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NSG3NCR Consolidating Reflective Clinical Practice Management

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Section 1 Planning

What is your topic and what are your objectives?
When you present this case to the Quality and Safety Committee, you are required to de-identify the patient due to privacy issues
Who is your audience (identify who are the members of a Quality and Safety Committee within a hospital)?
Produce a brief outline of what it is you want to convey to your audience (you can use dot points for this section).
Identify which format you intend to use for your presentation and briefly discuss why you have chosen this format. Here are some examples of various formats:
  1. powerpoint
  2. brochure
  3. e-poster
  4. Support your choice with evidence from literature – include references for this step.
Identify and discuss the method you will use to evaluate that your message has been received and understood by your audience.

In your discussion explain why you have chosen this method to evaluate the impact of your presentation to the Safety Committee. Use current professional literature to assist you to develop and support your approach. Some examples of evaluation approaches include paper surveys such as questionnaires, face to face interviews with individuals, or interviews with a focus group.

Section 2 – Presenting your research

Your presentation to the committee can be in any one of the following formats. Only choose one format:

- A power point presentation which could be presented as an oral presentation to the intended audience. Power point Guidelines: Must not exceed 12 slides. Attach your power point as slide handouts to an audience. Submit as either a Word or pdf document – with no more than 2 slides per page and follow submission guidelines in the assignment template.

Section 3 – Seeking Feedback

As this clinical project forms part of your graduate year, you require feedback from the Quality Health and Safety Committee members, so that you can include their feedback as evidence in yourportfolio.

  • A paper based evaluation tool which would be handed out to your audience or
  • An interview schedule (specific questions) if you were to conduct individual or focus group interviews to evaluate the effectiveness of your strategy.

Section 4 - Literature Review

A final component of your graduate year project is to reflect upon implementing your changes in practice. You are required to conduct a literature review of the current professional literature on implementing change in clinical practice (in other words, translating research evidence to practice).

- the barriers to change in clinical practice overall

- the facilitators to change in clinical practice overall

- how might the barriers and facilitators impact on the implementation of the changes you wish to make regarding Betty White’s care

Answer:

Section 1

Two safety standards that could have been maintained on the concerned patient’s admission to the hospital are prevention of surgical site infections and prevention of injury from falls. Falls resulting in injury are a prevalent patient safety problem (Healy, 2016). Due to lack of attendance by the nurse-in-charge, the patient suffered a fall and got severely injured. 4 days post her surgery for the fractured femur, the nursing staff found an infection with distinct smell around the wounded edges of the hip. In order to control this infection and injury from falls, some strict policies should have been followed in her nursing care (Grealish & Chaboyer, 2015). Any patient can be vulnerable to falls due to certain physiological changes related to medications, nursing, surgery procedures that leave them weakened. Surgical site infection is another common infection related to healthcare that occurs among patients and is responsible for about 77% patient deaths (Rasouli, Restrepo, Maltenfort, Purtill, & Parvizi, 2014). This project addresses the formulation or designing of interventions based on research and presenting them to the quality and patient safety control policy makers to integrate the improvement outcomes into making decisions on the treatment of such patients in near future.

The Quality and Safety Committee comprises of a Chief Senior Associate Medical Officer, medical directors, clinical staff president, nursing staff president, departmental quality officers, performance improvements representatives and some leaders appointed by the Chief executive officer. They are responsible for identifying, prioritizing and monitoring the effects of improvement activities, which include patient safety in the healthcare center (Parand, Dopson, Renz, & Vincent, 2014). They make recommendations for improvements in clinical practice and for changes in surgical procedures. They serve as a forum where information on patient safety and quality of the hospital is exchanged (Millar, Mannion, Freeman, & Davies, 2013).

Section 2

In order to avoid any untoward incidents like the ones which occurred during the patient’s stay in the hospital, certain health safety standards should be followed.

  • The clinical project will utilize sustainable evidence-based approach that can be applied on healthcare settings.
  • It will assess the safety standards that had been breached on admission of the patient to the hospital and will reinforce fall prevention and surgical site infection practices by prioritizing patient safety needs (Mosadeghrad, 2014).
  • It will provide a framework upon which a comprehensive and integrated program can be delivered, which will reduce negative impacts on patient health during their stay at the hospital (Lam, et al., 2016).
  • This program will help to monitor and improve the quality and safety of patient care delivered. This plan will support the organizational mission to provide clinical excellence at a reasonable cost and to continuously improve patient outcomes (Damberg, et al., 2014).

