Nursing-sensitive indicators produced by NDQF are indicators that reflect the quality of nursing care provided to the patient that represents competence, devotion, and level of education / certification of nurse and organization. All indicators are based on empirical evidence. The indicator would be the number of patients falls (ANA)
State the problem and mission in measurable terms; clearly state the unit of analysis.
Explain why your selected nursing indicator is a priority for your organization and support your selection with data.
Identify which quality improvement model best fits your nursing indicator and justify your selection with evidence from the research literature.
Detail the primary measurement that you will be utilizing, and the goal, in comparison to an external source (i.e. scores received by other similar health care organizations on your nursing indicator).
Synthesize strategies for managing any ethical dilemmas presented by the initiative.
Falls are a major problem amongst the elderly, particularly amongst the 656+ population and can lead to so many related problems, occasionally to fatal results, that this essay considers it a crucial topic for nurses and caregivers to look into and investigate.
Approximately, a third to one-half of individuals fall each year (Downton, 1991), whilst in the United States, alone, one in three people, who are over 65, fall at least once a year, and this incidence increases to one into two people for those who are over 80 (Rosendahl, et al. (2003). The severity of fall complications also increases over age, particularly with females, resulting in more mortality and morbidity related to fall with individuals whose age exceeds 70 than with those who are younger (Gillespie, et al., 2009).
Consequences of falling can include post-fall anxiety, fractures, head injuries and loss of independence through falling, each of which has far wider ramifications impacting physical, social, meant, emotional, and behavioral spheres of the patient’s life. The ramification of falling, therefore, for the elder person has a wider and far-reaching impact that touches virtually every segment of his or her life. Falling can, accordingly, result in premature death. In the United States alone, the economic cost procured through fall-related injuries is predicted to total $32.4b by 2020 (Brown 2012)).
There is an extensive literature on the best methods to prevent falls, but the literature is so extensive that some of these methods are sometimes contradictory, and not all of the research has been scientifically conducted.
The Model for Improvement, developed by Associates in Process Improvement, is the tool that will be used in connection with these indicators as means for investigating and accelerating improvement. This model has been used successfully by many health care organizations in many countries to improve many different health care processes and outcomes.
It has three parts:
1. The Plan-Do-Study-Act (PDSA) cycle to test and implement changes in real work settings. The PDSA cycle guides the test of a change to determine if the change is an improvement. Team needs to know what they wish to accomplish
2. Team plots and assesses change
3. Teams decides whether more improvement is needed (Langley et al. (2009)
The importance of this essay is evident: prevention of falls among the elderly population can prevent so many of the complications form occuring. Life can be extended, negative ramifications (in all spheres of the individual’s life) be prevented; cost can be reduced; the terrific burden of care caused by providing care to the patient can be ameliorated; and quality of life — amongst other factors — can be enhanced. Furthermore, both primary health care and long-term nursing care would benefit from a comprehensive assessment of the methods most effective for preventing falls. As Brown (2012) pointed out the responsibility of nurses obligates them to expand their knowledge and skills on evidence-based interventions that are most effective in reducing frequency of falls for the individuals who are under their care.
Brown (2012) argued that in order for falls to be most effectively treated, causes of falls among the elderly population had to be analyzed, and their literature investigation led them to believe that cause could be categorized into two dynamics: (I) falls related to intrinsic factors (such as to medication or illness (such as Parkinson or hypertension; dizziness; depression; inadequate exercise; visual and/or hearing problems; anxiety of falling; diabetes; emotional and so forth)), and (ii) falls related to extrinsic factors (such as to environmental hazards; new and unfamiliar environment; footwear). It has been found for instance that the unexpected hospital environment or introduction t the unfamiliar setting of a nursing home can encourage falls.
Of concern and limitation to the literature on falling is that the construct is itself inadequately defined. Methods used for recording falls vary (Wolf, 1996) and consequent definition of falling can alter results of studies used to analysis the phenomena on and devise intervention. A consensus definition of falling, therefore, needs to be adopted in order to facilitate comparison and better theoretical and practical treatment of the subject. The Preventions of Falls network Europe (PROFANE) is in the midst of putting together such a package.
