Along with reforms in health-care, the desperate need for quality of care and cost effectiveness as well as sophisticated growth of systems of health-care has become an amplified emphasis on outcomes and evidence. Such elements, plus the growing concern on changes in skill-mix, encouraged nursing to focus much on identification of outcome indicators that are sensitive to indicators nursing inputs as well as staffing levels. The first part of this paper looks at nursing-sensitive analysis and its importance in improving the effectiveness in nursing performance.
Nursing-sensitive indicators do define the end results of the nursing interventions and indicate problem progress or resolution towards symptom or problem resolution. Nursing outcome can be defined as a status or measure of nursing diagnosis at a point in time after the nursing intervention, while the nursing-sensitive outcomes can be defined as health status changes upon which care of nursing has influenced directly. Variables that affect patient outcomes include socio economic factors, diagnosis, family support, gender and age. The other one is the care quality provided by support workers as well as other professionals.
In the RTT1 situation there are many mistakes done that could lead to health care problems if not handled with care. Below is a summary assessment of the situation;
Figure: unethical issues analysis
Poor healthcare issues discovered
NCA fails to take measures to report patient condition after being informed by patient’s daughter.
Wrong diet fed to a patient with indications on meal showing that the patient is being fed with the right meal
Nurse sees a mistake and fails to report to protect the supervisor.
Hospital administrator reveals that the problem has been going for a long time.
It is the use of the sensitive outcome indicators that help focus attention on quality and safety of patient care as well as the care outcome measurements.
IMPORTANCE OF NSI DATA COLLECTION
It is vital for health care facilities and nurses to collect data, which helps in monitoring the ongoing quality as well as cost of patient care (Corrigan, 2002). The use of sensitive outcome indicators is critical to demonstrate effectively that hospitals and nurses make crucial cost effective differences in the provision of safe and high quality patient care. Another thing is that the significance of articulating nursing-sensitive indicators is not easy to overstate.
QUALITY CARE THROUGH OUT THE HOSPITAL
Such articulation as well as correlation of nursing activities with outcomes of health does provide do provide strong support to the appropriate allocation of resources of health care. For instance, studies that compare patient outcomes and staff levels do show that in a case where there are many nurses who are registered, patients do experience shorter stay lengths, fewer implications, overall lower costs as well as decreased mortality rates (Corrigan, 2002). In similar, a consisted and strong relationship has been established between staffing of nurses as well as five outcomes of patients in medical patients: pneumonia, urinary tract infection, upper gastrointestinal bleeding, shock, and length of stay. This does mean that higher nursing staffing levels are associated with lesser adverse effects.
All in all, nursing-sensitive indicators are projected to draw the correlations between resulting health status and nursing interventions that patients have received.
They are meant to be an attempt for measuring the effectiveness of care of nursing through measuring patient outcomes. It becomes easier to see linkages after diagnosis, intervention as well as outcomes are identified. Since nurses happen to be an essential part of the system of health care delivery, nursing sensitive indicators do capture what nurses do, the outcomes that they achieve as well as the costs involved. This happens to be a significant pace in suitable allocation of resources of healthcare and in making contribution of nursing to healthcare visible (M, Johnson, & S., 1996).
Nursing sensitive indicators can be can be used in assessing health care issues in three main ways:
– Indicators may be used to improve purposes within applied settings in monitoring performance and progress as well as supporting evidence based decision making.
– Indicators may be used in supporting informed policy analysis in relation to accreditation or regulatory requirements, reimbursement and workforce development.
– They can be used in researching role of nursing care in determination of patient safety outcomes through examination of structure outcome, structure process outcome relationships and process outcome (M, Johnson, & S., 1996).
For the purpose of mortality the following indicators are used:
– Heap replacement mortality rate
– CEA mortality rate
– AAA repair M, rate
– Craniotomy mortality rate, among others (M, Johnson, & S., 1996).
Specific indicators that could that help identify issues interfering with quality care in this scenario includes:
– Patient prolonged stay in the hospital
– Prevalent constraint
– Patient satisfaction
Some specific resources, referrals and colleagues that could help a nursing supervisor resolve the ethical issue within the scenario include the following:
– Use of a patient dieter to cater for matters of patient diets, also may consider a dieter familiar with local community norms. Also encourage diet enquiry.
– The supervisor can encourage doctor/nurse friendship and trustworthiness towards patients.