A Powerpoint presentation will be used to improve organizational practices associated with patient safety. It will involve an oral presentation that will focus on key points with the aim of facilitating learner’s achievement of the primary objective. The visual displays and graphs used will enable the audience to gather effective information and assimilate them for improving the health outcomes (Farrell, et al., 2014). The information will have a greater visual impact and the necessary health issues can be confronted.

Focus group interviews will be used as an evaluation tool. Focus groups are used in healthcare research to explore patient perspectives related to their healthcare facilities. An interview with the focus group will assist in identifying and clarifying their views on patient safety measures. The interview will contain not only specific research based questions but will also contain questions on sociological research related to the target group. Their shared experiences and opinion will offer a large context of research content (Krueger & Casey, 2014). The responses will help to structure information on their perspectives and will help to improve the establishment of recommended practices.  The interview questions will be arranged in such a way that a broadest response is obtained regarding needs of patient priority and safety.

Section 3

The interview will act as a quality improvement process that will seek to improve patient outcome through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Some of the questions to be asked ion the interview are as follows:

  1. What is the primary work area of this unit and how long has it been involved in the area?
  2. How are other members of the healthcare team communicated?
  3. When a medical error or mistake in patient management is identified, how often is it reported?
  4. When a breach of safety standard occurs, how often is it immediately rectified to prevent negative impact on the patient?
  5. Is patient safety sacrificed to get more work done?
  6. What are the common ways by which surgical site infections can be prevented?
  7. How do you know if the patient is VRE or MRSA? (Kiran, Murray, Chiuzan, Estrada, & Forde, 2015)
  8. What precautions should be taken to prevent infection in such patients?
  9. Describe the steps that need to be taken while preventing infection while inserting screws or plates in fractured areas?
  10. Why should the staff wash their hands and wear gloves?
  11. How do you know if the surgical instruments have been cleaned?
  12. How can injury from falls be prevented?
  13. How do you feel about patient falls in your hospital?
  14. What do you perceive to be the real cause for these falls?
  15. Is the nursing staff adequately trained to prevent such incident?
  16. Where do caregivers document their assessment?
  17. What should nurses do when such an incident occurs?
  18. How effective will practicing of health standards be in maintaining patient safety?
  19. Can you give examples of other interventions that might help such patients?
  20. How soon should intervention strategies be adopted?

Section 4

Medical healthcare facilities are technically complex at the system level, individual provider level and at national level. The huge amount of new knowledge that is generated every year due to evidence based clinical research is often applied directly on patients.  This knowledge can be used to overwhelm the physician and nurses who provide healthcare facilities. Optimizing the care that is provided to patients is of prime importance. Patient safety is thus an emergent discipline that is growing in the form of a trans-disciplinary system on research literature. The terms and definitions, which are associated with patient safety are quite complex. While maintaining patient safety emphasizes on proper report, analysis and prevention of medical errors that can lead to adverse healthcare outcomes among patients, certain concepts of risk factors, hazards and associated harm are involved with it. Furthermore, the lack of comprehensive education system related to healthcare professions is another contributing factor to performance deficiencies in the system (Jun, Kovner, & Stimpfel, 2016). In this review, relevant literature will be critically examined to identify the factors that address the attitudes and behaviors, integral to patient safety in hospitals. Several authors proposed a theoretical framework for promoting a safe culture. The review will organize different properties of patient safety by analyzing several studies and will provide evidence for a define safety model that could act as a valuable tool in supporting hospitals to improve safety culture.

 An analysis of patient safety standards require considering the potential hazards present in the concerned healthcare setting. It also evaluates the risks linked to these hazards and the possible consequences. If the hazards and their root causes are not properly considered, effective solutions to minimize risks of their occurrence and causing harm in the patients cannot be formulated. For this literature review, database searches were done using MEDLINE, CINAHL and SCOPUS databases. Following the search, all papers that were considered applicable and relevant to the purpose of this review were retrieved and assessed. Research provided evidence for barriers that are associated with clinical practice. The most prevalent barrier is the unfamiliarity of nursing staff with clinical practice guidelines and resource material. Studies proved that most of the medical staff was not aware of the guidelines that existed in relation to prioritizing patient safety standards and providing a holistic care facility (Antunes, Harding, Higginson, & EUROIMPACT., 2014). Staff usually confuses these guidelines with different types of paperwork that includes regulations formulated by the state, the reports of incident, nursing manuals, training tools and standing orders. Licensed practice nurses and other staff also display lack of education facilities. The senior administrative nurses often expressed worry regarding the fact there is limited scope of practice and training resources available with the licensed or registered nurses. This hampers their ability to implement an accurate clinical protocol or practice guideline. Limited health literacy among staff members is another barrier to effective clinical practice. This suggests the need if simplified literacy tools that can educate the staff on considering patient safety of utmost importance (Joseph-Williams, Elwyn, & Edwards, 2014). Often the scientific protocols are difficult to interpret by the staff. This creates a hindrance in providing adequate care to the patients. Multiple healthcare providers like physicians and nurses often reported that the protocols and guidelines are sometimes inconsistent with the idea of providing patient centered and individual care. Moreover, these guidelines are often placed inferior to the professional experience that they have.

