P- Patient or population (problem)
One of the primary determinants of the quality of care provided in a healthcare setting is the type or kind of leadership within that setting. The nurse leader or Nurse Manager therefore plays a critical role in helping determine the quality of care. When the leadership style they utilize augurs well with the opinions and needs of their staff, then the quality of care is assured to be high and effective for the current patient population (The Joint Commission National Patient Safety Goals, 2012). However, in those instances where the leadership style does not suit the staff nurses and other workers, then the level of collaboration, communication and association is diminished which ultimately affects the overall quality of care. While working in a major orthopedic unit, I realized that as much as the available resources are highly effective, the overall determinants of the conical outcomes is solely based on the satisfaction of the nurses within that particular setting (Berg, Sailors, Reimer, O’Brien & Ward-Smith, 2012). When nurses are sidelined and considered as subjects of a particular rule, even with the utmost clinical experience, knowledge and skills, they may not necessarily deliver care to the optimal capacity they should or can perform (Galbraith, Butler, Memon, Dolan, & Harty, 2011). This particular setting had a total capacity of 180 beds and there was an average filling capacity of about 90%. The staff nurse population was between 54-64 when I first began working in this setting but the numbers have since risen to between 90 and 100. The staff delivery is something that was highly regarded as critical during the recruitments sessions and this was mainly due to the diverse patient population within the setting. On average, the staff nurses comprised of whites (41%), Latino (20%), African Americans (20%) and other minority groups taking up the remaining 19% of the staff nurses population.
The Nurse leader within our setting at the time highly valued collaborative approaches in resolving clinical issues and regarded all experiences within the settings as a learning experience for every other member of the workforce. This aspect of collaboration was essential within this setting especially due to the workload and in particular the diversity of needs as well as the changing needs of patients in orthopedic units. In most orthopedic units, patient frailties are a major concern for the staff nurses. These frailties are a potential risk factor for patient falls which result to unforeseen costs of treatment, increased lengths of stay in hospitals as well as higher morbidity and mortality rates for orthopedic patients (Neville, Lake & LeMunyon, 2012). The CDC estimates that by the year 2020 the overall costs of treatment of patient falls in clinical settings will rise to over $43.8 billion (The Joint Commission National Patient Safety Goals, 2012). In this view, the Center for Medicare & Medicaid Services (CMS) in early 2008 implemented policies that would ultimately deny reimbursements and payment of care costs related to patient falls within clinical settings (Galbraith, Butler, Memon, Dolan, & Harty, 2011). This was aimed at facilitating self-regulatory measures within healthcare facilities so that they can focus on measures and care models that reduce these preventable issues and their apparent strain of the budgets (Deitrick, Paxton & Swavely, 2012).
Within our orthopedic unit, there was a record of over 200 falls within the first two years since I began my practice within that setting. This was essentially a high number and worse still the repercussions of these falls seemed to place a strain on the budget of the orthopedic unit. On the other hand, the frequent falls implied higher morbidly and mortality rates for orthopedic patients which could have been prevented with effective measures in place (Berg, Sailors, Reimer, O’Brien & Ward-Smith, 2012). The staffing ratios within the setting were mot the primary cause of these frequent falls essentially because we had achieved the minimum staffing levels even within an increasing patient population. The major problem was the approaches of prevention of falls even before they could occur. With these falls, there were increased costs of treatment and the patient satisfaction as well as nurse morale was primarily affected especially due to the efforts placed in restoration and recovery of patient health (The Joint Commission National Patient Safety Goals, 2012).
Nurses would view these falls as a negligence of the patients and the patients or their families would regard these falls as a negligence factor on the aspect of the nurses and the physicians. This overall blame game resulted in poor service delivery, low satisfaction for patients and their families as well as strain, burnout and fatigue for nurses due to increasing complexities of patients’ health status (Neville, Lake & LeMunyon, 2012). The bed side safety rails policy was not working and there was a need to refocus on new strategies to overcome the apparent problem within the facility. Within this scope, this paper will seek to explore the problem as it were and the new interventions proposed to overcome this problem guided by the research question stated as follows; For Orthopedic patients, is hourly rounding a more effective care model as compared to use of restraints such as bedside rails in reducing patient falls?
Intervention: Hourly rounding
With the current policy of physical restraints (bedside rails and side rails) having proven to be non-effective in minimizing the falls, the need for a new strategy is more than inevitable. After deliberations between the Nurse Leader and the staff nurses it was agreed that the current records are not something that can be assumed as normal or self-resolving even with time (Neville, Lake & LeMunyon, 2012). It was the right time to shift from the current policy to a new strategy but this time based on evidence-based supported models of care that would resolve the primary problem of frequent falls as well as the related issues such as patient satisfaction, reducing nurse burnout and fatigue and increasing the availability of reliable patient clinical records for future reference. The only favorable strategy available that would provide a multiplicity of solutions to the apparent needs was the implementation of hourly rounding within the units. Hourly rounding is a strategy that involves the nurse or the nurse assistant to check in on each individual patient on an hourly basis and make a detailed documentation of the patient’s progress as well as address their immediate needs.
