NURSING LEADERSHIP 11
A1.Introduction to the Problem
Conscioussedation, also termed as moderate sedation, presents a crucial topicin the medical world. The process involves administration ofmedicines that allow a patient to be relaxed (sedated) and to have nopain during a medical procedure. As the name suggests, the patienthas the conscious ability to be awake during the medical procedure,but with limitations when it comes to speaking (Wechter et al.,2015). Conscious sedation is widely practiced because it is deemed asbeing safe, given that quick recovery is almost a guarantee for apatient.
Onearea that has seen a broad application of conscious sedation is theprocedures that are done in the gastrointestinal sections. GastroIntestinal Endoscopy defines the procedures that are done in theaforementioned body parts. GI Endoscopy procedures have been noted tobe on the rise, as indicated by Borgaonkar et al., (2012), given thatthey are considered as being fundamental aspects of conventionalmedicine.
Withthe increment in the application of the procedure, it is critical tonote that service provision variation are quite evident, asidentified by Borgaonkar et al., (2012). Studies have in fact beendone to assess the quality of the GI endoscopy procedures that havetaken place (Borgaonkar et al., 2012). Research has confirmed thatthere is a noted increase of near misses in GI Lab with conscioussedated patients.
Thewidespread usage of conscious sedation, in GI endoscopy procedures,presents the hurdle as mentioned earlier, which requires immediateattention. Without adjustments being made to correct the aboveproblem, a rise in the statistics of adverse events associated withnear misses in GI sedation will continue to be on the rise. The paperwill seek to navigate through various sections, in the pursuit toidentify the ultimate solution that will be vital for the reductionof the cases of near misses attributed to GI endoscopy conscioussedation.
A1a.Explanation of the Problem
Onereason that has been presented to explain the increment of the risein the cases of near misses in the GI lab during conscious sedationis attributed to limited staffing. There has been the identificationthat registered nurses who administer moderate sedation have too muchto handle, to the extent that they lose focus on their primaryfunction of monitoring the patient`s response to sedation during amedical procedure. RNs tend to be overwhelmed with playing roles inboth the administration of sedation (moderate) while performingtechnical assistance, in a medical procedure. The aftermath is thatthe nurses lose out when performing both tasks, especially in caseswhere intensive technical support is of the essence. Calderwood etal., (2014) presented guidelines on the staffing recommendation thatis required for the various levels of patient sedation. Theguidelines for moderate sedation (conscious sedation) indicate thatin cases where an intensive technical role is paramount during amedical procedure, it is essential for an RN to have much-neededassistance to ensure that the nurses in question function effectivelyin their roles. Calderwood et al., (2014) confirms that theadditional assistant will have to play technical assistant duties.The above recommendation indicates that moderate sedation is adelicate procedure that requires the full attention of the serviceprovider (RN). The absence of complete attention, by dint of limitedstaffing related issues not only compromises on the safety of thepatient because of poor quality services, but also on the ethicalprinciples that are essential in the medical world.
Thenurses` priority in any given medical intervention is patient safety.When looking at prolonged endoscopic procedures, what has come outstrongly is that there is the dire need of having assistance in thesedated patient monitoring. The challenge that manifests as nurseswork to ensure the safety of the patient by administeringhigh-quality care is that of multitasking, ‘thanks to` inadequatestaffing. Inadequacies in staffing impair the process of havingnurses benefit from the coordination that would be present when thereis an assistant in place (UAP, LPN or an RN) during moderate sedationprocedures. The aftermath of the ‘poor staffing’ results in theincrement of the cases of near misses during conscious sedation. Therecommendations presented by the American Society of GastrointestinalEndoscopy Unit (Calderwood et al., 2014), confirms that one of themost critical aspects in GI sedation is staffing. However, even withthe identification of the role that staffing plays it is notablethat the level of staffing that is evident in endoscopy is wanting.
