TL - Transformational Leadership

TL10EO: Visibility, Accessibility, and Communication-Describe and Demonstrate changes in the work environment and patient care based on input from the direct-care nurses.

The following are examples of changes made in the work environment and patient care based on input from direct-care nurses:

Example of changes in patient care as a result of direct-care nurse input

Nurses from the Medical-Surgical units, 6 west specifically were concerned about Pain Management. The unit is a 38-bed Medical Surgical Unit that provides a number of services that include: eight (8) detoxification beds, two (2) epilepsy beds, and 28 medical/surgical beds. The surgical division includes trauma, bariatric, spine, neurology and orthopedic cases. Obstetric and Gynecological procedures as well as Oral Maxillofacial procedures are also handled on this unit.

The survey was conducted from January to April 2012 and divided into two (2) phases. The Phase I aim was to determine baseline data on how 6 West nursing staff attends to patients’ pain needs under the surgical and orthopedic services and to increase Patient Satisfaction scores (HCHAPs) on pain management rating from 50% as of mid January to 70% by the end of the survey. Phase I was conducted from January to February in 2012 for baseline data gathering. The patients were provided with the survey forms to complete during their hospital stay and note times and pain relief achieved. New clocks were installed inside the patient’s rooms so they could note times. After interventions were initiated, Phase II of the survey was conducted in April, 2012 to show improvement from the baseline data. Review below Table for baseline data:

TL10-Table 1

This Pain Management project was a part of the TCAB (Transforming Care at the Bedside) initiatives, and Lady Mendez BSN, RN, and Angelica Calaquin BSN, RN, staff nurses on 6 West were the Team Leaders for this process.

In Phase II of the project they began to implement their changes. They performed an educational session with the patients when they are first admitted and reviewed their pain medication history and listed the pain medications that they were currently prescribed. The nursing staff notes on the white board when the next pain medication is due and informs the patient of the possible side effects and/or interactions with other drugs they may be taking. They closely monitor the side effects and remind the physician/PA if bowel regimen medications are not ordered. They attempt to provide continuity of nursing care and utilize non-pharmacologic remedies in the interim period. The patients are supplied with educational material when they are discharged and the nursing staff insures that they have all the proper prescriptions.

Phase II data from April, 2012

TL10-Table 2

The wait times improved from 78% to 87%, however, the pain relief decreased slightly following administration of the medication. They did achieve their goal of raising the patient satisfaction scores (HCHAPs) from 64.5% to 71.9%. See graph below:

TL10-Table 3

Example on the Psychiatric Unit of nurse input on patient care

Pamela Santiago, BSN, RN, BC, a staff nurse on 5 West, Behavioral Health, was interested in reducing the use of seclusion and restraints on the unit. Ms. Santiago thoroughly researched the evidence and concluded that there is little support in the literature for the efficacy or benefits of seclusion or restraints. In fact, the opposite is true; restraint and seclusion have deleterious physical and psychological effects on patients and staff members. Ms. Santiago discovered that violence, self-harm and threats were the primary reasons that restraints were utilized. Ms. Santiago’s goals for this project were:

  1. Reduce or significantly limit the use of seclusion or restraints on 5 West
  2. Reduce the time or duration spent in seclusion or restraint while maintaining a safe environment
  3. Increase staff’s awareness of their attitudes toward the use of restraints
  4. Improve staff and patient safety and welfare

The tool that was used to measure the number of restraints used was developed by the staff of 5 West. The criteria for evaluation and use were as follows:

TL10-Table 4

There was also an area for comments on the tool. This data was collected on a daily basis on every patient with restraints or in seclusion.

The strategies that Ms. Santiago utilized to implement this project were:

  1. Quarterly staff (RN and PCTs) educational in-services regarding diagnoses and treatment, therapeutic communication skills training, alternative interventions, etc.
  2. Increased staff-to-patient ratios (staffing based on acuity levels)
  3. Treating patients as active participants in restraint/seclusion reduction interventions
  4. Treatment plan improvement
  5. Monitoring seclusion episodes
  6. Post incident debriefing and analysis
  7. Informing staff about the negative effects of restraints and seclusion and training staff in less restrictive ways in dealing with aggressive and violent patients i.e., Behavioral Management training on 5 West

Ms. Santiago implemented her program in January, 2011, and she has had some consistent results. Comparative baseline data used for this project was 2010 as compared with 2011 (after implementation). Ms. Santiago and the 5 West team decreased confinement episodes (seclusions and restraints) by 44 incidents in 2011 as compared to 2010.

Patient Restraints/Seclusion on 5 West