The nurse manager proposes that the problem of falls within the unit be resolved using physical restraints to prevent patients from leaving their beds- a solution that has not yet born fruit in terms of significantly reducing falls within the orthopedic unit.
Hourly rounding is one of the best practices in fall prevention. It is unquestionable that most hospitals have installed the necessarily fall prevention infrastructure but falls continue to remain a major challenge (Tucker, Bieber, Attlesey‐Pries, Olson and Dierkhising, 2012). Arguably, falls are not necessarily tied to lack of proper infrastructure such as slippery floor but rather are tied to physical weaknesses, cognitive and emotional weaknesses of patients, notably considering that they experience some level of pain-something that impairs their cognitive and physical abilities. Majority of falls occur when a patient tries to access the bathroom or washroom or even reposition in the presence of physical or cognitive impairment, subjecting them to a high likelihood of falling. Nonetheless, as a feasible proposal, hourly-rounding can potentially reduce falls among orthopedic patients since patients will no longer have to perform some basic activities such as accessing the washroom, repositioning or picking an item, say a utensil by themselves (Tucker, Bieber, Attlesey‐Pries, Olson and Dierkhising, 2012). Evidence suggests that hourly-rounding increases contact or interaction between the patient and the nurse and significantly helps the nurse in understanding the fall risks or needs of the patient are respond to them in a timely and proactive manner. Moreover, the more orthopedic inpatients see nurses or caregivers doing rounds, the less likely they are to try to perform toileting or ambulate.
It is guaranteed that the wish of every caregiver is to as much as possible enhancing comfort and healing through a humane, ethical and compassionate manner. According to Fisher, Horn and Elliot (2014), hourly rounding seemingly finds its roots in the concept of compassion and human interaction- concepts that are quintessentially patient-centered and pursues to provide care that is based on human ideals of sympathy and concern. Humans are purely social and our social and belonging needs cannot be met devoid of interacting with other people. This phenomenon of care that is characteristic to hourly rounding has a high likelihood of influencing staff motivation in a positive way and at the same time improve patient outcomes and hence satisfaction (Fisher, Horn and Elliot, 2014).Evidence suggests that most hospitals that have managed to zero on patient falls have moved towards hourly rounding since it has proved to guarantee near-zero risk of fall among orthopedic patients.
Among the primary issues that should be handled by the nurse or the nurse assistant during hourly round include the pain assessment, patient positioning, toileting or potty needs as well as vital patient possession such as the call or alarm button functionality. The primary objective of hourly rounds is to meet the immediate patient needs as well as ensure patient safety at all times. Those healthcare settings that practice hourly rounding as a strategy to minimize patient falls have been proven to record significantly lower patient falls as well as recording positive improvements in patient satisfaction, needs and safety (Galbraith, Butler, Memon, Dolan, & Harty, 2011). In orthopedic units, patients tend to be highly restricted in movement due to the apparent physical limitations of their joints and bines caused by injuries, old age or chronic illnesses. In this regard, their movements form one position to another even as they strive to satisfy their basic needs is a major loophole along which falls may occur. On the other hand, for these patients, the apparent injuries or illnesses are a limit to their independence and autonomy which explains the high levels of aggression in the realization that they cannot meet their self-care needs and that they need an assistant most of the times (Deitrick Paxton & Swavely, 2012). Such aggression leads to high levels of disorder in orthopedic units and nurses may at times feel overwhelmed by patient demands. Hourly rounds are effective in minimizing such incidents since they provide an even through which patient needs can be met without delay and patient will rarely recognize their apparent limitations in meeting those needs (Neville, Lake & LeMunyon, 2012).
Comparison: (Use of physical restraints)
Use of physical restraints includes installation of bedside rails and physical restraints on the wheelchairs. While it is an attempt aimed at resolving patient falls within the care facility, this approach seemingly present serious violation of ethical guidelines, notably, guidelines touching on patient autonomy and independence. It is highly recommended that whichever fall prevention approach undertaken, it should balance with the autonomy and mobility needs of the patient. Believably, apart from preventing falls, a patient has other equally important needs such as mobility and failure to balance fall prevention with these other needs, the patient can be termed to be receiving sub-optimal care. Additionally, using this method could in the process present other risks and complications to the patients.