– Encourage co-operation between employers
– Encourage staff to promise hope to patients
– Use health-care workers awareness as a resource to help them understand how to deal with mistakes that occur in their line of duty. For instance to report them instead of being silent about them.
– As a supervisor, he/she should questions procedures and policies inconsistent with outcomes of patients/ therapeutic patent safety standards and best practice
– The supervisor can employ a system of addressing problems immediately after they arise to avoid repetition over long time.
M, M., Johnson, M., & S., M. (1996). Classifying nursing-sensitive patient outcomes. . J Nurs Scholarsh , 28.
CNA. (2010). Improve Quality, Reduce Risk by Identifying Causea. Analyzing Errors , 4.
The Canadian Nurses Association Code of Ethics for Registered Nurses. (2008). Nursing Practice Standards. Alberta: College and Association of Registered Nurses of Alberta.
The second part of the paper seeks to complete a root analysis cause, develop an improvement plan, and use failure mode analysis to project the likelihood that improved plan will not fail.
Step 1: Root Cause Analysis
RCA happens to be a structured method that is used to analyze events that are seriously adverse. Preliminary developed for the analysis of industrial incidents, it is widely deployed today as a tool of error analysis in health care. A central RCA tenet is the identification of underlying issues that bring an increase in the likelihood of occurrence of errors and at the same time avoiding the trap to focus on individual’s mistakes (Agency of Health Care Research and Quality, 2012). The main objective of RCA is the identification of both active errors (those which occur at the interface point between complex systems and humans) and talent errors (problems hidden within the systems of healthcare, which make a contribution to adverse events). The protocol followed by RCA begins with collecting data as well as constructing the event under consideration through review and participation interviews RCA aims at elimination of future harm through elimination of the latent errors, which so often do lie beneath diverse events (Agency of Health Care Research and Quality, 2012).
The root cause analysis takes into consideration the causative factors that led the sentinel event (the patient’s outcome). The multidisciplinary team consisting of a team leader, nursing and medical staff, pharmacy as well as a patient’s parent are the group conducting the exercise.
Type of factor
A patient was not placed under continuous B/P, ECG and pulse oximeter throughout the procedure and until the patient met specific discharge criteria.
Back up staff was not called or did not offer to assist when there was congestion of incoming patients; the patient’s family was left to monitor the patient.
Moderate sedation on a patient was performed by an unqualified practitioner who had not successfully completed the hospitals moderate sedation training module, which includes drug selection and acceptable dose ranges.
Patient received medication without considering adequate background information leading to medication failure to take effect.
Family ordered life support to be removed causing death of patient
Agency of Health Care Research and Quality. (2012). Root Cause Analysis. Retrieved june 3, 2014, from psnet.ahrq.gov: http://www.psnet.ahrq.gov/primer.aspx?primerID=10
Step 2: PROJECT DEVELOPMENT (THEORY CHANGE) TO ENSURE THAT THE OUTCOME OF THE SCENARIO DOES NOT REOCCUR.
A theory change happens to be the articulate of underlying beliefs as well as assumptions that guide a strategy of service delivery and they are believed to be crucial for producing improvement and change. Change theories do represent beliefs about the needs in a healthcare service and the strategies to help meet those particular needs. They do establish a context of considering the connection existing between a mission of system, strategies as well as actual outcomes, at the same time creating links that gets to be served, the activities or strategies, which are being implemented, and the outcomes that are desired (International Network on Strategic Philanthropy, 2005).
Theory change has two main components. The first one involves conceptualizing as well as putting into operation the theory’s three core frames, which include:
– Population- who is being served
– Strategies- what strategies are believed to able to bring about the desired outcomes?
– Outcomes- what is intended to be accomplished?
The 2nd component in theory change does involve the building of an understanding of relationships existing between the three core elements as well as clearly expressing the relationships clearly. The theory change can be defined by these three core-elements as well as the relationship existing between them.
Some of the reasons for developing theory of change include the following:
– It helps move people involved from a state of being passive collectors as well as users of information to active information users for service delivery and system planning.
– It helps programme staff and system to understand better the evaluation information type needed in making daily decisions (International Network on Strategic Philanthropy, 2005).
– It helps the evaluator develop research questions, which focus measurements on the changes, which can occur given specific schemes that are operative at the programme, system and client level.
– They do facilitate some understanding in the link between achievement of outcomes and strategies change theories facilitate data integration from a broader evaluation and accreditation to local evaluation efforts (International Network on Strategic Philanthropy, 2005).
