Role of Nurses in patient outcome

Q.1 Order of tasks on the basis of priority:

The noble profession of nursing plays different roles in the lives of all nurses. Nurses are entrusted with a variety of tasks, such as, acting as a care provider, advocating for patient rights, liaisoning, providing education, and many other responsibilities. Furthermore, nurses also play a crucial role by acting as leaders in interdisciplinary medical teams. The health outcomes and satisfaction of patients are greatly dependent on the role and clinical expertise of a nurse.

In addition, nurses display excellent clinical judgment skills that are governed by their communication capabilities and delegation skills (Huber, 2014). In the given context, the primary objective should be to prioritise addressing needs of the elderly patient, who has been found unconscious. This situation should be considered a medical emergency, which if not treated immediately, might result in potentially harmful and fatal health consequences.

Owing to the fact that there are a plethora of issues in this context, I would focus on delegating the nursing staff according to their expertise and scope of clinical practice. The NMBA standards of practice (standard 6) illustrates the importance of delivering high quality, and responsive healthcare services to all patients, which in turn is facilitated by effective delegation of enrolled nurses and other staff according to their scope of practice and clinical roles (NMBA, 2018). In a similar way, I would request the concerned NUM, also a registered nurse to collaborate with us, in this emergency situation.

I would also seek help from the surgical consultant until appropriate services are made available by the emergency team. A patient’s health outcomes are directly influenced by medication administration. During our nursing course, we were taught the importance of checking and confirming the 7 rights related to medication administration by nurses, before giving any medicine to a patient. We were taught that ‘right time’ of administering a medicine is imperative to improved health outcomes of a patient, and that a registered nurse is bound to adhere to these guidelines.

Thus, I would attend the patient Mrs. Chew, and would reposition the cannula placement. I would also administer her necessary fluids upon arrival of the emergency team, following which the NUM would be requested to stay. Although, it is an essential duty of all nurses to document and record the exact time of antibiotic and other therapeutic administration, I would try administering the intravenous (IV) antibiotic to the patient, even if there is a delay in its administration by 30-60 minutes.

NMBA standards of practice for safe care

Recording accurate time of medication administration helps in preventing adverse health effects due to overdose due to the fact that there should be considerable time between administration of the first and second antibiotic (Roughead, Semple & Rosenfeld, 2013). I would also request the concerned enrolled nurse to provide proper medications to the patient Mr. Esposito, before sending him off for the medical procedure. She would also be requested to attend the visitor who has come to see Mr. Smith. Furthermore, I would also place a request in front of the AIN (Assistant in Nursing) for attending the visitor.

This would be followed by measuring the vital signs of the patient and subsequently reporting the readings to the EN or the physician, upon encountering abnormalities in the ranges. Enrolled nurses also have the expertise of measuring vital signs of a patient (NSW Health, 2010). In addition, the ward clerk would also be requested to assist in solving the problem of blocked toilet for the staff. The clerk would also be asked to reassure the patient Mr. Smith, and his family members, regarding his recovery.

This would be followed by a discussion of the error that occurred due to a delay in administering the antibiotic, with the surgeon because it does not show any adverse effects on the patient’s health at present. Situations as such are often encountered in the nursing profession due to the fact that health of an individual is a dynamic state of the wellbeing and often makes it difficult to anticipate beforehand.

Thus, it is essential for all nurses to have an idea that such emergency situations might arise in a healthcare setting. Therefore, it is imperative for all nurses to have a sound understanding of the rights related to workforce delegation, task prioritization, scope of practice, critical thinking, effective communication, and clinical judgement, with the aim of improving the overall health, wellbeing and satisfaction of all patients.  

References

Huber, D. (2014). Leadership & nursing care management (5th ed.). St. Louis: Elsevier/Saunders. Retrieved from 

NSW Health. (2010). Assistants in Nursing working in the acute care environment. Retrieved from 

Nursingmidwiferyboard.gov.au. (2018). Nursing and Midwifery Board of Australia – Registered nurse standards for practice. Retrieved 3 March 2018, from 

Roughead. L., Semple. S., & Rosenfeld, E. (2013). Literature Review: Medication Safety in Australia. Retrieved from  

Module2

Identify factors that determine which healthcare professionals are required to be involved in a health care team?

