NUR 435/445 Denver School of

NUR435 Discussion post:

Step 1 Consider a change in practice that took place at your workplace.

Step 2 Answer the Prompts:

·         What was the involvement of team members in the change process? Did “rank and file” members of the team participate on the team planning for change?

·         What steps were taken to prepare for change?

·         How were the goals and outcomes communicated to team members? Was the communication clear or could it have been improved?

·         What was the outcome of the change?

·         In your opinion, what elements are required in order to have a culture that is open to change?

Step 3 Read other students’ posts and respond to at least two of them.

Read and respond to at least two other students’ posts. Use your personal experience, if it’s relevant, to help support or debate other students’ posts. If differences of opinion occur, debate the issues professionally and provide examples to support your opinions.

NUR435 Student Posts:

Student #1: Organizational change is a term used to refer to the process by which a company changes essential aspects of its policy or processes (Beech & MacIntosh, 2017). These may include changes in corporate culture, management structure, or essential activities and goals. One of the change practices that has taken place in my workplace is the implementation of new technology.

The team members at the workplace were involved in the change management by being involved in the planning phase of the change. The persons responsible established clear points and other inputs required in the change management since they critically affect them. The management invited the team members, including ‘rank and file members, to share their opinions and ideas crucial for the change to happen. This involvement is very significant since it helps the team members accept the change as a necessary step that builds their morale.

Some of the steps involved in the change management included preparation for the change, a rough draft for the change, implementation of the change, embedment of the change with the organizational culture, and a review of the change progress. For the management team to communicate the change to the team members, they shared the visions, encouraged the team members to become change agents, kept communicating to them about the organizational change, and kept them in the loop (Beech & MacIntosh, 2017). The communication was clear enough since all the members of the organization accepted the change.

Some of the change outcomes included increment in the team members’ organizational productivity, efficiency, and morale. The change also responded to the organizational changes efficiently and minimized any possibility of change in the organization. In my opinion, some of the elements necessary for an organization that is open for change include the ability to create, communicate to team members, implement and critically evaluate the change.

Student #2: I will say the latest change that takes place in my workplace is bedside report. The bedside report should have been implemented a long time ago, but it is better late than never. This change was considered based on patients’ survey results that took place at my workplace. Patients were stating they have not been include in the bedside report, and most of the time, they have a lack of information given to them on their plan of care. Before that, Nurses were sitting down at nurses’ stations or the hallway taking a report, and sometimes the report might not be accurate. The implementation of the new change has been going on now for about a month. We have shift supervisors following us around to make sure we are reporting at the bedside correctly and addressing patients’ concerns. At the end of each report, both nurses and patients have to sign a paper stating they understand their plan of care and their concerns have been addressed. We continue to have a meeting and in-service to touch bases on how crucial the change is.

The benefits of bedside reporting are numerous and include increased patient involvement and understanding of care, decreased patient and family anxiety decreased feelings of abandonment at shift changes, increased accountability of nurses, increased teamwork and relationships among nurses, and decreased potential for mistakes(Rush, 2012). I am starting to see progress with the bedside report shift. Patients stated they have no concerns, and the pain has been managed enough. Although we still see a very few nurses still reluctant to adhere to the new change, we are still reinforcing the change.

NUR445 Discussion Post

Step 1 Read the case scenario.
You are part of an interprofessional team working on an evidence-based project to look at falls in patients with dementia in the long-term care setting. The team was brought together in response to a noted increase in the incidence of falls in residents with dementia over the past three months. One of the recent changes before the increase in falls was a mandate to no longer use physical restraints on residents. Several staff members feel that the use of restraints is a must, and they do not have time to use the restraint alternatives that have been suggested. They also feel they do not have enough time to continuously check on residents. This has caused major issues of concern and has compromised the quality and safety of the residents.

When the team meets together, one of the first items discussed is the clinical question. The team uses the PICO question format to develop the following question:

In patients with a diagnosis of dementia in the long-term care setting (P), how does the use of a comprehensive falls assessment prevention plan that includes restraint alternatives (I) compare with the use of a fall prevention protocol that includes the use of restraints (C) affect the number of falls that occur (O)?