The guidelines are not patient specific and need to be followed by focusing on each patient requirement. Family members and residents sometimes act as a barrier and create conflicts when the recommended clinical guidelines are implemented on patients. Most of the patients show noncompliance to effective treatment methods. Appropriate management steps are often not available to the nursing staff. This prevents implementation of strategies that can improve quality of holistic care and its timelines (Devaraj, Sharma, Fausto, Viernes, & Kharrazi, 2014). Following the protocol makes it difficult for the staff to look into the finer details of clinical practice. Designing of a checklist would help in promoting thoroughness in patient centered care. Practicing clinical guidelines makes the nurse-in-charge understand the rationales that need to be applied for the recommended care in the patient. Memories of previous incidents create a hindrance in continuing the practices based on the guidelines. These memories make the staff practice ineffective clinical care practices that fails to promote healthcare. There are several facilitators that enable prioritization of patient needs. Some studies focused on qualitative analysis to produce a conceptual framework on the barriers and facilitators that are related to efficient clinical practice guidelines. The facilitators were identified using semi-structured interviews that assessed the attitude of healthcare staff towards the practice protocols. The staff was made to describe the healthcare facilities provided to the patients and were made to explore whether the guidelines were followed in each case (Taylor, Machta, Meyers, Genevro, & Peikes, 2013). 2 types of practice development facilitators exist: internal (insider) and external (outsider) practice development facilitators.  Studies have identified external practice development facilitators as persons who are not a part of the healthcare organization (outsider). On the other hand, staff and physicians who belong to the healthcare setting are internal practice development facilitators. Both the external and internal facilitators were regarded to be caught in the middle between managerial and clinical constructions. They have to strive to move in the direction of synergy between bottom-up and top-down itineraries in the healthcare setting.

Effective clinical communication and teamwork act as facilitators for clinical practice.  This includes recording the context of the clinical incident, evaluating probable actions in the healthcare unit, promoting reflexive practice, disseminating valid information and working accurately.  Careful assertion, listening to the woes of the patient and observing any challenges that arise from the practices promotes efficient maintenance of care standards (Gagnon, Nsangou, Payne-Gagnon, Grenier, & Sicotte, 2014). Workplace culture, which refers to behavior and accepted social norms helps in proper implementation of clinical guidelines. According to one study, interprofessional collaboration amongst the staff and other team members depends on leadership qualities. Therefore, an excellent leadership style is generally identified as a relevant skill that the staff should posses. Several respondents who participated in the research studies proposed that if a leader is able to and responsible for making decisions related to providing quality care to the concerned patient, by collaborating with other team members, it acts as a source of motivation and promotes clinical practice protocols. 

Shared decision making and inclusion of all staff who are involved in the healthcare setting empowers them to treat patients with care. Transformational leadership fosters collaboration with others through shared power and shared decision making, which are also core elements of the care environment and care processes (Légaré & Witteman, 2013). Through transformational leadership everybody takes responsibility for quality of care. Effective time management acts as another facilitator. All staff remains busy while working in clinical areas and have high workload. When the staff was found to be less obsessed with their tasks, they provided more time to care for individual patients. This resulted in a holistic approach to patient centered care without any rush.  Continuous evaluation and monitoring of the success, while implementing the clinical protocols acts as a vital process in offering valuable information that helps in improving care facilities (Keiffer, 2015).  

When the evaluation processes are clearly planned and defined, they often identify several data-management plans and responsibilities. These observations appear appropriate and feasible methods during collection of data. When these resources are properly utilized, standards of clinical practice get improved. Staffs that evaluate patient records, compile them and adhere to the guidelines are responsible for providing comprehensive data that assists in identifying any gaps, which exist during implementing evidence based results. Therefore, these barriers and facilitators should be properly put into action while recommending strategies for improving the health outcome in the patient. Good working relationships need to be developed with the healthcare providers and the systems located across the hospital setting.  These evidence-based approaches need to be taught to the concerned healthcare professionals.  Availability of adequate resource material will help them in improving the standard clinical protocols that is required to be followed to reduce the negative healthcare impacts on the patient (Hebert & Glasser, 2014). Conduct quality improvement efforts with targeted healthcare systems and provider practices to improve health care processes and outcomes.  Specific quality measures and patient panels should be identified for each patient subgroup who is suffering from similar kind of health condition. Monitoring and institutionalization of standardized or aggregated quality measures should be available to all healthcare providers (Yevchak, et al., 2014). The concerned staff should have 4-7 years of experience in the healthcare system. They should display a firm understanding of practice workflow, care delivery and management.