Major factors are associated with disease severity. Motor Neuron Diseases (MND) are most commonly found to affect the ability of a person to talk, walk, breath or swallow food. Therefore, it is essential to seek help from a respiratory specialist for addressing the respiratory distress, the patient is suffering from. An occupational therapist and physiotherapist will be called for assisting the patient in improving the motor skills, thereby facilitating mobility. Social workers and case managers will also play a crucial role in managing the financial and social issues faced by the patient. Furthermore, a speech pathologist will prove effective in treating the impairment associated with language comprehension and swallowing food. The neurological abnormalities will be treated by a neurologist and an MND nurse specialist.

Medication Administration and its importance

Who should lead the health care team?

The MND nurse specialist shall be held responsible for leading the healthcare team due to the fact that she would be responsible for forming a liaison with other members who are a part of the multidisciplinary team, thereby facilitating solving of the medical issues that have been identified in this context. 

Who is the most important member of the health care team?

All members of a healthcare team are equally important, as they are responsible for maintaining safety and optimal health outcomes for their clients. However, a patient is the most essential member of the team because the experiences, preferences and demands of a patient assist the healthcare professionals to deliver appropriate healthcare services. Moreover, it is the primary right of all patients to remain involved in their treatment. This concept of respecting the autonomy of a patient is therefore responsible for challenging the paternalistic duties of a physician (Carman et al., 2013).

ACTIVITY 2: CASE STUDY 3

Robert Hughes is a 52 year old male who was injured in a bicycle accident two months ago where he suffered fractures to his (R) tibia/fibula and (R) radius. Robert is intellectually impaired and was living with his elderly mother until the accident. Robert has been known to engage in verbally aggressive outbursts towards staff and other patients. His mother who is now 75 years of age feels she can no longer look after Robert. You are the NUM of the rehabilitation unit that is admitting Robert for his ongoing rehabilitation. You are required to gather together a health care team to determine immediate and long term care options for Robert.

What are the key issues in this situation?

One major issue in this context refers to the incapability of the patient Robert’s mother, the primary carer, aged 75 years, to care for her son. Old age of his mother does not permit her to provide appropriate healthcare services to her son, thereby resulting in her impairment to improve Robert’s optimal health outcome. Another issue is associated with Robert’s intellectual flaws that restrict him from taking self-care.

This makes him dependent on his mother. Socio-economic factors might also have an influence in this context. This can be attributed to the fact that although Robert is 52 years old, he does not earn a living. This makes him being looked down upon by members of his community and society. Moreover, his mother also demonstrates a failure to control his unruly behaviour, as evident by his bicycle accident and verbally aggressive behavior towards the nursing staff and co-patients. Another issue could be poor literacy about role of the community support system in providing help, as demonstrated by his mother.

Delegation of tasks and teamwork

Who would be included in the health care team and what role would they play?

A clinical psychologist or a neurologist will be included in the multidisciplinary team for managing the neurological abnormalities that result in intellectual impairment in the patient. An orthopaedic surgeon will also play an essential role in addressing the physical problems that are presented by Robert, following his accident. This surgeon will be able to collaborate with the pain management team, in treating the fracture and associated pain. Moreover, a physiotherapist will also play a crucial role in making him show compliance to exercises that would improve his mobility, muscle and bone strength.

An occupational therapist might also be included in the team with the aim of providing necessary equipments that would assist Robert to perform daily activities, all by himself. Similarly, a nurse specialist having expertise in treating intellectual disabilities can also be asked to adorn the role of an educator, and advocate, in addition to liaising between all members of the interdisciplinary team. The nurse will also be imperative in conducting a holistic assessment of the patient that will include a thorough measurement of his bio-psychosocial aspects.

A case manager and social worker will be able to provide assistance to Robert, with regards to better living amenities, and an appropriate physical, psychological and medical environment. This in turn will relive his mother of her responsibilities, and of the fact that Robert might get hurt in a new environment. Furthermore, a vocational trainer or recreational therapist can also be contacted for arranging music or art classes that would engage Robert in an activity of his interest (Clare et al., 2017). Depending on his symptoms, assistance can also be taken from an optometrist or a speech pathologist (Carmeli & Imam, 2014).