Step 2 Post to the discussion forum.
In your initial response, address the following questions:

  1. Determine the best resources to use when conducting a search on the topic. Consider these questions: What databases would be most appropriate? Where would you locate clinical practice guidelines that could be used in the EBP process for this issue?
  2. Conduct a search using the resources you identified in Step 2a. What key search terms did you use? What filters did you use?
  3. From your search, identify at least three articles that you would consider using in an EBP project such as the one described in the case scenario. If possible, suggest resources that meet the highest level (Level I) of evidence. Why would these sources be most appropriate in determining best practices and supporting clinical decision-making for this issue?

Step 3 Read other students’ posts and respond to at least two of them.
Comment on at least two posts that recommended resources different from those you selected. Conduct a search using the resources and key terms identified in your peers’ posts. Describe how the search results using their criteria differed from your original results, including the quality and quantity of resources the search retrieved. In your reply, share any questions or considerations their responses provoked for you on the topic.

Use your personal experience, if it’s relevant, to support or debate other students’ posts. If differences of opinion occur, debate the issues professionally and provide examples to support opinions.

NUR445 Student Posts:

Student#1: Using the best evidence-based research resources provides the most reliable data that can be used to back-up the findings of a study. When conducting research on the topic of falls in patients with dementia in the long-term care setting, the most appropriate databases for acquiring evidence-based resources would be the CINAHL, Google Scholar, Cochrane Library, EMBASE: Excerpta Medica Database, and MEDLINE through Ovid and PubMed (Campbell et al., 2015). Globally, these databases are top-ranked and recommended by associations of nurses and physicians. I would locate the clinical practice guidelines from the databases mentioned above and The Emergency Care Research Institute (ECRI) Guidelines Trust and Agency for Healthcare Research and Quality (AHRQ) databases.

When searching, the keywords that I used were “fall rate in dementia patients” and “diagnosis of dementia in the long-term care.” I used the “date customization” filter to obtain the most recent resources. I also used the “show all results” filter to get all the resources relevant for my topic (Campbell et al., 2015). Additionally, I used the “sort by relevance” filter to arrange the resources starting by the most relevant to the least relevant.

While working on an EBP project related to the topic mentioned above, I will consider using the following sources:

  1. Bayen, E., Jacquemot, J., Netscher, G., Agrawal, P., Noyce, L. T., & Bayen, A. (2017). Reduction in fall rate in dementia managed care through video incident review: pilot study. Journal of medical internet research, 19(10), e339.
  2. Kosse, N. M., de Groot, M. H., Vuillerme, N., Hortobágyi, T., & Lamoth, C. J. (2015). Factors related to the high fall rate in long-term care residents with dementia. International Psychogeriatrics, 27(5), 803-14.
  3. Fink, A. (2015). Dementia and long-term care-an analysis based on German health insurance data. Health Among the Elderly in Germany-New Evidence on Disease, Disability and Care Need. Berlin: Barbara Budrich Publishers, 139-56.

Student #2: Using relevant evidenced based resources helps provide the most effective resources when conducting a search on a topic, it minimizes and prevents health care problems. Since majority of my patients are intubated and sedated, I use soft wrists, universal and sometimes even four-point restraints for safety purposes. I do find restraints important in emergent or life-threatening situations. Although I’m an advocate for restraints I do find using restraints for patients with dementia to prevent falls can cause ethical issues.

Evidence is published across a variety of sources, including scientific or academic journals, books, conference proceedings, websites, and news reports. Databases that are most appropriate are academic publications in scientific journals are generally considered to be of higher quality due to the independent, peer-review process (“What Are”, 2018). Key terms I would use to identify in this case scenario would be falls in patients with dementia, physical restraints to prevent falls in patients with dementia and restrain alternatives to prevent falls. Filters I would use year to date to find the most recent evidenced based resource to support my research. My favorite databases to acquire evidenced based practice are NCBI and AJN.  Three articles I would consider when conducting my research pertaining to the case scenario are;

Bayen, E., Jacquemot, J., Netscher, G., Agrawal, P., Tabb Noyce, L., & Bayen, A. (2017). Reduction in Fall Rate in Dementia Managed Care Through Video Incident Review: Pilot Study. Journal of medical Internet research, 19(10), e339.

Evans L, & Cotter V. Avoiding restraints in patients with dementia; Understanding, prevention, and management are keys. American Journal of Nursing. 2018. Volume :108 Number 3 page 40-49.