Part 2: Describe the team: membership, roles, facilitators, background/experience, and motivation within, followed with an analysis of the leadership role of the sponsor for this project.
Document the team process: determine meeting frequency, ability to fulfill roles on the team, etc. As this is a simulation exercise, you will create this information using best practices as a guide.
What leadership qualities should this “senior leader” or sponsor possess?
Do you believe this sponsor to be a transactional leader or a transformational leader?
What managerial attributes and actions would this senior leader need to employ to ensure that the staff will buy into workplace changes?
Predict how the senior leader role will evolve throughout the quality improvement journey.
Nurses may be student nurses, at least second year, compassionate, familiar with patients and hospital routine and acquainted with conducting experiments. Each of the participants will be motivated to reduce the amount of times patients fall and will be interested in patient’s welfare. The nurses will be working in medical institution or in a nursing home. All of the them will belong to the same institution.
There will be 2 to 3 meetings to discuss literature on research and ways of putting it into effect into following 9 months program as well as ways of evaluating it. The leader can use PowerPoint to delineate and may hold a training session if participants think it necessary. Handouts that outline main points will be distributed. Part of the session can involve role-modeling so that nurses understand all details. Nurses will be given opportunity to ask question following session.
The leader leading the program will have the qualities of transformational leadership
Transformational leadership is a term that was coined in the 1980s by Bass (2005). He uses it to distinguish between what he calls ‘transactional leadership’ where one simply ‘manages’ an organization or leads the other in a certain way so that employees achieve what the organization wishes them to. A transformational leader goes beyond that in that he actually transforms the follower: changes him, has an impact on his life, motivates him in an extraordinary way so that he work towards the good of meaningful and substantial goal in a passionate and, frequently, self-sacrificing manner. Transformational leadership may possibly be the highest level of leadership that one can attain and its responsibility is enormous given the huge impact that transformational leadership can make on the lives of followers and on those connected with followers. Ramifications are therefore enduring and trans-generational as well as, sometimes, global. Examples of models of transformational leadership are clergy, teachers, nurses, social workers — in fact anyone involved in the helping profession. Transformational leadership often involves taking a stance even though by so doing one may place one’s position in jeopardy.
Transformational leadership is distinguished by four different characteristics:
1. Transformational leaders have the ability to create visions and employ charismatic behaviors
2. Bass described transforming leaders as purposeful leaders who seek to understand the motivation and needs of their followers.
3. Transformational leadership generates collective purpose and can be judged effective if actual social change results.
4. When on or more persons engage others in such a way that leaders and followers raise one another to higher levels of motivation and morality, true transformational leadership is present.
.Although supposedly effecting employee burnout, Bass (2005) propose that the opposite is the case. By influencing and motivating followers, transformational leaders only increase efficacy of the other. Similarly and counter-intuitively, transformational leadership may be more effective than so called passive leadership in influencing others. It is to that end, therefore, that transformational leadership may be the best paradigm for the type of leadership that nurses should adopt and would be ideal in this case for leading a discussion/workshop group.
The entire process will be conducted according to the nurse ethics delineated in the ANA code (2001). These are essentially nine moral provision that are nonnegotiable in regards to nurse practice. Although not explicitly proscribing certain types of relationships with physician, they do provide an idea of the overall conduct that nurse is required to follow. The prescriptions include wisdom, honesty, and courage, as well as human dignity, integrity, respect, health, and independence.
Part 3: Formulate possible evidence-based practices and an action plan that could work towards achieving improvement outcomes.
Provide insight into the diagnostic processes (e.g., root cause analysis) used to determine the primary causes of the problem. Consider both qualitative (cause-effect diagram, barrier analysis), and quantitative (theory testing or drill down analysis) methods.
Analyze the cost-effectiveness of your initiative and how your initiative mitigates risk and improves health care outcomes.
Countless interventions have been used for fall prevention amongst the elderly population. These include risk-assessment and management programs, I.e. Designed to screen those who are most at risk and to design interventions that will reduce their risk of falling; exercise programs slanted dot enhancing flexibility, endurance, and strength; education programs (including one-to -one counseling on methods to prevent falls); environmental modification in homes or institutions (and amongst environment engineers in the outside environment such as parks streets and so forth); medication; and nutritional or hormonal supplementation. .