References

Carman, K. L., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., & Sweeney, J. (2013). Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Affairs, 32(2), 223-231.

Carmeli, E., & Imam, B. (2014). Health promotion and disease prevention strategies in older adults with intellectual and developmental disabilities. Frontiers in public health, 2, 31. 

Clare, I. C. H., Madden, E. M., Holland, A. J., Farrington, C. J. T., Whitson, S., Broughton, S., … & Wagner, A. P. (2017). ‘What vision?’: experiences of Team members in a community service for adults with intellectual disabilities. Journal of Intellectual Disability Research, 61(3), 197-209. DOI: 10.1111/jir.12312 

Scope of practice and prioritizing tasks

MODULE 3:

You are working on the morning shift on the ward, and receive a patient from ED. The ED nurse provides you with the following handover, using the ISOBAR format. Further information about the ISOBAR format can be found on page 7 of this module. Please click on the handover link in LEO within Module 3 section, titled: ‘Module 3 Activity 2 Verbal Handover’. Listen to this recording, and then please answer the following:

What further questions will you need to ask the nurse?

The handover in this context covers all essential aspects of the ISOBAR framework. Hence, it can be considered satisfactory. However, there are few details missing in the handover. I would like to ask few questions related to measurements of the patient’s vital signs for determining presence of any potentially threatening infections in the body. An analysis of the responses to the questions will help me evaluate presence of tachycardia, hyperthermia, tachypnoea, hypertension, and low oxygen saturation. Presence of pneumonia is confirmed by the current handover.

Moreover, I would also question on the medications that are currently being administered to the patient and would try to find out previous history of allergies or surgeries. Furthermore, positive diagnosis for pneumonia would also require maintaining adequate droplet precaution. I would also question the nurse on symptoms of weight loss and abdominal pain.  

List specifically what further assessments you would complete when the patient arrives onto the ward 3.

On arrival of the patient to the ward, I would perform a comprehensive assessment of the physiological condition. My assessment would be based on a systematic examination from head to toe, such as, pain assessment, temperature sensation, CVS assessment which includes measurement of vital sign, perfusion, and capillary refill. I would also determine whether the patient demonstrates and accurate orientation to place time and person. This will be followed by conduction of a detailed GI and respiratory assessment, with procedures, such as auscultation, inspection, percussion and palpation. I would also assess his skin condition and evaluate presence of pressure injuries, or sores. This will be followed by determining placement of the IV cannula.

I would also evaluate conditions that require ambulation. Baseline measurements of the patient would include checking his weight and BGL. I would also record the patient’s subjective data that will provide information on presence of pneumonia like condition. This data would be based on measurements related to swallowing difficulty, and persistent cough. This can be attributed to the fact that since the patient is aged (92 years old), it can possibly result in aspiration pneumonia. His recent hospitalization can also contribute to hospital acquired pneumonia (Suarez & Ortega, 2011).

Critical thinking and judgment

Furthermore, I will record information related to his social history such as the primary caregiver, his living conditions, current medications and previous history of hypersensitivity. During a clinical placement, it is essential to select a patient who presents symptoms that are off interest. Selecting a patient what difficulties faced while linking clinical theory to nursing practice would be helpful. The clinical reasoning cycle worksheet, present on the LEO page will be filled up for providing assistance in understanding the current physiological conditions of the patient. 

References

Suarez, M. & Ortega, S. (2011). Pneumonia. New York: Nova Science Publishers. Retrieved from  

MODULE 4:

You are a Registered Nurse on the afternoon shift on a short-stay (24 hours) surgical ward. One other RN, an EN and three AINs are also on duty. The NUM is off sick and the other RN is acting as NUM as well as taking a patient load. The ward is full: there are 22 patients, 14 of whom went to surgery in the morning, and 8 are going on your shift. Half of these a patients have intravenous access and antibiotics at some time during your shift.

Using your knowledge and experience of various patient allocation models (e.g. total patient care, team nursing and task allocation), outline how you would allocate the staff to the patients. Include in your discussion your rationale for the model of allocation chosen and the scope of practice of the various staff.