Theresearcher shares the views of Calderwood et al., (2014), who intheir article described in a given GI endoscopy functional unit,safety commences with the presence of leadership that is bothtransparent and efficient. With the presence of such a nursingleadership, what is bound to be instigated is a culture of safety,integrity, transparency, and teamwork, in the hunt to mitigate theoccurrence of adverse events. If a nursing leadership embraces thestrategies that have been put forward to maintain the safety of a GIendoscopy unit, (the report being centered on staffing), then nearmisses will be ‘a thing of the past.’
A2a.Evidence of Problem
Actualdata comes in handy when identifying the magnitude of the happeningsthat take place on the ground. Careful assessment of data sources is,therefore, critical in the bid to protect the integrity of theinformation that is presented. Actual events that have been collectedin line with sedation and medical errors confirm that something hasto be done to eliminate their occurrence. The data available from theJoint Commission (2016) indicate that actual events that have beenrelated to anesthesia in 2014 and 2015 were noted at six and fivecases respectively. By the end of the second quarter in 2016,anesthesia-related adverse events totaled at 3 (The Joint Commission,2016). Between the years 2005 and the second quarter of 2016, thenumber of reported events was noted to be at 105 (The JointCommission, 2016). Moving on to the number of medical cases that havebeen reported over a similar period in 2014, 2015 and the secondquarter of 2016, the figures stood at 20, 46 and 14 respectively.Over a span of a decade, between 2005 and the second quarter of 2016,the numbers collected that report on the medical errors were recordedat 460. Also, the statistics indicate that the setting of the adverseevents is the hospitals, recorded at 67% over the period between 2005and the close of the second quarter of 2016 (The Joint Commission,2016).
Thestatistics as mentioned earlier present a trend, which portrays thatmedical errors have been present and they will continue to exist ifsomething is not done to mitigate and then further eliminate them.The fact that self-reported cases, as well as errors reported byvarious means, have been present since 2005 until now, indicates thata gap exists, thus impairing the process of offering quality and safecare to the patients. Given the finding that 67% of the sentinelcases occurred in the hospital setting (between 2005 and 2Q 2016),means that changes in how things are done in the setting have toundergo a major transformation.
Thenumber of medical errors was noted to be at a high of 46 in 2015,while the second quarter of 2016 identified 14 cases. Anesthesiaevents, on the other hand, were maintained in the range of betweenfour and six between 2014 and 2Q 2016. The fluctuation noted in thetrend of medical and anesthesia errors confirm that a much-neededsolution is of the essence, particularly with the knowledge of thedata of the aftermath of the sentinel events.
Whenlooking at the figures presented by the Joint Commission (2016) inthe identification of the wake of the occurrence of the sentinelevents, various outcomes manifest. The higher extreme result that isnotable, and which will continue to be present with reported cases ofadverse medical events is the death of the patient. Other outcomesmay include body harms (both temporary and permanent), need foradditional care, and possible loss of function (The Joint Commission,2016). Some outcomes, according to the Joint Commission (2016) areyet to be known or assigned, which is a pessimistic scenario.
Thedisturbing fact is that some of the adverse events attributed tomedical errors and sedation may be going unreported, and it is thisconcern that the researcher is of the opinion that a proactiveattention ought to be considered. In the pursuit of the much neededimmediate attention, the researcher acknowledges that a strategy onthe element of staffing and continuous improvement therein isimperative, as the different sections of the paper will confirm.
A3a.Areas Contributing to Problem or Issue
Certainfactors contribute to the emergence of near misses in the GI lab,during conscious sedation as seen below.
Loopholesin the Role and Management of the Nursing Staff
Someof the issues that have been presented by Matharoo et al., (2016), asbeing critical factors in the prevention of Patient Safety Incidents(PSI) is the selection, administration, titration and monitoring ofthe sedative and sedation process. The above processes have beenidentified to be essential in the course of offering sedation topatients. If a loophole manifests resulting in impairment in any ofthe processes mentioned above, a compromise on the safety of thepatient will be likely to occur. It is, therefore, clear thathospital staff members owe patients the duty of care when it comes toreporting or taking action when an adverse occurrence takes place.Rigid nursing management that does not pay much attention tooverburdening of the fixed RN human resources worsens the role thatthe RNs play.