In a 20001 exhaustive review of 62 studies and trails and incidents related to falls amongst an elderly population (65 +), Gillespie and colleagues concluded that the most effective interventions are those that target already known fallers, rather than being general in their approach. Individual tailored packages may be no less effective than ‘packages delivered INS group format, and duration or intensity of management is also not shown to have significant results.
Exercise is effective, particularly that focusing on endurance, balance, and strength. Of all the exercises types, they found brisk walking to have the least impact. Ebrahim (1997) for instance reported that al his women in his brisk walking study group had had a limb fracture within the last two years, and progressive resistance exercise also consequents in more falls. Environment modification (aimed to reduce falls form occurring on the home premises by modifying elements) appears to be somewhat successful, but only when used in synthesis with other strategies.
There was no evidence that cognitive / behavioral interventions alone reduced falls, and incomplete evidence discovered that gradual reduction of medication reduced falls. In a more specific sense, vitamin D supplements do show some promise for reducing falls, but more studies have to be conducted to corroborate the effect.
In a met analysis study conducted by Chang et al. (2004), researchers scrutinized the following five factors — multifactorial falls risk assessment (I.e. individuals who had a history of falling and were most likely, therefore to fall), management program addend to individuals who displayed increased risk of falling (addressing these risks; such a program often included drugs), exercise, environmental modification, and education. The researchers discovered that the interventions most effective in preventing falls were exercise and falls risk assessment and management program. Education (aimed to instructing seniors how to mitigate their tendency to fall and conducted via pamphlets or posters at community centers to more intensive one-to-one counseling) was found to have negligible effects, as too was environment modification (where the immediate housing environment was engineered so as to prevent falls form occurring, more especially and to exemplify to monitor lighting, sliding carpets etc. And to remedy situation). For falls reduce the risk of falling of people who fell at least once and curtail the monthly rate of falling. Corroborating previous research that measured types of exercise (including endurance, tai chi, resistance, platform balance, and flexibly) it was found that no difference what the type of excise, exercise as a whole, particularly that that includes aerobic endurance, walking, cycling, gait-related practices, and other endurance related themes – was effective in reducing falls. Balance, gait, and strength were the recommended areas of focus. An integrated approach combining all three was ideal.
An international analysis of falls found that proportion of falls had risen in recent years (Brown, 2012). Why this is so, and indeed if this is so, is an interesting question in its own way. It may be that the incidence of higher increase f elderly and of people living longer lives may consequent in the larger record of falls. Either way, Chang et al. (2004) emphasize that understanding incidents that can induce and are related to falls is crucial in order for nurses to prevent falls form occurring and to deal with their patients in a mascot effective way. One of the ways in which this can be done is by recognizing individuals who are more immune to falling and by designing the institutional / hospital environment in such a manner so that it more readily discourages falls.
Chang et al. (2004) recommend adopting a two-pronged approach to fall intervention where a multifactorial falls risk assessment would be used in combination with a management program that would largely revolve around exercises. Both, too, would be targeting a selected population who has a history of falls, although the exercise programs could be generalized to anyone. Level of supervision and intensity are needed.
Implementation of such a program would help elder adults retain two of their most valuable resources — independence and functionality — as well as (amongst other factors) reducing burden of care on caregivers and reducing related national cost.
In a similar manner, Gillespie et al. (2001) recommended a program of muscle strengthening and balance retiring, as well as a 15-week Tai Chi group intervention program. Unlike Chang and colleagues, they thought home modification could be helpful; that psychotropic medication should be reduced; that a multifactorial risk assessment and management program should be implemented in connection with both individuals and in institution, and that this should be targeted towards individuals with a history of falling; and that cardiac pacing should be inserted in fallers with a history of cardio inhibitory carotid sinus hypersensitivity. Interestingly enough, individual exercise seemed more effective than exercise delivered within a group environment; national supplement was questionable; as was pharmacological therapy, home modification delivered alone; hormone replacement therapy; and correction of visual deficiency. Brisk walking in women over 65 should be discouraged.
A program could be put in place that would integrate each of these approaches mentioned above; the program would feature a combination of exercise, diet, instructional, and environmental components.