Excellent interpersonal skills are required. The nurse-in-charge should pay more attention to the reports of the family regarding the patient and provide extra supervision if required. The root cause of delirium in patients should be identified and protocols should be accordingly implemented. The staff needs to develop excellent decision-making skills, troubleshooting abilities and self motivation.  Outstanding written and oral communication skills will help them to establish consultative relationships with the patient and the family members (Kelley, Kraft-Todd, Schapira, Kossowsky, & Riess, 2014). Moreover, they should adhere to the guidelines that are needed to be followed while performing any surgery on the patient. Adequate information on all forms of sterilization protocols, application of antimicrobial prophylaxis, skin incision safety precautions should be made available to the staff.

Thus, it can be concluded that education and clinical literacy play a central role in development of evidence based practices. Introduction of a sustained work culture, effective time management strategies, leadership qualities, constant supervision of the patients, continuous evaluation of the healthcare outcomes, identification of necessary competencies and shared decision making are fundamental in improving the health condition of a patient.

References

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Damberg, C. L., Sorbero, M. E., Lovejoy, S. L., Martsolf, G., Raaen, L., & Mandel, D. (2014). Measuring success in health care value-based purchasing programs.

Devaraj, S., Sharma, S. K., Fausto, D. J., Viernes, S., & Kharrazi, H. (2014). Barriers and facilitators to clinical decision support systems adoption: A systematic review. Journal of Business Administration Research, 3(2), 36.

Farrell, E. H., Whistance, R. N., Phillips, K., Morgan, B., Savage, K., Lewis, V., & Edwards, A. (2014). Systematic review and meta-analysis of audio-visual information aids for informed consent for invasive healthcare procedures in clinical practice. Patient education and counseling, 94(1), 20-32.

Gagnon, M. P., Nsangou, É. R., Payne-Gagnon, J., Grenier, S., & Sicotte, C. (2014). Barriers and facilitators to implementing electronic prescription: a systematic review of user groups' perceptions. Journal of the American Medical Informatics Association, 21(3), 535-541.

Grealish, L., & Chaboyer, W. (2015). Older, in hospital and confused–The value of nursing care in preventing falls in older people with cognitive impairment. International journal of nursing studies, 52(8), 1285-1287.

Healy, J. (2016). Improving health care safety and quality: reluctant regulators. . Routledge.

Hebert, D. L., & Glasser, E. (2014). Clinical Practice Guidelines. Drugs, 1, 10.

Joseph-Williams, N., Elwyn, G., & Edwards, A. (2014). Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient education and counseling, 94(3), 291-309.

Jun, J., Kovner, C. T., & Stimpfel, A. W. (2016). Barriers and facilitators of nurses’ use of clinical practice guidelines: An integrative review. International journal of nursing studies, 60, 54-68.

Keiffer, M. R. (2015). Utilization of Clinical Practice Guidelines. Nursing Clinics, 50(2), 327-345.

Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J., & Riess, H. (2014). The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PloS one, 9(4), e94207.

Kiran, R. P., Murray, A. C., Chiuzan, C., Estrada, D., & Forde, K. (2015). Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Annals of surgery, 262(3), 416-425.

Krueger, R. A., & Casey, M. A. (2014). Focus groups: A practical guide for applied research. Sage publications.

Lam, C. F., Hsieh, S. Y., Wang, J. H., Pan, H. S., Liu, X. Z., Ho, Y. C., & Chen, T. Y. (2016). Incidence and characteristic analysis of in-hospital falls after anesthesia. Perioperative Medicine, 5(1), 11.

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Taylor, E. F., Machta, R. M., Meyers, D. S., Genevro, J., & Peikes, D. N. (2013). Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers. The Annals of Family Medicine, 11(1), 80-83.

Yevchak, A. M., Fick, D. M., McDowell, J., Monroe, T., May, K., Grove, L., & Inouye, S. K. (2014). Barriers and facilitators to implementing delirium rounds in a clinical trial across three diverse hospital settings. Clinical nursing research, 23(2), 201-215

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