A plethora of models exist related to patient care and allocation such as, team nursing, indivisible patient allocation, primary nursing, total patient care, and functional nursing. However, there is lack of evidence regarding the model that is most effective in enhancing patient health outcomes, through delivery of optimal health care services. Most research studies have been found to establish the effectiveness of team nursing as the commonly preferred patient allocation model (Fairbrother, Jones & Rivas, 2010; Dubois et al., 2013).

Several factors, such as, complexity of the current clinical situation, structure, and organizational policies, availability of adequate funding, nursing scope of practice, skill mix, and an increase in demand of experience of healthcare professionals play a major role in determining the allocation and care model that should be applied while treating a patient (King, Long & Lisy, 2014). In the current case scenario, I would implement team nursing model for treating the patient. This model will be selected due to the fact that it focuses on management of the entire multidisciplinary team by a registered nurse, who functions as a team leader. In such cases, there is enormous workload on the nursing staff.

Handling medical emergencies

Moreover, all healthcare professionals demonstrate differences in their clinical competencies and level of nursing education, thereby collaborating together, with the primary objective of improving health outcome of the patient. Furthermore, this model will also assist nursing stuff in realizing their maximum potential, while delivering optimal health care services to the patient (Tran, Johnson, Fernandez & Jones, 2010). Further benefits of the team nursing model are associated with its potential in advancing and promoting role of RNs as effective care coordinators and team leaders. However, it is crucial for the team leaders to display appropriate delegation skills and interpersonal communication skills, in addition to adequate knowledge on the scope of practice of their colleagues (Tran, Johnson, Fernandez & Jones, 2010).  

According to Polis, Higgs, Manning, Netto and Fernandez (2017) the team nursing model have been proved successful in improving optimal patient outcomes, enhancing patient safety, and reducing adverse events such as death. Moreover, the model has also been effective in staff retention and enhancing job satisfaction among healthcare professionals. It has also proved beneficial in supervising staff with less experience and providing them adequate support. Thus, this team nursing model is most commonly used in instances where there is an amalgamation of wide variety of nursing skills.

This can be elucidated by the fact that enrolled nurses display different levels of nursing expertise, upon comparison with registered nurse, and AINs. However, all of them are required to work in collaboration in healthcare settings while caring for a patient (Ferguson & Cioffi, 2011). Therefore, I would follow this model and allocate AINs to experience EN and RNs. The patient load will be divided  accordingly, such as, 8 to myself and the AIN with whom I form a partnership, 8 to another AIN in partnership with an EN, and 6 to the partnership of an RN (working as NUM) and an AIN.

The registered nurse will work as NUM because she will be responsible for managing the entire word as well. The NSW health standard state that AINs are entrusted with the responsibility of performing simple clinical tasks related to measuring vital signs of patients admitted in acute health care ward (NSW Health, 2010). Hence, I would request all the AINs to measure vital signs of their corresponding patients. I would also presume that the EN has relevant knowledge in medication and is competent with administration of intravenous drugs.

Thus, I would expect them to appropriately administer medication two patients present in the surgical ward. I would also delegate the EN for administering intravenous drugs when required, and would ask her to seek assistance if needed. According to the NMBA (2018), enrolled nurses should be capable of administering drugs intravenously, provided they have completed their education on IV medication administration. Moreover, I would also focus on using other intravenous antibiotics for the concerned patient, and would provide assistance to other registered nurses, because the core idea of team nursing model is focused on supervising and helping each member of the team. 

References

Dubois, C. A., D’amour, D., Tchouaket, E., Clarke, S., Rivard, M., & Blais, R. (2013). Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals. International Journal for Quality in Health Care, 25(2), 110-117. 

Fairbrother, G., Jones, A., & Rivas, K. (2010). Changing model of nursing care from individual patient allocation to team nursing in the acute inpatient environment. Contemporary Nurse, 35(2), 202-220. 