Also,the dependence on the hospital staff in the voluntary detection ofnear misses should not be the case. In fact, patients should have acritical role in ensuring that their safety is upheld at all costs.Patients have a role in engaging their caregivers with questionsregarding the care that they are receiving. Patients in other casesmay be tasked with monitoring of the medication that is provided tothem as well as the medical procedures that are performed to them. Itis clear that with the roles presented above, patients can be viewedas important lines of defense, in guarding against near misses asnoted in the section below.
Loopholesin the Patient’s Role
Thesad occurrence, however, is when patients do not quite realize theircrucial role in as far as the safety and integrity of their healthare concerned. On that note, it can be deduced that the lack ofpatient knowledge on the role that they are playing in as far astheir safety is concerned, in the hospital setting, is a contributingfactor to the near misses that occur during conscious sedation forinstance. The situation worsens when looking at the possible risk ofbeing addicted to the analgesia administered during conscioussedation, where some patients may fear reporting on the need forhaving pain medication. In addition to patients not realizing theirroles in fostering their health and wellbeing, there is theunderutilization of the said patients’ role in the identificationof errors that manifest when acquiring healthcare.
Itis worth to note that as much as some of the errors manifestingbecause of the reasons presented above may not have consequences thatare serious, they, however, represent latent errors in the system ofoffering quality care to patients. It is for this reason that theresearcher proposes a proactive solution that is presented below.
ThePresence of Reactive Systems rather than Proactive ones
Finally,poor systems of taking reactive actions in the event of a near misscaused by a staff occurs do not function to solve the problem of therising cases of PSI. Learning from the trends of staff related nearmisses has to be done to deal with the root taxonomies of theproblem.
Thesolution that the researcher proposes is in line with the need forhaving patient safety being embraced during the offering of care tothe patient, commencing from the GI lab. The researcher proposes theidentification and use of a patient safety checklist for GI endoscopyprocedures. The checklist will seek to function in accordance withthe safety quality assurance guidelines that are presently available,and as a result, reinforcement will be noted in offering quality careto the patients.
A4a.Justification of the Proposed Solution
Theresearcher, in line with the views of Matharoo et al., (2016), is ofthe opinion that through documentation done by the nursing staff,understanding and initiating a response, avoidance of errors inendoscopy will be considerably mitigated. However, the researcherwould wish to go a little bit further from the kind of documentationthat is proposed by Matharoo et al., (2016), by proposing thedevelopment of a database where the collected checklist data will bearchived by the nursing staff on duty.
Therewill be an identification of whether compliance with the checklistsis, in fact being done and even with the compliance, whether nearmisses occur and if the near misses occur, their frequencies and theunderlying causes that trigger them. What the researcher is trying toput across in simple terms is the need for continuous qualityimprovement in offering care to patients. One better way of doingthis is through the proactive measure of learning from trendscollected in pools of data, and thus striving to make committedchanges to the way things are normally done in as far as staffingneeds are concerned. After the aforementioned activities are done,then a critical role will be noted in the improvement of theendoscopy practice, particularly during conscious sedation processes.
Itis important to note that all the information present in thechecklist will have to be filled before the endoscopy practicecommences, and then fed into the incident prevention database. It isalso worth to understand that the information, which will becontained in the checklist, will have a section that will be filledby the nursing staff in charge, the assistant, and the patient (orhis/her family members). Incorporating the patient’s slot will becritical in ensuring that there is maximum utilization of the role ofthe patients in ensuring that they receive the best possible qualityof care. The information drawn from the patient will be paramount inoffering reinforcement to the nursing process and decisions duringmonitoring.
