Blog 5: Nurse’s Role Requirements and Expectations Reflection

Standard 12 Education: Registered nurses play a major role in healthcare. To be able to provide quality care in our ever-changing and challenging healthcare system, nurses are expected to be competent. Education is a major factor in nursing practice as knowledge and qualification can only be achieved through education. This will enable nurses to perform their roles competently. Besides nursing school, it is nurse’s responsibility to keep updating themselves through training, continuing education, and certifications. In addition to the broad knowledge acquired from education, it also helps with license protection since we can proficiently discern the do’s and don’t in nursing. Education equips nurses with the skills needed to practice competently delivering safe and quality care to clients which is a major role and responsibility in nursing.

Standard 9 Communication: Communication is important in coordinating patient care. It is required for an effective nurse-patient relationship. Sometimes, therapeutic communication helps the mental status of a client which can promote recovery from an illness. Another example is when effective communication helps nurses understand the needs of clients. Through communication, the needs are sometimes made known to other team members for more deliberations on the best care required for a certain client. Communication is necessary for successful teamwork in which nurses are involved to ensure quality care. Another importance of communication is the avoidance of errors. Errors and risks are avoided. For example, if a care partner notices that a confused patient is climbing out of bed to use the bathroom, and it is communicated to the nurse, appropriate measures will be put in place to prevent the patient from falling and sustaining injuries. These measures could include assisting the patient to the bathroom at a certain scheduled time thereby reducing fall risk while the patient is under our care.

Blog 4: Applying a Change Model Reflection

This Blog will address the application of ADKAR a change model to Sylvia O. Quality Improvement project. Nurses are change agents and they participate in different types of change.  These changes can occur at work, within the working environment and while caring for patients. Nurses assist clients who need certain adjustments for health purposes and are finding it difficult to adapt. These adaptations are some changes nurses are involved in. For instance, a client with coronary heart disease might find it difficult to comply with the required diet regimen, but a nurse can help educate the patient to realize the need to abide by it and assist them on ways to achieve this while providing support. These actions by the nurse could bring “the change” to effect.

In the Sylvia O. QI project, an increase in the missed appointments of patients was a problem. This led to the decrease in revenue which was a serious issue in the ambulatory care center. One of their goals was to lower the missed appointments to no more than 5%, thereby cutting down on the “no show” rate. To achieve this, some changes could be made using the ADKAR model of change. The ADKAR model consists of five components that are required for a successful change. The components are as follows:

Awareness, Desire, Knowledge, Ability, & Reinforcement.

These components facilitate change and will be applied to the Sylvia O. QI project.

Awareness: The staff of the ambulatory care center should be aware of the changes to be made and the reason for them. Sylvia needs to communicate effectively with the staff involved on the need to reduce double booking. This was affecting patient outcomes and causing prolonged waiting time between patients. Effective communication will create an awareness and the scheduling unit will be aware of the change as well as the reason for it. The staff also need to be aware of the “no show” rate issue and the changes to be made such as the increase in the reminders for appointments. If the staff are aware of the positive impact of an updated address and an effective reminder system, then they would desire it.

Desire: When the staff knows the reason for the change and the negative effect on the revenue, they will desire and support the change. Once there is desire and support, the staff will be willing to participate in the change. For instance, the staff in charge of scheduling will be willing to do what is required in an effort to reduce double booking. If the desire is there and an obstacle arises, the staff will be willing to go the extra mile to resolve the issue. For example, if Sylvia experiences any technical or IT issue, a staff who knows about it might willingly volunteer to check the system or even say “Let’s call the IT to quickly help us get this straight.” Having the desire for a change facilitates it.

Knowledge: Sylvia has the responsibility to help the staff understand how the changes will take place. The knowledge of this will help the staff prepare. She needs to be sure that they have the knowledge required to facilitate the change. For instance, to reduce the “no show” rate, the staff involved needs to know the various ways reminders can be sent to patients as well as how to operate them. Also, a knowledge of the plan on how to get the addresses updated will also be necessary for this project.

Ability: For a successful change to occur, Sylvia needs to assess the ability of the staff to implement the change. She will work on ensuring that the necessary materials needed are provided. Having the ability and positive behavior will enable the staff to implement the change. For example, If the schedule will be changed to reflect less of double booking, the staff involved should be willing to effect the change and should have the ability to be able to update the schedule in the system. For the set up of reminders, the staff should also be skilled and be able to program it as needed.

Reinforcement: The aim of reinforcing a change is to make sure it stays in existence the way it should, by supporting it. Sylvia should reinforce the changes made from time to time to be sure things are in order. And if adjustments are needed, she will be able to catch it early enough before it further impacts the revenue of the Ambulatory Care Center. The Patient satisfaction comment card should also be used to know if things are getting better with the change or there are still some other issues. Reaching out to physicians will also help to know if the changes are decreasing the waiting time and if they have the required time needed to achieve quality patient care.

