Nursing Administration -- Controlling Nursing Admin-Controlling

Situation analysis

The FOCUS model requires the nursing administrator to find out what the main problem is, obtain information about this problem, communicate effectively with the nurses and patient, understand the needs of the nurses and the patient, and finally summarize these findings for the patient and nurses Dlugacz, 2009.

In this scenario, the process to be improved is responsiveness and willingness of the nurses to help the patient's situation.

Using the FOCUS model, the nursing leader should identify and clearly define the problem. To do this, they must recognize the role of the patient and the nurses in the situation and prioritize the potential improvements in the process Kreitner, 2008.

They also need to draft this problem statement in a clear way. The problem statement for this scenario is that the nurses feel inadequate in responding to the situation where the patient needs complex psychological, medical and social care. The patient has a need for control that they exhibit through aphasia, aggression, and anger.

The next step is to organize a team that is knowledgeable about the problem and how to lead improvements. In this scenario, the nursing leader identifies a mental health professional, the nurses who faced the situation of Mr. X first hand, the ICU nurse, respiratory staff, physician and physician's assistant and the hospital administrator. The mental health professional is the facilitator because they are well knowledgeable about dealing with behavioral emergencies. The leader of the team will be the nursing leader. The other team members are included because they would understand what they should have done differently to help Mr. X.

The third step would be to clarify the current knowledge regarding the problem. This is done by first analyzing and recording the events that happened during the time and asking the team members to identify critical points of care. They should also assess the legitimacy of the patient's actions and views while maintaining a nonjudgmental view of the scenario. Following this analysis, the team should be asked to recognize important points where their actions could have been critical in providing care and what they should have done differently. This will allow them to recognize performance indicators.

The next step is to understand the causes of process variation by understanding the needs of the nurses and the patient. The nurses focused on their individual needs, which led them to fail to act in the situation. They did not want to risk getting hurt or harming the patient as they tried to do procedures. The patient, on the other hand, needed psychological, mental, and social care, which the nurses failed to provide. The hospital also did not have procedures and guidelines for dealing with patients with a behavioral emergency in a non-psychiatric setting.

The last step is to select the process improvement. To improve this situation, it is important for the nurses to understand the degree to which behavioral emergencies present in non-psychiatric situations. They will enable them to appreciate the risk of such behavioral emergencies. The team should also list potential liabilities associated with these behavioral emergencies and understand the associated risks. The last step would be to discuss risk management strategies to mitigate risk of harm to the nurses and the patients.

Improvement plan

The Plan, Do, Check, Act (PDCA) model is the best for developing an improvement plan for the process that needs improvement Zuzelo, 2010.

This situation will use the PDC steps in the PDCA model.

Plan

The plan is to start with trainings for the nurses to understand the risk exposures in behavioral emergencies which include adverse media coverage, regulatory risk potential, liability risk potential, and health facility licensure action potential. They will also be trained on effective strategies to implement to mitigate risks to the patients and themselves. The facility will also need to develop a risk-screening tool to determine risks to patients. This risk-screening tool should encompass both risk factors and protective factors. To handle behavioral emergencies in non-psychiatric settings, it is important to identify and establish a safe room or if not possible, a safe area to handle behavioral emergencies Kleespies & Association, 2009()

Do

The staff will be trained on how to conduct on-the-spot risk assessments in behavioral emergencies in order to find a safe treatment environment for the patient. They should also understand the importance of appropriate monitoring of patients who have been involved in behavioral emergencies. Nurses and other caregivers should also receive refresher training on stigma related to patients presenting with behavioral disorders and the importance of conducting a risk assessment to determine potential harms to the nurses and the patient. Nurses should...

They should also train on important of rapid stabilization of agitation or psychosis, safe transfer of patients between treatment areas and enlisting help from family members or friends.
The nurses should also be trained on how to manage manipulation of patients effectively. This means they should try to communicate with patients effectively and set clear limits on behavior which affects the well-being of the patient and nurses. They should not be punitive to the patients and where possible should avoid power struggles and debates. These staff once trained will train others on how to handle behavioral emergencies in these non-psychiatric settings.

The risk factors may include past history of self-harm or attempts to harm others, current thoughts of self-harm, social isolation, recent significant life changes, or feelings of anger, hopelessness, anxiety, panic, or hallucinations. Protective factors may include communication and engaging behavior, coping skills, acceptance of treatment, availability of social support, responsibility for children, or moderate cultural or religious beliefs. Using this risk-screening tool, each risk factor identified in the patient will give 1 point while each protective factor will take away one point. Then for patients with scores between zero and two, these are classified as low risk and assigned to routine monitoring. For those who score between three and five points, they are classified as moderate risk and assigned to close observation. Patients with scores higher than five points are classified as high risk and assigned to constant observation Zun, Chepenik, & Mallory, 2013()

The safe room or area should be well equipped with appropriate tools and medication and other necessities for handling such emergencies. Security and care should be ensured in this safe area to remove any harmful objects and ensure that the risk to the patient and the nurses is greatly reduced considerably. All sharps, mediations, and other risky tools such as belts, shoelaces should be removed from the safe area. Only disposable meal trays, plates, spoons and knifes should be used in such safe areas. This environment should be surveyed routinely.

After behavioral emergencies, these patients should be monitored, assessed, and reassessed regularly. Appropriate levels of monitoring and observation should be used based on the results of the risk-screening or assessment tool. It is important for the nurses to identify the needs of the patient and try to meet them.

Check

In order to ensure that the plan effected is followed through, effective evaluation strategies should be developed. This includes establishing effective competencies and training programs for staff members to understand the implementation plan. The hospital should also establish a culture that promotes safety of patients and nurses and emphasizes all aspects of the implementation plan. The risk of patients and to the organization should be evaluated regularly to determine the effectiveness of the plan. Whenever nurses encounter behavioral emergencies, they should be asked to document what they did in order to see whether it meets the evaluation plan.

Unit protocol

Whenever a behavioral emergency in a non-psychiatric setting is encountered, the following steps should be taken.

1. The patient should be transferred safely to the safe room, whenever possible.

2. The safe room should be checked thoroughly to ensure all sharps and other harmful objects are removed.

3. The nurses should attempt to communicate with the patient to understand their feelings of pain, anger, depression, or frustration.

4. The nurse should administer medication to calm the patient, if the patient is violent or deemed to be a hazard to themselves and others.

5. A risk assessment of the patient should be done and an appropriate monitoring schedule initiated depending on the outcome of the risk assessment.

6. Psychiatrically trained staff or consultants should be approached for help if the patient is deemed to be at high risk of harm to themselves or others or if the patient is violent.

7. Attempts should be made to contact the patient's family or friends to determine possible causes of action and diagnoses.

8. Counseling for grief or other possible causes should be initiated when the patient is able to communicate effectively.

9. Patient should be reassessed routines and all assessments should be documented.

10. Suicide risk assessment should also be conducted and documented.

11. The safe environment should be routinely checked and assessed to be safe.

12. When discharging the patient, family members and friends should be informed of the patient's status. The crisis hotline or treatment options should be clearly explained to the patient and their family or friends. A signed…