120 Hour Journal1
Journal Number Two 126.5hours with Michelle LoydRN at Crystal Clinic
Christopher Roth
N40045 Integration of Leadership and Management in Nursing
Phyllis Defiore-Golden MSN, RN
July 27, 2012
120Hour Journal
Part I: Integration of Leadership and Management
Quality Improvement
Quality improvement plays an essential role at Crystal Clinic. McLaughlin, Houston, and Mattson (2012) explain quality improvement as a “systematic process of organizationwide participation and partnership in planning and implementing continuous improvement methods to understand, meet, or exceed customer needs and expectations and improve patient outcomes” (p. 477). Crystal Clinic is currently involved in several quality improvement measures. These include their Call Don’t Fall program, monthly staff meetings, fire drills, nurses self-scheduling, and nurse practice counsel. The Call Don’t Fall program includes yellow socks and arm bands for high fall risk patients. Also, each patient newly admitted on the floor is required to sign a safety contract stating that they will use their call light before reaching, stretching, or getting out of bed. Along the hallway walls are poster boards that remind patients to call for help before attempting to try something that may be unsafe. A yellow star on the doorway indicatesto healthcare workers that the patient has a high fall risk. Monthly staff meetings ensure communication is current and ongoing. Fire alarms are tested daily to ensure proper working order in case of a real emergency. Nurses are able to schedule between themselves to ensure that they are happy with their schedules and in return are in agreement onworking selected days. Suggestion boxes are also on the floor so data can be obtained to look at areas that may need improvements. One representative from each shift will look at the needs of the floor nurses and will address issues as they arise or send them to the nurse practice counsel if further investigation is needed. The nurse practice counsel is in place to take concerns of the nursing staff to higher levels of management to negotiate solutions. Quality improvement staff provides data at staff meetings to explain new research or provide alternative ways of performing procedures. My preceptor is aware of quality improvement on her unit and knows that anyone can be involved in data collection by communicating to nurses and submitting findings to the suggestion box. I have ideas about improving Crystal Clinics’ online charting system by informing staff about the need to eliminatedouble charting. A study by Olrich, Kalman, and Nigolian (2012) indicated the need for quality improvement by increasing hourly rounding by nurses. “Hourly rounding is an important part of quality patient care” (p. 26). The results of their study indicated that fall rates decreased with increased hourly rounding and emphasized the importance of the hourly roundspart of quality patient care.
Change/Power/Conflict
Miller, Maloney, R., and Maloney, P. (2012) explain how “Effective nurses are powerful. With objectivity, creativity, and knowledge, they influence others through their practice. They develop and exert power from multiple perspectives; they use an understanding of power to motivate others, accomplish organizational goals, and provide safe, competent care” (p. 284). All hospitals experience potential conflicts that require resolution on a daily basis. In handling these changes at Crystal Clinic, floor nurses can present problems directly to their supervisor for each shift and add suggestions to the suggestion box. As mentioned above, a change I would try to make would be to eliminate charting twice in areas of the patient assessment. Since this is not a life or death decision that needs immediate attention, I would just make a note in the suggestion box. On my unit in particular, I have seen my preceptor use different types of power in talking to patients, families, fellow coworkers, and staff. She is able to ask probing questions and respond to doctors and patients in a professional charismatic way. Kim (2009) explains that“in many of the major studies power was significantly and positively related to empathy, job satisfaction, decision making, organizational commitment, self-esteem” (p. 25). I have also observed conflict on the unit in terms of the different responsibilities of day versus night shifts. These issues were resolved by having a group meeting to clarify assignments and responsibilities of each shift.