Reference

Quyen Wong. (2019). Leading change with ADKAR. Nursing Management50(4), 28–35. https://doi-org.proxy.library.vcu.edu/10.1097/01.NUMA.0000554341.70508.75

 

 

 

 

 

 

Blog 3: Reflection Change Agent

Change Agents include nurses who identify problems of all sorts and try to fix them. Fixing a problem might involve making a change. To effect changes, one of the components that is essential for a successful change is communicating the reason for the need to make a change. This will avoid the resistance to change but rather aid the acceptance of the change. In this Blog, a clinical issue is identified and related to each component of the model of Professional Practice Regulation from the base to the peak of the pyramid.

The above diagram shows the components of the model of Professional Nursing Practice Regulation.

I worked in a wound care clinic where I took care of patients with wounds. Wound dressings were changed and topical medications were applied in line with the doctor’s order. I followed the standard of practice and worked within my scope of practice while caring for patients. I also performed wound assessments as trained. Sometimes, I had to attend seminars and training on wound care and the different kinds of dressings for different wounds. My manager was wound care certified and she cared for patients following the standard of practice. (Nursing’s Professional Scope of Practice Standards of Practice, Code of Ethics, and Specialty Certification).

During patient care, confidentiality is paramount and information can only be disclosed to only individuals involved in the patient care or health decisions. I had a challenging experience where a wound was draining excessively. I knew the current dressing was not the best as it was soaking the good skin causing more harm to the wound and surrounding skin. Following the Nurse Practice Act, I am not supposed to change orders or practice medicine without a license but I can advocate for the patient. (Nurse Practice Act & Rules and Regulation).

In order to advocate for my patient and make the required change, I had to inform the nurse manager first. This was the protocol that existed. Also, there was a policy that existed on assessing a wound both old and new wounds with each dressing change. The wound had to be assessed by the nurse directly involved in the care and evaluated by a certified wound care nurse which was my manager. Although I knew a change had to be made after my assessment, complying with the protocol was important. The nurse manager after her assessment reached out to the doctor and informed the doctor of it. She also gave me the phone to explain the issue at hand in detail since I was involved directly with patient care. (Institutional policies and Procedures).

I explained the need to change the dressing twice a day and as needed (PRN) as against daily which was the order. This was to protect the skin surrounding the wound thereby maintaining skin integrity. I knew that this change will further prevent infection and worsening of the wound. My advocacy and determination led the doctor to give me a new order for more quality patient care. I was determined to make a positive change for a better patient outcome. (Self Determination).

Reference

Med, W. R. A. 150-. (1970, January 1). Prompt #2: Defining Ethics (Nursing)- Bradley Robinson. http://wramed.blogspot.com/2016/02/prompt-2-defining-ethics-nursing.html.

American Nurses Association. (2015). Nursing : Scope and Standards of Practice: Vol. 3rd edition. American Nurses Association.

 

 

 

Blog 2: Model of Nursing Practice Regulation

The decision-making framework provides a guide for nurses to follow to ensure that they continue to act within the scope of practice. The models contribute towards the regulation of the nursing practice. Some components of the model include the:

  • Nursing’s Professional Scope of practice, the standard of practice, code of ethics, and specialty certification.
  • Nurse Practice Act rules and regulations.
  • Institutional Policies and Procedure
  • Self-determination

I worked as a wound care nurse in a hospital-owned wound care center. The team members worked within their scope of practice. For example, If I assessed a wound and the wound bed needs some debridement, I usually call the surgeon since surgical debridement is not within my scope of practice. Ethical responsibilities were seen as each staff carried out their role. “The ethical tradition is self-reflective, enduring and distinctive” (ANA, 2015). Ethics is very important as nurses work within their scope of practice and follow their standard of practice. For example, it was my responsibility to inform the right person first (surgeon) about a wound that needed debridement and also ensure that a follow-up appointment is scheduled. This helps with the continuity of quality care. When wound healing is not progressing, early detection can also help prevent it from becoming worse. In addition, we had weekly meetings where team members collaborate on difficult cases. The members include nurses, certified wound care nurses, a surgeon, a podiatrist, and a CHRN (Certified Hyperbaric RN). The aim was to ensure optimum patient outcomes. A lot of evidence-based practices are seen in the wound care setting. These practices enhance the quality outcome of patients such as the use of silver products to dress a wound or the use of synthetic skin grafts for diabetic ulcers. Special specific certifications and training are required to ensure that nurses are competent and able to provide safe care to patients. An example was when I was trained specifically on wound vac application. Whenever a wound vac is needed and ordered for a specific duration, I will apply it in line with the order. This example answers the “why”, “where” and “how” of nursing (Scope of Practice, Standard of practice, Specialty Certification).

The Nurse Practice Act (NPA), encourages a safe quality nursing practice for the benefit of the public. Delegations made were in line with the NPA requirement and the criteria for delegation were met. For example, the qualification of nurses, the safety of patients and the five rights of delegation were considered during delegation. For example, I have been delegated by my manager to set up an ultrasonic debrider for the doctor, but I have never been delegated to use it because it is not within my scope of practice and I am not qualified to use it (Nurse Practice Act & Rules).

