentation of the practice issue and evidence summary to the Unit Council for consideration. Daniel plans to recommend a Modified Early Warning Scoring (MEWS) system and emphasize the dangers of HAIs, patient safety concerns, unsatisfactory patient outcomes, and the variances in nursing practice from unit to unit in caring for patients with central lines.
For his evidence summary, Daniel hopes to convey:
· a statement of the problem and the possible related nursing practices that may be contributing factors
· the PICOT outline
· the chosen systematic review (related to improving professional adherence to guidelines for prevention of device-related infections)
· a summary of the review as it relates to the identified practice issue and suggested interventions to improve patient outcomes
As Daniel prepares his documentation, he is also aware that the Unit Council will want to know more about his implementation plan. He plans to address any limitations from the systematic review and how this could impact a trial.
Week 3: Lesson – Illustration
Daniel continues to think about a change intervention to support patient outcome improvement with HAIs. He begins searching practice guidelines and standards in order to further assess the feasibility of his planned intervention. His Unit Manager has suggested he do this in order to strengthen his rationale for this change and add to the evidence from the unit/hospital data and his chosen systematic review. Daniel has located and retrieved information from several other sources to add to his data and review. These include HAI-related articles and video presentations from the Centers for Disease Control and Prevention (CDC), The Joint Commission, and the Agency for Healthcare Research and Quality (AHRQ). He also retrieved a scholarly article about Modified Early Warning Scores (MEWS) describing how this system might be implemented. He plans to use all of this material in thinking about his recommendations for change.
Please watch the following video on Stakeholders:
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Daniel begins critically thinking about the possible costs of a change intervention and the stakeholders involved. He is aware that his organization requires permission to be obtained prior to trialing a change. Securing permission involves communication with all of the stakeholders for the change to be successful. He considers the culture of his organization, the informal and formal power structures, and the types of interactions he experiences with other nurses on his unit. Daniel is also aware of how change can be perceived differently by individuals so relating any potential changes to peers will require sensitivity and support. He knows his presentation to the Unit Council is a critical step in gaining further permission to proceed. In his hospital, the chairperson of the Unit Council will then make a presentation to the Quality Council for final approval.
Week 4: Lesson – Illustration
Daniel continues to work through the steps of the ACE Star Model (Stevens, 2013) as he further develops his intervention plan. In reviewing his scope of evidence, Daniel concludes that there are a number of variations in HAI prevention throughout organizations. Based on this, he decides to proceed with a plan to include the MEWS (AHRQ, Innovations, n.d.) system as well as periodic education sessions for nurses regarding central line best practices. Daniel works with his Unit Manager to create a plan to include the resources needed to initiate a trial of this system. Resource allocation is a critical factor for this intervention, therefore Daniel wants to also present evidence of the positive outcomes of using a MEWS (AHRQ, Innovations, n.d.) system based on experiences from other facilities. His Unit Manager has arranged a conference call to include Daniel and an assistant nursing director friend who currently uses the MEWS (AHRQ, Innovations, n.d.) system on her unit in a similar-sized community hospital.
During his conference call, Daniel learned that the patient outcome data indicated a positive impact due to an increase in nursing awareness and knowledge of HAIs as well as documenting of symptoms. However, there were still issues with nurse response times to patients whose symptoms changed. This information was helpful for Daniel and confirmed his intervention ideas of including an ongoing nursing education component as part of the introduction of an early warning system. With this added information, Daniel suggests to the Unit Manager that prior to his initial presentation to the Unit Council, education department personnel may need to be consulted regarding the feasibility of a related ongoing education initiative.
Daniel continues to identify team members in his plan and define their roles and responsibilities in this process. His thinking also includes attention to patient safety and satisfaction as well as the costs involved. Team members will include professionals from other disciplines. These members will also need educated regarding the MEWS (AHRQ, Innovations, n.d.) scoring system.