Restraining movement can potentially lead to problems such as pressure ulcers, deep vein thrombosis, de-conditioning and aspiration (Berzlanovich, Schöpfer and Keil, 2012). Convincingly, a care procedure should be pegged to the fundamentals of holistic and optimal care in order to ensure desired outcomes are attained at the end of the day. Of course, it is the intention of every nurse to provide care in a comprehensive manner that will ensure holistic healing and utmost comfort by the patient. While the proposed solution by the nurse manager may to some extent reduce falls, it does not present a holistic solution and as such, it can potentially weigh down the motivation of nurses due to a high likelihood of complications arising from the fall prevention strategy. Development of any of the above-mentioned complications such as deep vein thrombosis or pressure ulcers translates to along hospital stays by the patients and hence increased workload per nurse-something that contributes to fatigue and work-related stress.
In fact, orthopedic patients are encouraged not to stay on bed for long and move around if possible to enhance muscle functionality. As such, there is an accentuation to come up with a fall prevention strategy or intervention that balances all the needs of the patients without necessarily making fall prevention a priority to other needs such as mobility and autonomy. It thus means that the best intervention should be tailor-made to prevent falls and at the same time, afford the patient some level of autonomy and freedom of movement.
The nurse manager depicts a blend of democratic leadership and transformative leadership, although he sometimes “puts a one man’s show”, adamantly sticking to his decisions and enforcing policies without seeking approval or suggestions from other staff. To a large extent this makes the staff feel overly supervised and under pressure to abide to the wishes of the nurse manager. Nonetheless, when his decisions or policies backfire or fail to meet expectations, he is quick to consult from other staff members and actively involve other nurses in pondering a solution. I believe, that the nurse manager loves to try out his ideas and he insists, it is good to learn from failures and that why failure should never be feared.
Outcomes
The intended purpose of implementing this evidence is to improve patient outcomes and nurse motivation. To a large extent, patient satisfaction is pegged on the level of satisfaction and motivation enjoyed by the nurse and in the absence of adequate motivation on the nurse or physician’s side, patient outcomes are liked to decline. As afore-mentioned, hourly rounding increases interaction between the caregiver and the patient-an aspect that increases emotional satisfaction for both the caregiver and the patient (Tucker, Bieber, Attlesey‐Pries, Olson and Dierkhising, 2012). Apart from the physical dimension of healing, the emotional aspect is equally paramount, bringing forth the need to provide care that satisfies both the healing needs of the mind and the soul. On the other hand, healing of the mind and the soul cannot be achieved devoid of a strong and regular interaction between the caregiver and the patient in a humane and compassionate manner. Hourly rounding is a proactive measure and among the intended outcomes of this intervention include;
Fostering the gaining of knowledge regarding patient’s fall risks and needs by the caregiver
Reducing falls within the orthopedic unit
Improving patient outcomes such as satisfaction
Reduce care costs associated with falls
Enhance staff motivation
Inculcate a proactive fall prevention culture
Prevent falls without necessarily having to curtail patient’s movement
Conclusion
Falls within the orthopedic unit form a major healthcare challenge and hence the need to review the current orthopedic fall prevention strategies that are in place. Sometimes healthcare providers are overwhelmed by the need to prevent falls, making other patient needs such as movement secondary. However, hourly rounding compared to use of physical restraints improve patient outcomes and help in avoiding the ethical and medical complications that arise from restraining patient’s movement (Tucker, Bieber, Attlesey‐Pries, Olson and Dierkhising, 2012). Moreover, and more importantly, hourly rounding has been tested and evidence regarding its effectiveness in terms of cost effectiveness and improving staff motivation has been documented.
References
Berg, K., Sailors, C., Reimer, R., O’Brien, Y. & Ward-Smith, P. (2012). Hourly rounding with a purpose. The Iowa Nurse Reporter, 12-14.
Berzlanovich, A. M., Schöpfer, J., & Keil, W. (2012). Deaths due to physical restraint. Deutsches Ärzteblatt International, 109(3), 27.
Deitrick, L., Paxton, H. & Swavely, D. (2012). Hourly rounding: Challenges with implementation of an evidence-based process. Journal of Nursing Care Quality, 27 (1), 13-19.
Fisher, S. K., Horn, D., & Elliot, M. (2014). Taking a stand against falls.Nursing2014, 44(10), 15-17.
Galbraith, J. G., Butler, J. S., Memon, A. R., Dolan, M. A., & Harty, J. A. (2011). Cost analysis of a falls-prevention program in an orthopaedic setting.Clinical Orthopaedics and Related Research®, 469(12), 3462-3468.
Neville, K., Lake, K. & LeMunyon (2012). Nurses’ perceptions of patient rounding. Journal of Nursing Administration, 42 (2), 83-88.
The Joint Commission National Patient Safety Goals (2012). Fall Reduction Program. NPSG: Goal 9. Retrieved from: http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=201& ProgramId=1
Tucker, S. J., Bieber, P. L., Attlesey‐Pries, J. M., Olson, M. E., & Dierkhising, R. A. (2012). Outcomes and challenges in implementing hourly rounds to reduce falls in orthopedic units. Worldviews on Evidence‐Based Nursing, 9(1), 18-29.