For proper protection, the organizational policy there was to treat all wounds as if they were infectious and could get infected. Standard precautions were always followed including gowns and shields in cases that could involve splashes. All non-disposable equipment used was sterilized after each use. These protocols were to protect the staff and patients from any infection that could arise. Also, we followed a protocol that involved a wound culture for every new patient. This helped a lot because it helped with early detection of infection and early treatment since infection is a major cause that can inhibit wound healing. (Institutional Policies and Procedures).

When all team members embark on their respective roles in line with their various scope of practice, there was progress towards achieving a set goal. I was also determined to do my part in ensuring quality care. I was able to advocate for patients and achieved the maximum outcome for the clients within my scope of practice. It encouraged me and gave me job satisfaction to see that critical wounds and traumatic wounds eventually healed after a joint team effort. As I progress in nursing, I am determined to practice professionally within my scope of practice and contribute towards a safe and positive patient outcome (Self Determination).

Reference

American Nurses Association. (2015). Nursing : Scope and Standards of Practice: Vol. 3rd edition. American Nurses Association.

Blog #1 Reflection on Regulatory Agencies and Advisory Opinions

             

Advisory Opinion looks into a specific practice to determine if it is within the scope of practice of nursing or not. It analyzes a specific nursing practice question and may or may not give recommendations. The value attached to an advisory opinion differs from one state board of nursing to another. According to the Arizona State Board of Nursing, for instance, they describe advisory opinion as an “interpretation by the Board of what the law requires” and they see it as “more than a recommendation”. On the other hand, the Department of Human Services Nebraska considers their advisory opinion as “informational only and are nonbinding”. Therefore, it is important that registered nurses practicing in a jurisdiction are aware of their advisory opinion and the rules or restriction surrounding them. Another example of an advisory opinion is the administration of ketamine which will be compared between Arizona and South Carolina. In Arizona, registered nurses without CRNA (Certified Registered Nurse Anesthetist) cannot administer ketamine IV, or Intranasal bolus for the purpose of anesthesia or analgesia but can administer low dose ketamine for pain control, depression and sedation in line with their advisory opinion. For South Carolina, registered nurses can also administer low-dose ketamine but for specific diagnosis listed and not for sedation.

Arizona and South Carolina have some similarities in their advisory opinion regarding Ketamine administration which includes:

  • Registered nurses in both states can administer low-dose ketamine following monitoring precautions.
  • There must be frequent monitoring of patients such as frequent vital signs and the use of a sedation assessment scale.
  • Both states are mentioned that registered nurses can administer minimally low-dose ketamine.
  • Both states also mentioned that Ketamine is a controlled substance and therefore should be handled with precautions.
  • Both states’ advisory opinions are not intended for anesthesia.

Some of the differences between the two states regarding ketamine administration include:

  • In Arizona, health care professionals should have PALS and ACLS. This professional must be present from initiation till the end of the administration. Also, it is not within the scope of practice for non-CRNA registered nurses to administer ketamine bolus via IV or intranasal for analgesia or anesthesia. In South Carolina, it is within the scope of practice of a registered nurse to administer Ketamine IV push or continuous infusion for acute pain management and a list of other diagnoses. Other requirements include a physician order.
  • Although South Carolina has established some precautions, they allow facilities to make some decisions. Such as deciding the education and competencies required for the nurses designated by the facility to perform this role. On the other hand, Arizona seems to be more specific in stating what they want and defining the limits for their nurses.
  • In Arizona, standing orders or protocols are not used to adjust the infusion rate for low dose ketamine while in South Carolina, there can be an adjustment in line with the facility protocol but must be done under a physician’s supervision.

When advisory opinions are made, it requires competency on the part of the nurse for any nursing action performed. For example, if an advisory opinion states that registered nurses can administer naloxone in life-threatening opioid cases without an order. Even if it is not binding, it will still be the nurse’s responsibility to act competently and still be accountable for actions taken. The role of the regulatory agency focuses on making sure that the advisory opinions that are put out are adopted in line with the standard of practice. They also ensure that nurses are held accountable for their actions in the course of nursing practice.

References

Advisory Opinion Ketamine Administration. Arizona State Board of Nursing. (2020.). https://www.azbn.gov/scope-of-practice/advisory-opinions.

Nursing Advisory Opinions. Department of Health and Human Services, Nebraska. (n.d.). https://dhhs.ne.gov/licensure/Pages/Nursing-Advisory-Opinions.aspx.

Joint Advisory Opinion Issued by the South Carolina State Boards of Medical Examiners, Nursing and Pharmacy Regarding the Administration of Low Dose Ketamine Infusions in Hospital Settings, including Acute-Care, by Nurses. South Carolina-labor Licensing Regulation. (n.d.). https://llr.sc.gov/nurse/pdf/Low%20Dose%20Ketamine%20Joint%20Advisory%20Opinion%20Approved.