Thechecklist slot filled by the nurses’ on duty in a given procedureis essential in understanding the roles that will be played by eachof the nurse i.e. whether technical support or patient monitoringrole is taken up. The information that will be included in thechecklist is the selection, administration, titration and monitoringof the sedative that will be provided to the patient. As part of themonitoring process, emphasis will be placed on the need for havingtwo nurses in the GI sedation process, and so the names of the nursesthat will be involved with the process will be noted. The design ofthe checklist will be in such a manner that compliance with thesafety guidelines proposed by the ASGE will have to be upheld beforecommencing any of the GI Endoscopy procedures, particularly thestaffing guidelines, which are often ignored by the nursing managers.
Theprocess of implementation of the GI endoscopy checklist and theincident prevention database will be critical in as far as resourcemanagement is concerned. The cost of sales (COS) measure will come inhandy in the resource implementation procedure The COS will take intoconsideration all the costs that will go into the production of boththe checklist and the database. The section will seek to address thetime factor, materials that will be incorporated, personnel andmoney. On that note, changes to the gross profit of endoscopic unitswill observe a change where the COS will be deducted from the revenuethat is grossed by the units, in a given financial period.
A5a.Cost Benefit Analysis
ACost Benefit Analysis is paramount when it comes to identifying thebest alternative when it comes to determining the most beneficialoption when weighing between the advantages and disadvantages. TheCBA will look into the components presented below:
Designof the Checklist form Free
Hardware: Web server ($3000) – Available
Database(Sun Solaris) ($4977)
DesktopServer ($4100) – Available
TestingCenter Computers ($6200) – Available
Switches ($2200)- Available
Routers ($1000)- Available
Software: BuildingMaterials ($600)
Otherweb servers ($500)
Hiringmore nurses ($32.66/ hour* 20 nurses) $653.2 (hourly pay for 20 newRN)
($180/hr.* 1 consultant) ($180/ hr.)
WebsiteAdministration Support: ($12500)
QualityImprovement Training ($25/ hr.* all RN)
Checklistdevelopment will be done by the nurses and will be reviewed by thenurse manager before commencing usage. Trials on the checklist willbe done to ensure that it captures the roles of the caregiver and thepatient and that it is in line with the ASGE recommendations.
20Additional nurses will have to be hired at the cost of $32.66/hr.However, the nursing manager can reduce the number of new recruits byusing a lean team that is better compensated. Database support willbe provided by a consultant at a fee of $ 180/hr., for about200hours. However, employees with skills in database design can betasked to manage the support process with a pay increase, which ismuch cheaper than paying a consultant. Hiring individuals withspecialties in database management can be a cheaper option. Websitesupport and administration will be sourced at a low cost. The targetweb support providers will be employees with skills in web design.Quality improvement training will have to be done at the cost of $25/hour, by the use of consultants. The hospitals can, however, trainone or two managers who will be in a position to train the otherstaff, thus spending less.
Someof the hardware needed is readily available in the hospital, and soonly minor modifications will be done on the systems. The meaning isthat costs will be cut in the hardware development section, meaningthat the cost will be maintained at $ 4977and $1320 for the hardwareand software respectively.
Finally,it is critical to acknowledge that learning from the near misses thatoccur during conscious sedation can reduce a greater proportion ofthe approx. $9billion, which is spent in the event a preventableerror takes place in the hospital setting.
Theimplementation of the resources will take effect within certaindeadline limits. The Gantt chart provided below gives a breakdown onhow the project will be implemented.
Dec 2016- Jan 2017
Exploration stage (Needs assessment, intervention and its drivers, fit assessment of the new documentation system)
Installation (acquisition of implementation resources, staff preparation, identification of installation drivers)
1st Implementation (manage change, adjustments to the implementation drivers, improvement of initiation)
Complete implementation (monitoring and management of change drivers, achievements, and improvements)
A7.Identification of Key Stakeholders/ Partners
Inthe bid to meet the deadlines provided in the timeline, the projectwill require the input of different stakeholders. Some of thestakeholders that researcher notes will be of substantial importanceto the implementation of the vision of the proposal are thefollowing: Registered nurses, nurse managers, chief financial staff,IT personnel, the patients, and overall hospital managements at thelocal level.