The program would also feature incorporation of some novel findings that have recently appeared and are debated in medical literature, namely whether or not Vitamin D reduces falls. There is no conclusive evidence on the subject although researchers have unanimously agreed that providing the Vitamin can only help and currently does not hurt. We will, therefore, incorporate Vitamin D in our agenda and keep a regular log monitoring whether or not admission of the drug reduces falls.
Brahe’s germinal study on the subject investigated 2 questions: firstly whether or not Vitamin D was helpful in reducing falls. Secondly, if so which level of Vitamin D would be helpful in preventing falls. The study framework was a double blind, control design group. With participants being randomly selected and divided between 5 groups. The research design was done in as objective a way as possible. One single environment — the Hebrew Rehabilitation Center for Aged (HRCA) – was chosen. 187 participants were carefully selected from within this population. Even though this was a convenience sample, the participants themselves were randomly divided between the 5 groups (one control and 4 Vitamin D treatment oriented). The whole occurred over a 5-month span. Baseline measurements of Vitamin D (and other patient characteristics) were taken at the outset as well as during the session period. A database of the amount of falls that the hospital had experienced (the facility incident tracking database) was assessed. Nurses gave participants daily the Vitamin D / placebo. Blood serum was taken. An objective outsider matched the serum results with the ratio of falling. Compliance was also recorded by blister pack counts after the completion of the study.
The researchers measured their current quantity of falls to the amount of falls that had occurred in the hospital’s past amongst their participants. The other measurement was the blood serum of Vitamin D This seems reliable to me.
Baseline measurements of Vitamin D (and other patient characteristics) were taken at the outset as well as during the session period. A database of the amount of falls that the hospital had experienced (the facility incident tracking database) was assessed. Nurses gave participants daily the Vitamin D / placebo. Blood serum was taken. An objective outsider matched the serum results with the ratio of falling. Compliance was also recorded by blister pack counts after the completion of the study Analysis of variance (ANOVA) was used for continuous variables and chi-square tests were used for categorical variables. Poisson regression (to correct for over dispersion and used as model count) was used to compare the amount of falls of each of the groups to that of placebo group. Each of the analyses was adjusted for age and vitamin use. Because not all were taking the vitamin D and some may have been taking it outside of the study, a secondary statistical analysis was conducted investigating study pill + vitamin, again using ANOVA, chi-square and cox.
The researchers concluded that Nursing home residents in the highest Vitamin D group (800 IU) had a lower number of fallers and a lower incidence rate of falls over 5 months than those taking lower doses.
I elaborated on this experiment since it would be interesting to incorporate a routine of Vitamin D administration that would replicate some of the steps used in this experiment and where result could be assessed in the same or similar way that they were assessed in Broe’s (2006) study.
Broe’s (2006) study was objective, tightly controlled and reliably conducted in many ways. It seems to be credible. They concluded that Vitamin D would be helpful in preventing falls. They also presented a level of Vitamin D that they stated would be most officious in preventing falls. It would be intriguing to know whether this study holds up to preventing falls in our institution and we can only benefit by following it.
Part 4: Summarize the impact of the team process on the nurse sensitive indicator.
Analyze monthly or weekly data points of the nine-month period.
Include a timeline that documents the various milestones seen from implementation to completion of the nine-month quality improvement model. You may use the quality improvement model of your choice (PDSA, DMAIC, Lean).
Demonstrate meaningful improvement utilizing a key metric such as graphs, control charts, or other valid statistical analysis capable of showing trends.
Given that our nurse team are motivated and given the fact that we are led by a sponsor / manger that possesses the characteristics of transformational leadership, there is a high possibility that falls will be reduced in the institution. This is particularly so since the training lesson and plan has been premised on through research that has investigated strategies and methods that have failed that have succeeded and that are questionable in terms of controlling falls. We have also chosen those that are most effective, incorporating new methods such as introduction of Vitamin D that can only increase chance of success. Patients are inspired by a motivated team of nurses. This we certainly have. By patients being informed about the rationale of the training and the reason for their following certain routines, it is more likely (although not guaranteed) that patients will follow process.
Given each of these factors (and other ignored ones), it is likely that the impact of the team process on the nurse sensitive indicator will be a positive one.