Teamwork and Team Building
According to Harris and Anunciado (2012) the characteristics of a successful team are that they have a definite purpose, are comprised of health care professionals with varied skills and backgrounds, they communicate closely, and understand each other’s roles (p. 268). Teamwork is very important on the orthopedic floor at Crystal Clinic. Patients frequently need assistance such as being pulled up in bed or help in using the bathroom. These tasks require at least two people, especially with larger patients that have a high fall risk. Registered nurses work with L.P.N.’s and nursing assistants, along with medical assistants, and are responsible for the care that is provided from these members of the team. It is essential that effective, clear communication takes place between each level. Registered nurses must have another registered nurse look at and sign off on insulin, blood, and blood products like fresh frozen plasma. Also, registered nurses rely on other registered nurses for help with IV sticks and other tasks that may require a more experienced nurse to complete. Margo Hospodar (2007) looked at ways nurses could comply with double checking insulin if one of the nurses needed to stay with his or her patient. The system that she designed was “the nurse administering the insulin would bring a copy of the doctor’s orders, the insulin, and a sticker to another nurse who would double check the dose and sign the sticker” (p. 6). The results of compliance increased with the new sticker system in trials at Ohio State University Medical Center. This research proved that limitations can be overcome with proper planning and systems in place. Team building occurs with social activities outside of work, monthly lunch parties for birthdays and special occasions. Members of Crystal Clinic participate in the Heart Walk for the American Heart Association. Another example that Crystal Clinic utilizes to enhance teamworkisteam building games like key words or phrases that help to enhance each members understanding of different roles and what they mean to each other. If I was to promote team building, I would start with the unit manager Mary Beth to get a program going.
Part II: Goals
120 Hour Review of Goals:
- Time Management & Prioritizing Safely prepare and administer medications. Goal met: I made sure that I had the right patient using two identifiers. I corrected myself from my first 60 hours and continually checked the patient’s name and birthdate throughout the day.This system prevented medication errors. I checked the medication against the order and the medication administration record, where I verified strength, route, time, and medication. I looked up the drugs that I was unfamiliar with to make sure I understood why my patient was receiving the medication as well as any nursing precautions I should be aware of for the patient. I am now comfortable with intravenous pumps, how to prime tubing and hang bags of fluid and piggy back medications. My time management and prioritizing skills have increased and I now bundle tasks if they are beneficial for the patient, depending on their condition.
- Delegation Practice delegating and become comfortable delegating. Goal met. I was able to delegate obtaining vital signs, recording intake and output, and recording blood sugar readings. I feel comfortable delegating and feel like I am professional whendelegating by communicating my needs to others in a positive and professional manner.
- Psychosocial Effectively use and practice therapeutic communication with each patient and their families. Goal met. I was able to practice therapeutic communication on 7 West at Crystal Clinic. I was able to talk to families and the patient at their level using language that patients and families understand. If asked further about how a medication works, I then went deeper into the pathophysiology.
- Pathophysiology Goal met. I still have a tremendous amount to learn in regards to pathophysiology of specific injuries on the orthopedic floor, however, I feel like I have a good understanding of the basic procedures performed like lumbar fusions, fractures, and decompressions.
- Extra Goals I was able to perform multiple dressing changes and perform a number of IVs and blood draws. I was also able to remove a Foleycatheter on a male patient and obtain blood through the patient’s PICC line. I also had the opportunity to work with multiple splints, c-collars, and orthopedic stabilizing devices.
Part III: Personal Reflection
During the past 60 hours to finish my preceded hours at Crystal Clinic, I have taken care of a variety of patients. Many of these patients have hip fractures, spinal stenosis with herniated discs, or some type of orthopedic injury. I am now comfortable with secondary drips and giving pain medicine around the clock. I performed many I.V.s and a several blood draws. I also removed one catheter from a male patient. I felt I was successfully able to manage my time with four patients, plan my day more effectively, and feel confident in my skills. My preceptor,Michelle Lloyd, has been a great teacher throughout my preceptorship. I talk to my patients in terms they can understand and elaborate if asked. Evaluating myself, I feel like I can handle the roles of a registered nurse and function well with a team of healthcare professionals. I realize I have more to learn and look forward to continuing my education after my BSN. I could handle situations on the floor with more ease and calmness compared to the first 60 hours. Prioritizing my time with each patient and continually reassessing what I need to do first is a big part of nursing and what I learned on the floor. In the future I now know I can handlefour patients with complex needs as a result of this experience.