Daniel develops a timeline for the six month trial, including a pre-trial education period for the team members on the unit. Infection rates will be monitored as part of the data collection after the MEWS (AHRQ, Innovations, n.d.) system is in place for the trial. He and his Unit Manager complete a cost analysis of the trial resources to be used, including the costs incurred when patients develop central line infections, as a way to demonstrate how infection prevention will actually result in a cost savings.
Week 5: Lesson – Illustration
Daniel decides to prepare his presentation for the Unit Council in hopes of gaining support for his change process plan. His presentation will include the following:
· An overview of the ACE Star Model (Stevens, 2013) as a method to incorporate a change process with supportive evidence. This lets the Unit Council know he is using an evidence-based process in his assessment and planning efforts.
· An explanation of the problem identified, the scope of the problem, and an evidence summary will be detailed. He will include his PICOT question here.
· The evidence summary will include:
· potential interventions identified in a systematic review and other scholarly sources;
· specific data from his unit and other units in the hospital;
· information from professional practice guidelines and sources such as the CDC and Joint Commission; and,
· the information from his conference call regarding the use of early warning systems.
· Recommendations for change are described and based on the evidence summary.
· The identification of the stakeholders, the practice area, team member roles and responsibilities, and the required resources needed are included.
· The Action Plan including:
· the activities of the team involved through the process,
· ways to inform the staff of the plan,
· inclusion of data worksheets, tip sheets, and protocols;
· the coordination of ongoing weekly updates and education of staff, and
· the timeline to be used.
For the evaluation process, Daniel plans to include: a strategy for evaluating the results, who is to be involved in this collaboration, and next steps before disseminating information about the findings. Comparative measurable data outcomes will be recorded over the 6 month period with the hope that the MEWS intervention and education sessions will result in a decrease in central line infections on the unit. Daniel plans to use a bar chart throughout the timeline to illustrate the results on a poster within the unit.
If results are positive in decreasing the unit HAI rates, the decision for key hospital leaders will be to consider using a permanent warning system throughout the facility and then allocating the resources needed to accomplish this.
Daniel and his Unit Manager meet to go through the presentation content. Daniel is planning to use a PowerPoint presentation at the Unit Council meeting and also provide handouts to include his timeline, data worksheets to be used in the process, and the references and permalink to the systematic review article from the hospital library. His Unit Manager reminds him there are a few nurses she identifies as informal leaders on the unit that might be somewhat resistant to this type of change. These nurses are experienced and outspoken and have influence with their peers. Daniel considers ways to address this issue in hopes of gaining informal leader support.
Week 6: Lesson – Illustration
Daniel has successfully presented his change process proposal to the Unit Council and has received support for this practice change for the 6 month time period. He decided to invite two of the informal nurse leaders from his unit to the Unit Council meeting. They have been asked to serve as unit champions throughout the change process. This helped Daniel ensure these nurses were supportive of the plan and were willing to be involved. He understands the great influence informal leaders have and how valuable they are to the process. The Unit Council members accepted the idea of nurse champions to assist. This meeting helped reinforce the goals and the roles and responsibilities of those involved in this interprofessional team.
Daniel and the designated unit champions meet to discuss the tracking process involved in implementing this change. They will be using a form for tracking outcomes during this trial. The unit champions will be assisting in tracking data as well as the nurse response times to fluctuations in patient vital signs or lab findings. At the end of this implementation in 6 months, the results will be compared to the stated measurable outcome goals in order to determine success of the change.
Daniel and his Unit Manager discuss the specific elements they want to include in ongoing education sessions with the staff. They will need to collaborate with the Nursing Education Director to plan this weekly series. Daniel is also interested in receiving staff feedback throughout the process and thinks the education sessions might serve as a time to survey staff or have a discussion.
Moving forward in the process, Daniel schedules his meeting with the Nursing Education Director to outline content. In these sessions, he is wanting to review policies and protocols already in place and emphasize best practices for central line infection prevention. Meanwhile, his Unit Manager agrees to work with the Chief Nursing Officer and other leaders to coordinate scheduling for unit staff to attend the educational sessions.