The idea for the training program can be illustrated thusly;
1. The Team decides what they wish to accomplish
2. Team plots and assesses change
3. Teams decides whether more improvement is needed
The entire process is one of acting, studying, planning and doing.
Part 5: Summarize the positive attributes of the team process in creating improvement.
Attributes can include, but are not limited to: motivation to improve, conflict and conflict resolution, change theory as applied to implementation strategy, negotiation, the role of senior leader in securing resources for the team, and other organizational and team dynamics.
The team is motivated this is particularly due to the fact that nurses are given responsibly in planning, implementing, and evaluating nursing care which boosts esteem and makes them feel responsible for outcome. There is also a collaborative atmosphere.
Furthermore, whilst urged and encouraged to work as teams, nurses are also adjoined to closely accord to the ANA (2001) code of ethics for nurses and to take the most scrupulous regard in not violating their working relationships. The Code of Professional Conduct for Nurses (CPCN) outlines the values and principles to which nurses are expected to heed and this helps create improvement in that it guides process in an ethical, respectful manner. The ethical principles and rules that commonly globally guide nursing conduct consist of nonmaleficence, beneficence, autonomy, fidelity, veracity, and justice.
Provision 1.5 of the CPCN provides that “the nurse should work collaboratively and co-operatively with other members of the health care team and should not hesitate to consult appropriate professional colleagues when needed.” This stricture will also guide and benefit the evolving process. All the time too, the team will practice a fidelity which refers to loyalty to commitments and to the profession, and avoidance of conduct (in terms of relationships) that is derogatory to either patient or colleague. This spirit of motivation to improve and desire to evade conflict and if and when it occurs to engage in conflict resolution, will also creates improvement.
Our nurses are empowered; independent, aware of ethical needs, and are each highly educated people who respect their profession. Each of these characteristics will supply a highly motivated stimulating environment
Our team also shares an adherence to Watson’s theory of patient-centered relationship. One of the theories that most contributed to and enhanced dignity for nurses was Jeanne Watson who recognized the tendency of nurses to relapse into demotivation for their job and into trivializing it which sometimes caused blurring of degree between doctor and nurse (since nurse failed to take her job seriously and was bored). Watson recommends a turning back to the remembrance of our original desire for wishing to become a nurse. The duties of nursing, she proposes, has turned us from motivation (or “body”) into machine, making us lose our original purpose and turning nursing into a profession that is contrary to what it is inherently supposed to be. Nursing is supposed to be a spiritual profession involving healing as per the literal and traditional sense of the word, literally ‘nursing’. To retain that focus and adherence to the meaning involves a holistic, spiritual focus on being ‘into’ nursing as a profession and we can do this by perceiving nursing as acting in the moment. Doing so, will enable our interactions with patients to be more humane and caring. According to Watson (2001), we can do this following the three grounding principles of her theory which are: (a) the carative factor by mindfully and calmly practicing loving kindness to the patient, (b) the transpersonal caring relationship and, (c) the caring occasion / caring moment which is a special kind of human relationship that transcends one’s own ego in caring and dedication to the needs of the others. Over and again, Watson’s emphasis was on the patient and she asserted that the patient’s needs must precede those of the nurses’ or traditional dictate of nurse to heed physician. The patient, according to Watson comes first.
Given these conditions that drive motivation and competence of our nurses and the intensity of our training programs it is likely that the NDQF indicators of patient falls will show marked improvement in the 9-mothnst program.
ANA Nursing-Sensitive Indicators. http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/Research-Measurement/the-National-Database/Nursing-Sensitive-Indicators_1
Butts, JB Ethics in professional Nursing Practice
Broe, K et al. (2007) a Higher Dose of Vitamin D Reduces the Risk of Falls in Nursing
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Moore, MD (1995) the basic practice of statistics New York: W.H. Freeman,
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Brown DI (2012) Falls in the Elderly Population: A Look at Incidence, Risks, Healthcare Costs, and Preventive Strategies Rehabilitation Nursing, 20, 80-89
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Ebrahim, S (1997) Systematic review of randomised controlled trials of multiple risk factor interventions for preventing coronary heart disease, BMJ, 314
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