Professional Issue
A patient on the floor with a history of atrial fibrillation is on Coumadin therapy taking 6mg Monday, Wednesday, Thursday, Saturday, and Sunday. On Tuesdays and Fridays the patient takes 3mg of Coumadin. The patient had an International Normalized Ratio (INR) of 2.22 before his first surgery. According to Newman and Zhitomirsky (2006) “Nontherapeutic INR levels are a source of risk for patients receiving oral anticoagulant therapy, and the targeted therapeutic INR range is extremely narrow. An INR below 1.7 has been associated with a doubling of stroke risk, whereas an INR above 3.0 doubles the risk of major hemorrhage” (p. 183). Fresh frozen plasma was given prior to the first surgery. After lab work was completed the patient had an INR level of 1.9 and the patient was cleared to go down for surgery. After the patient returned to the floor allblood thinning medication was held and with the next morning’s labs the patient had an INR level of 2.38. This value was out of range for this patient for the next scheduled surgery, so two units of fresh frozen plasma were administered. Before lab could draw blood for an INR value the patient was taken to surgery. Also, the patient was taken while the second infusion of fresh frozen plasma was still infusing and before another set of labs could determine if the patients INR was still too high.
Susan, the registered nurse on the floor, notified surgery staff members that the fresh frozen plasma was still infusing and INR levels still needed to be drawn. After she notified the team about the situation she charted the incident to cover all the events that transcribed. The hospital staff proceeded to take the patient down to surgery even while the fresh frozen plasma was still hanging and the latest INR was not drawn.
Nurses are liable for their actions or lack of actions while on the floor. This incident concerned Susan and she had to document everything she could to cover herself if an adverse outcome occurred. After discussing the incident with Susan, I know what I would do in a similar situation if it arises on the floor. I would first monitor the INR levels before hanging fresh frozen plasma. Next, during the infusion I would look for signs of fluid overload. Finally, after the infusion, I would again monitor the INR results and see if they are in the range set for that patient before sending the patient to surgery. If this INR was not in range or fresh frozen plasma was still infusing, and a new INR needed to be drawn, I would call the physician to explain the situation and ask if it would be possible to hold off on surgery if need be to finish the infusion and collect the appropriate lab values. As stated earlier by Newman and Zhitomirsky (2006) there is a narrow range for INR. This incident changed how I would handle myself in the future with any blood products. I now know that communicating with the physician prescribing the order and with other nurses is a key part of my role.
Final Preceptor/Student Evaluation
See separate attachment in email
Final Log of clinical Hours
See separate attachment in email
References
Harris, K. P., Anunciado, C. J. (2012) In P. Kelly (Ed.) Nursing Leadership and Management (3rd ed.: pp.267-282). Clifton Park, NY; Delmar, Cengage Learning
Hospodar, M. (2007). Sticking Together! A Creative Approach to Documenting Insulin Double Checks. From Rehabilitation Nursing 31(1), 6-8.
Kim, T. S., (2009). The Theory of Power as Knowing Participation in Change: a Literature Review Update. CINAHL Plus 16(1), 19-39.
McLaughlin, M., Houston, K., Mattson, E. H. (2012). In P. Kelly (Ed.) Nursing Leadership and Management (3rd ed.: p. 477). Clifton Park, NY; Delmar, Cengage Learning
Miller, T. W., Maloney, R. J., Maloney, P. L., (2012). In P. Kelly (Ed.) Nursing Leadership and Management (3rd ed.: p. 477). Clifton Park, NY; Delmar, Cengage Learning
Newman, D. H., Zhitomirsky, I. (2006). The Prevalence of Nontherapeutic and Dangerous International Normalized Ratios Among Patients Receiving Warfarin in the Emergency Department. Elsevier Science. 48(2), 182-189.
Olrish, T., Kalman, M., Nigolian, C. (2012). Hourly Rounding: A Replication Study. From MEDSURG Nursing, 21(1), 23-26.