Peek K, Bryant J, Carey M, et al. Reducing falls among people living with dementia: A systematic review. Dementia. 2020;19(5):1621-1640. doi:10.1177/1471301218803201

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NUR 435 445 Denver School of

NUR435 Discussion post:

Step 1 Post your response to the discussion board.

Currently, nursing services are considered an expense for which healthcare organizations cannot bill separately. Cite your references using APA 7th edition and respond to the following questions and, if appropriate, include personal experience as part of your answers:

  • Why are healthcare organizations unable to bill separately for nursing services, and what is the impact on nurse leaders?
  • What can the nursing profession, and specifically nursing leaders, do to change this issue?
  • Why are nursing services considered an expense and not an income generator?

Step 2 Read other students’ posts and respond to at least two of them.

Ask questions of the other students that promote further thinking and discussion on the topic. Consider the changes to billing identified by the other students. Do you agree or disagree that these changes can make an impact on nursing services? Why or why not?

Use your personal experience, if it’s relevant, to support or debate other students’ posts. If differences of opinion occur, debate the issues professionally and provide examples to support opinions. Cite your references using APA 7th edition.

NUR435 Student Posts:

Student #1: The reason that healthcare organizations are unable to bill separately for nursing services is due to the coding process in the billing aspect of the organization. “A major concern for nurses is that the bills submitted to third-party payers and consumers from healthcare organizations bundle nursing services with the flat daily charges, such as the cost of the hospital room and housekeeping. The specific cost of nursing has neither been separated nor given a dollar value. This has hindered the ability of nurses to receive specific payment for their services from third-party payers” (Healthcare Finance, n.d., Topic 3). The impact this has on nursing leaders is how it effects the budget they work with. In trying to properly staff a unit it would go a long way to have all services rendered have a set cost, therefore the more services rendered the more the unit would gross. The problem is that health insurance is already so expensive and adding costs to a hospital stay may make it unattainable for the average American as the insurance company would surely pass the cost on to the consumer.

In nursing there has already been a move towards billing separately for services, at least in the world of nurse practitioners. “Nursing leaders have opportunities to influence policy and delivery of care initiatives. The increasing focus on nurse-sensitive indicators gives nursing leaders the opportunity to highlight the specific nursing interventions that ensure optimal patient outcomes” (Healthcare Finance, n.d., Topic 4). By advocating for this type of separate billing for services, nurse leader could boost productivity, help contain cost, and increase their budget.

The basic answer as to why nurses are considered an expense and not an income generator is that they are paid through the budget process. As such, expense is, “defined as the costs or prices of activities undertaken in the organization’s operations” (Huber, 2021, p. 388). In this way of looking at nursing in the organization it is considered a cost not a revenue source. In fact, “staffing expenses generally are the largest portion of the nursing operating budget, nurse managers and nurse executives need to have a consistent and well-defined approach to estimating staffing expenses” (Huber, 2021, p. 392). One way to change this is to have separate billing and effective cost control over supplies used on a unit. If nursing services were billed separately and the revenue gained went back to the unit it could be used to increase the budget, incentivize nurses, and improve the patient outcomes.

Student #2: Several healthcare organizations cannot bill separately for nursing services, which negatively impacts the nurse leaders. Due to the purpose of the documentation, the coding system, and other requirements related to this process, medical institutions cannot charge only for nursing services (Kennedy et al., 2017). They can calculate working hours, but they pay more attention to patients, and therefore, they cannot be registered. This effect reduces the payment process in the nursing field.

The most exciting part of looking at healthcare as a cost is the opposite of what hospitals think of other healthcare providers. Doctors and most (but not all) different therapists (respiratory, specialist, and physiotherapist) are often seen as the cost of a service that earns a hospital income. To change this problem, the nurse needs to understand the billing process. Nursing practitioners and nursing leaders can take specific actions to change this issue. They recognize the needs and conditions of their services. Care facilities must have written documentation.

Nursing services are considered an expense and not an income generator. If the patient’s care costs more than the reimbursable amount, the hospital incurs a financial loss (Huber, 2018). Among the incidental costs that hospitals incur to provide medical services are appropriately licensed and trained personnel, medications, technology, food, supplies, and equipment (Huber, 2018). Hospitals must consider all these expenses when they enter into managed care contract negotiations with insurance companies to provide healthcare services for their members (Huber, 2018).