IMPROVEMENT PLAN FOR DECREASING THE LIKELIHOOD OF REOCCURRENCE OF OUTCOMES IN HEALTH CARE ORGANIZATIONS/ HOSPITAL EMERGENCY DEPARTMENT (Change Theory)-RTT2
Departments of emergency are high risk areas; overburdened due to overcrowding leading to treatment delays, prolonged hospital stay, wrong administration of medication, delayed lab results among other shortcomings. The proposal will be focusing on health organizations especially the emergency departments. It will focus on improving health care especially drug administration in order to ensure non-reoccurrence of near misses and medical mistakes which are the known main causes of sentinel cases in the scenario at hand.
All the staff that provides health care increases their knowledge on patient backgrounds.
Change in policies
Specific policy changes.
Increase in policy statements that support patient care.
Policy makers draft legislation reflecting on health care.
Policy makers maintain and fund legislation that supports healthcare.
Funding of legislation that supports health care.
Recruiting qualified staff.
Staffs perform only tasks that they are qualified to perform.
Staff awareness on usage of equipment in the hospital.
Recruitment of enough staff.
Ensure staff are not overworking of staff
Right equipment should be implemented to avoid improvisation
Good care for equipment to avoid short life for equipment.
Available equipment to be put in use all the time.
Use of right equipment for the right task.
Prescription to be bone in good timing, correctly and accurately
Monitoring of patients during and after administration of drugs
Consideration of patient information during drug when prescribing
FAILURE MODE AND EFFECTS ANALYSIS
FMEA is a orderly approach way of evaluating a process to identify how and where it may fail and assess the impact relative to different failures, so as to identify the process’ parts that need change. A familiar mode and effects analysis in this scenario will focus on prescription of drugs to patients. In the scenario, the patient received drugs that did not perform as expected because the patient was earlier using much stronger medication. This process will evaluate the causes of possible failures and prevent them from happening again in the future through correcting the processes rather than waiting to react to adverse events after occurrence of failures. The process will be useful specifically in evaluation of new processes prior to implementation as well as assessing impact of proposed change to the existing process (Institute for Healthcare Improvement, 2014).
Failure mode and effects analysis tool
– Conscious Sedation in ER FMEA
AIM- decrease RPN for negative outcomes of conscious sedation by 100%
Wrong medication given
Lack of patient information
Gather enough patient information before prescribing
Staff involved failed to follow proper protocol while administering conscious sedation. Respirations, SPo2, B/P along with ECG not assessed properly
Limited staff on duty. Doctor should have had knowledge so as to order these assessments as well
Patient began to deteriorate. Warning signs were not properly assessed leading to patient’s desmise.
Staff will be re-educated on proper protocol with the procedure. Competencies will be there now as well as each year for keeping the knowledge up to date. Monitoring will be frequented to ensure adherence to proper policy.
Low o2 sat
Routinely administer supplemental o2
Monitoring was not properly initiated
Limited staff on duty
Patient deteriorated resulting to death at the end
Figure: Failure mode and effects analysis tool (Conscious Sedation in ER) ( Institute for Healthcare Improvement, 2014)
THE KEY ROLE OF NURSES
Nurses play very important roles in ensuring petient care and improving the patient lives. These role include the following:
– Caregiver- nurses perform activities of assisting patients psychologically and physically while prserving their dignity. Caregiving does comprise of psychological, physical, developmental , spiritual as wwell as cultural levels.
– Communicator- communication is essential to all roles of a nurse. They communicate with the sick, support them as well as other people within the community (International Culinary Institute, 2014).
– Teacher- they help patients understand their health as well as health care procedures that they need to perform in order to maintain or restore their health. A nurse does assess a patient’s learning needs and learning readiness, sets particular goals in conjunction is/her client enacts strategies of learning and measure learning.
– Client advocator- As a patient advocate, the nurse acts to protect the patient. In this role, a nurse may represent the wishes and needs of the client to other clinical professionals.
– Counselor- Nurses offers psychological, emotional and intellectual support to their clients.
– Change urgent- Nurses assist patients to modify their behaviours.
– Other nursing roles include leadership,management, case managent, research consumer, clinical spacialist, nurse practitioner, nurse midwife among many others (International Culinary Institute 2014).
International Culinary Institute. (2014). Role and Function of a Nurse. Retrieved june 11, 2014, from rnpedia.com: http://www.rnpedia.com/home/notes/fundamentals-of- nursing-notes/roles-and-function-of-a-nurse