Ferguson, L., & Cioffi, J. (2011). Team nursing: experiences of nurse managers in acute care settings. Australian Journal of Advanced Nursing, 28(4), 5-11. Retrieved from-

King, A., Long, L., & Lisy, K. (2014). Effectiveness of team nursing compared with total patient care on staff wellbeing when organizing nursing work in acute care ward settings: a systematic review protocol. JBI Database of Systematic Reviews and implementation reports, 12(1), 59-73. doi: 10.11124/jbisrir-2014-1533

NSW Health. (2010). Assistants in Nursing working in the acute care environment. Retrieved from 

Nursingmidwiferyboard.gov.au. (2018). Nursing and Midwifery Board of Australia – Fact sheet: Enrolled nurses and medicine administration. Retrieved 3 March 2018, from 

Polis, S., Higgs, M., Manning, V., Netto, G., & Fernandez, R. (2017). Factors contributing to nursing team work in an acute care tertiary hospital. Collegian, 24(1), 19-25. 

Tran, D. T., Johnson, M., Fernandez, R., & Jones, S. (2010). A shared care model vs. a patient allocation model of nursing care delivery: Comparing nursing staff satisfaction and stress outcomes. International Journal of Nursing Practice, 16(2), 148-158. DOI: 10.1111/j.1440-172X.2010.01823.x

Consider the patient situation What current information do you have on this pt? What new information have you gathered?	The handover of the patient, Mrs.  X, admitted to the palliative care was send to me. She reported impaired mobility and decreased appetite. She demonstrated a healthy skin turgour and was tachypnoeic. The RR was 28 rpm.
Collect Cues/Information What further cues and information would be useful? Why?	Patient history- Pelvic mass, adenocarcinoma (probability of having ovarian cancer with metastasis in the bones), left lung pulmonary embolism, right leg deep venous thrombosis. In addition to skin turgidity, the pulse rate of the patient should also be recorded (Wise, 2014). The patient also reported severe pain in her body. Her weight was 74.8 kgs.
Process Information What changes do you notice in the cues and information provided? Which changes are significant for this patient and why? What do you think these changes could indicate and why? What could be the outcome of these changes?	RR- 28 rpm. Respiratory changes are of significance for a patient since it is much above the normal range of 14-20 RPM (Jacox& Cole, 2012). The physiological changes and vital signs of the patient indicate a deterioration of her health. If these changes persist for a prolonged period of time, they can result in adverse health outcomes.
Identify Problems/issues Given the facts that you have available and comparing those to what you think the changes could indicate/identify one potential patient problem/issue.	Upon comparison, I found that the patient manifested signs and symptoms of tachypnoea. I also found an elevation in her RR, beyond the normal ranges. This indicated adverse health condition (Schwartz, 2012). I would request presence of the physician for a discussion. I would also communicate the current health abnormalities with the family members of the patient.
Establish Goals Describe what you want to happen.  Who do you want involved and what do you want them to do? In what timeframe?	There should be a precise documentation of the physiological signs, followed by adequate supervision and monitoring of the patient’s condition  (Felton, 2012).  An effective collaboration should be developed between the healthcare professionals such as, physicians, nursing staff and cardiologists. This collaboration would bring about an enhancement in the overall health and wellbeing of the patient and would significantly improve health outcomes.
Take Action What nursing actions will you take? What will be your nursing priorities?	The vital signs of the patient will be recorded, followed by a precise documentation. My nursing priority would focus on continuously monitoring the patient and regularly the vital signs. I will also administer oxygen and inform about it to the concerned medical officer.
Evaluate Outcomes What do you expect to achieve from the actions have taken?	I expect to observe a reduction in the patient’s respiratory rate, in addition to stabilization of other vital signs. I also expect a reduction in bodily pain manifested by the patient. A PQRST assessment would be conducted. I would also ask the patient if she requires any pain breakthrough. I would try all possible efforts to make her comfortable during mobilizing or while she is in bed.
Reflect on Process and new learning What have you learnt from this exercise?	I understood the significance of appropriate documentation and supervision of patients. Helping mobility and giving pain medication prior will be my reminders. Respiratory team R/V. I learnt how to take care of patient by re-assurance and communication. Also, asking about pain and giving medications accordingly. This exercise helped me learn importance of appropriate supervision and documentation of a patient. I learnt that it should be my utmost priority to assist all patients while moving. I also realized that careful administration of pain medications is essential. I also learnt that providing reassurance to a patient through effective communication is imperative for nursing duty. Furthermore, a patient should also be questioned for pain assessment and current medications.