A7a.Importance of Key Stakeholders
Theregistered nurses will be of the essence in the implementation of theapproach that will be utilized to curb near misses. They will playthe active role in checklist filling and update in the database thatwill be used. They will have to abide by the guidelines presented inthe ASGE, particularly in the area of moderate sedation. The nursemanagers will assume an essential role in overseeing the function ofthe nursing staff members who report to them. They will be the visionbearers in as far as monitoring continuous quality improvement of thecare offered to patients. They will also play a critical role inmaking sure that the ASGE guidelines are followed to the latter,particularly in the strategy that involves the staffing needs. Thechief finance personnel will be substantial in the disbursement offunds that will be critical in the upgrade of the documentationprocess in the hospital. They will also offer advice on the viableoptions of the materials that will be utilized in the projectimplementation. The IT personnel will come in handy in facilitatingtraining, upgrade, and customization of the new documentation system.The patient’ role will be essential in acting as key players in thechecklist filling given that their input will help the nurses on duty(monitoring and technical support) to make modifications to the carethat is provided to them. The patients will simply guide the staffingneed of the hospital, which is critical in fostering quality care.Upon engaging the above stakeholders at the hospital level, therewill be the need of escalating the system to the local level, if thesystem is proven to work. In such a case, the hospital and endoscopicunit managers at the local level are fundamental in the progressionof the vision of considerably reducing near misses in the GI labs.
A7b.Engagement with Key Stakeholders
Thehealthcare scene has seen multiple transformations, most of whichacknowledge the views of stakeholders. In the bid to fosterengagement with the stakeholders in the project, the researcher willtake into account the issues that are presented below:
Disclosureof information will be done, where communication regarding alldecisions will be conveyed early into the project and throughout theprocess. Consultations will also be done with the stakeholders aswell as conduction of follow ups to gain feedback regarding theinformation (input) that will be discussed. Also, negotiations willbe made throughout the project particularly when dealing withcomplicated issues. The outcome of negotiations will ensure that theneeds of all the project actors are addressed. In addition, anyconcerns or grievances that will be raised by any stakeholder will bemanaged in a responsive manner. Additionally, stakeholders will beinvolved in the monitoring of the project. Reporting mechanisms willbe in place to facilitate communication on the overall performance ofthe project. Finally, the management will function in such a mannerthat monitoring of stakeholder engagement will be in place, mainly tocapture the level of commitment from the key players.
Theresearcher will seek to use communication tools that will be centeredon awareness and the need for fostering continuous qualityimprovement in patient care. The researcher will use persuasiontechniques, which will be backed by sentinel data on why action tosalvage the occurrence of near misses in the GI lab ought to be done,and why the urgency.
Theproject implementation will be organized in three stages (theexploration phase is already done) namely installation, firstimplementation and finally, complete implementation. The installationphase will address the development of communication modes,identification of the responsible human resource staff, funding,carrying out purchases (technology) and licenses and finally, theintroduction of competency to the user. The first implementationphase will make considerations for training and coaching of the newsystem. Notes will be taken at this stage for continuousimprovements, which will be instigated rapidly. The completeimplementation phase will involve the active employment of the newpractices propelled by the ASGE guidelines (applicable to the nurses,patients, nurse managers). The nurse managers at this phase willprovide an infrastructure that will support the nursing staff even asthey carry out the sedation in the GI lab. Integration of novelprocedures will be promoted primarily in the hunt to escalate theproject to the next level.