NUR445 Discussion Post: 

Step 1: Discuss the importance of advocacy as it pertains to patient care.

What is the nurse’s role in patient advocacy? Describe a situation in which you were involved with patient advocacy. Explain what the advocacy accomplished for the patient, and what the repercussions would have been if the patient would not have had an advocate. Cite your references using APA 7th edition.

Step 2 Read other students’ posts and respond to at least two of them. Cite your references using APA 7th edition.

NUR445 Student Posts:

Student#1: What is the nurse’s role in patient advocacy?

Patient advocacy in nursing refers to the act of making sure that the patient’s rights are always protected, ensuring that the medical care administered to the patient is correct and making sure that all the benefits entitled to the patients are provided, for example financial support. It is an important aspect in patient care as it ensures that there is patient equality in provision of health care facilities to all patients despite their race, socioeconomic status, and their religion. It also helps to reduce patient suffering, not only the disease-caused suffering that is the pain management and the physical suffering but also other types such as depression and emotional suffering by identification of patients in such situations and helping them overcome the suffering. Nurses have the role of preserving a patient’s dignity at all costs by respecting cultural and ethical beliefs and accepting them especially in situations where they have great influence on the patient’s physical and emotional well-being. In addition to that, they must ensure that all the information relating to the patients’ illness remain private and confidential. Equality in the service of healthcare offered to the patients must be practiced by serving every patient with the same degree of professionalism and compassion. A nurse has the obligation of serving as the communicator, interpreter and as the caregiver to the patients.

Describe a situation in which you were involved with patient advocacy. Explain what the advocacy accomplished for the patient, and what the repercussions would have been if the patient would not have had an advocate.

I was once involved in a patient advocacy situation where I spotted one of the patients who seemed not contented with the information he was given about his illness. I approached him and initiated an open dialogue where I asked him several questions and gave relevant feedback concerning his state of health to help him arrive at a final answer on the method fit for his treatment. Having educated the patient on his rights and our obligation as nurses and doctors he had to select the best treatment method for his condition from the possibilities he had prior been informed about.

It’s mostly likely that the patient would have ended up choosing a treatment method that would have severe effects on his lifestyle or even one that will not solve his health issues, considering the fact that he had no information on the different methods offered to him.

Student #2: The role of patient advocacy in nursing is many faceted, we are the last line of defense for many of our patients. I like the way it is summed up in an article from Sage Nursing Journals;

“The attributes of patient advocacy are safeguarding (track medical errors, and protecting patients from incompetency or misconduct of co-workers and other members of healthcare team), apprising (providing information about the patient’s diagnosis, treatment, and prognosis, suggesting alternatives of healthcare, and providing information about discharge program), valuing (maintaining self-control, enabling patients to make decisions freely, maintaining individualization and humanity, maintaining patient privacy, and acting in the patients’ values, culture, beliefs, and preferences), mediating (liaison between patients, families, and healthcare professionals, being patients’ voice, and communicate patient preferences and cultural values to members of the healthcare team), and championing social justice in the provision of healthcare (confronting inappropriate policies or rules in the healthcare system, identifying and correcting inequalities in delivery of health services, and facilitating access to community health services and health resources)”  (Ahmadi, 2019, para. 3).

The situation that comes to mind that I was deeply involved in patient advocacy was when I was in the role of charge nurse, a patient had fired her nurse and I had to go talk to the patient to help sooth the situation. As I entered the room, I realized right away that the patient was extremely angry. She is a deaf woman who cares for her disabled brother who was also in the hospital just down the hall. The reason she was so upset was she was best at reading lips, and we all had to wear masks with COVID-19. She also refused the use of MARTTI as she considered it demeaning. The woman was also quite concerned about her brother as he is also deaf and really only able to communicate with his sister. The way I advocated for her was by taking the time to write out my end of our conversation (practically a book!) and show her each of her medications in the package before opening them. I also got her attending physician to come discuss what would happen when she was discharged. She was refusing discharge because she wanted to be near her brother. The next step in advocating for her was to contact my manger to see if she could stay with her brother for the duration of his stay. I was able to secure this exception and made her much more comfortable and she even smiled. If I had not advocated for in these and many other ways, she may have refused discharge indefinitely, been confused about the medications she was taking, and not understood what was next for her and her brother upon discharge. Ironically, the next time she was hospitalized I was her primary nurse and we got along quite well!

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