A8a.Evaluation for Success of Implementation
Implementationsuccess will be guided by cross checking the evaluation criteria ofthe occurrence on the grounds. On that note, the criteria that theresearcher will employ to evaluate the efficacy of the project willtake note of checking whether the staff and patients are working inunison in implementing the new practice of reporting anddocumentation. There will also be the assessment of whetherinfrastructure that supports the nursing staff needs has been rolledout and is in fact working. The researcher will, in addition,evaluate the flow of funding and its sustainability. Finally, theresearcher will assess whether the new system facilitates learningand that a reduction in near misses is becoming visible.
SectionB: Personal Role Reflection
Inthe search to come up with the proposal, the researcher assumedvarious roles that were essential. Some of the characters that weretaken up included that of the scientist, detective, and the managerof a healing environment. The researcher assumed the roles in themanner that has been presented below.
B1.Role of a Scientist
Scientistsassume numerous roles however, the most common position is one thatrevolves around curiosity in the bid to seek answers. Scientificresearch, precisely, is conducted with the aim of identifying a newerapproach in dealing with a problem. The researcher assumed the roleof a scientist in a similar respect. The researcher was concernedwith the rising number of near misses in the GI lab and as a resultsought to find answers as to how the hurdle could be mitigated. Inthe end, the researcher identified that a newer approach todocumentation, with the main aim of continuous quality improvement,was the much-needed solution to curb the problem at hand.
B2.Role of a Detective
Theresearcher assumed the role of a detective by groping through pagesof literary material containing possible evidence in the bid tocomplete the puzzle for the ‘missing jigsaw pieces` in as far asidentification of the reason behind near misses in the GI lab isconcerned. The researcher incorporated his experience of seeing whatgoes on in conscious sedation and thus identified a loophole, whichhe saw were critical to research on and address before the nearmisses graduate to being serious adverse events.
B3.Role of a Manager of Healing Environment
Theresearcher took up the manager’s role of a healing environment byidentifying the key stakeholders in line with the cases of nearmisses during conscious sedation. The researcher then sought todetermine ways of engaging the stakeholders, in the search toidentify a solution to the problem at hand. The researcher, as partof his decision making duty, identified the cost-benefit analysis ofthe available options that will go into the providing an affordablesolution, thus indicating the role of being an overseer of financesand budgeting activities. The researcher assumed the role of amanager when the solution he identified was meant for the overallquality improvement of the integrity, commitment, and transparency ofthe personnel, which would in turn trigger safety in the care offeredto patients.
Insummary, the researcher is of the opinion that the proposed methodswill work to cut the number of near misses that occur in the GI lab.The researcher is also hopeful that continuous improvement of theimplementation details will yield positive results, and can beextrapolated to higher levels of patient care as well as becustomized for usage in other industries.
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Borgaonkar,M. R., Hookey, L., Hollingworth, R., Kuipers, E. J., Forster, A.,Armstrong, D., … & Dube, C. (2012). Indicators of safetycompromise in gastrointestinal endoscopy. Canadian Journal ofGastroenterology and Hepatology, 26(2), 71-78.
Calderwood,A. H., Chapman, F. J., Cohen, J., Cohen, L. B., Collins, J., Day, L.W., & Early, D. S. (2014). Guidelines for safety in thegastrointestinal endoscopy unit. Gastrointestinal Endoscopy, 79(3),363.
Matharoo,M., Haycock, A., Sevdalis, N., & Thomas-Gibson, S. (2016). Aprospective study of patient safety incidents in gastrointestinalendoscopy. Endoscopy International Open.
TheJoint Commission. (2016). Summary Data of Sentinel Events Reviewed byThe Joint Commission. Retrieved January 10, 2017, fromhttps://www.jointcommission.org/assets/1/18/Summary_2Q_2016.pdf
Wechter,D, G., Zieve, D., Ogilvie, I., and the A.D.A.M. Editorial team.(2015). Conscious sedation for surgical procedures Retrieved January10, 2017, from https://medlineplus.gov/ency/article/007409.htm