Nursing Leadership Assignment 3: Personal Case Study and Solution

Nurses are the largest part of the healthcare professionals and the quality of care provided is directly linked to the performance of nursing staff. The issue of nursing staff shortage affects many healthcare organizations leading to adverse events and poor patient outcomes, especially during emergencies (Rosenberg, 2021). To address this challenge, institutions are supposed to provide, within the specialty capability of its medical staff, an on-call panel to backup nurses and physicians. However, the lack of clear guidelines in many facilities hinders the implementation of this change.

Case Study

It is on a Saturday afternoon at the Bethany Medicine unit, a 72-bed acute care facility proving care across all populations. At around 2:30 pm, Mr. James, a 64 year-old-male patient is brought to the unit from the emergency department with a diagnosis of left hip dislocation. The patient is moaning and complaining of severe pain in his leg and hip area after falling at home. He explains that he lost his balance and fell after tripping over a log in his compound. The nurse takes the history to confirm the patient’s health status. He states, “My leg and hip area hurt badly. This is the worst pain I have ever had.” The nurse performs a pain assessment and Mr. James rates his pain at 10 out of 10 on the verbal pain scale. Further history reveals that the patient has COPD and uncontrolled diabetes but has been receiving treatment. The last visit to the doctor also indicated that the patient has high cholesterol and lipids. A combination of these medical conditions and the present history prompted the admission of the patient to the medical unit.

Staffing on this day consists of two nurses; one registered nurse and one LPN. There is also one medical unit physician available to cover two other departments in the facility. At the time of Mr. James’ arrival, the LPN nurse is busy preparing medications for other patients in the unit. The registered nurse is busy monitoring Ed, a 45-year-old male patient with an acute asthmatic attack. The nurse is also checking the vitals for another patient complaining of a throbbing headache. The patient rates his pain at 8 out of 10 and explains that he has not responded to any medication since the last two shifts. The registered nurse is awaiting for the doctor to come back from the other unit to review the asthmatic patient who has been on nebulization for the past 30 minutes. On the nurses’ list is a 15-year old boy admitted at 12:45 pm for possible appendicitis. The laboratory workups and other investigations are back confirming the diagnosis. The patient now awaits the doctor’s review.

At 3:00 pm, the doctor is back to review the three patients that seem to be in critical condition. He starts with Ed and instructs the RN to continue with nebulization for the next 30 minutes with regular reassessment of his vitals. The patient is put on oxygen and connected to a monitor for effective monitoring. The doctor proceeds to review Mr. James who has not been attended to for the last 20 minutes. He determines that he needs moderate sedation for manual manipulation, relocation, and alignment of his hip. The doctor writes orders for the nurse to administer diazepam 5mg IV. After 5 minutes, the medication seems to have no effect on the patient. The doctor instructs the nurse to add another 5mg of diazepam and reassess after 5 minutes. The patient still does not respond to medication and this prompts an additional 2mg of hydromorphone by the LPN.

Finally, at 3:25 pm, the patient appears to be sedated and successful reduction is done. The patient is not currently on any supplemental oxygen. At this time, the RN receives a call from the ER to prepare to receive a 75-year old male patient with CCF. The patient is in acute respiratory distress and will require close monitoring. The doctor receives a call from the second unit and leaves immediately to attend to another patient. The registered nurse calls the matron to communicate that she needs an additional nurse in the unit due to the workload. She explains that the two staff are overwhelmed by the number of patients requiring special care. The matron explains that it may be difficult to get additional staff because of the pending approvals for backup staff in other units. She explains that currently, only the ER has a clear backup plan for staff in case of emergencies. However, she promises to call back after 30 minutes with an answer.

To prepare for the incoming patient, the RN nurse places Mr. James on an automatic blood pressure monitoring machine to monitor his BP and pulse every 15 minutes. The nurse also instructs Mr. James’ son to sit with him as he is being monitored. The LPN is in the process of finishing the administration of medications to other patients and has two pending discharges to process. At 3:50 pm, Mr. Jame’s son comes to inform the nurse that the monitor is alarming. The nurse is now busy receiving the 75-year-old male with acute respiratory distress. After checking on Mr. James two minutes later, she notes that he has low oxygen saturation. He puts the patient on supplemental oxygen and proceeds to connect the newly admitted patient to oxygen. The RN calls the matron again to confirm if any backup is available, but she does not receive a satisfactory response. After 5 minutes, Mr. James’ son comes again to report that the monitor is alarming. The nurse checks the monitor and notes that the BP is 52/30 mmHg and the oxygen saturation is 75%. The patient is not breathing and she cannot seem to find his pulses. A STAT code is called and begins resuscitative efforts while his son is escorted to the waiting area.

Case Analysis

Identification of the Problem

Mounting evidence demonstrates that lack of adequate staffing is a global public safety issue that may require a prolonged policy approach (Zolot, 2017). The quality of healthcare provided is likely to be impacted by understaffing alongside other effects like burnout to nurses. Healthcare organizations are required to have measures put in place to deal with the shortage of workers, especially in departments that are busy like the ER, medical units, and the ICU. The above case study demonstrates a real-life scenario on how the shortage of healthcare professionals and lack of backup mechanisms can impair the quality of care given to patients. The case describes a series of events leading to the poor management of Mr. James.

The primary problem observed is the lack of adequate staffing in the medical unit. At the time Mr. James arrives, the registered nurse and LPN have a lot of patients requiring special care. The LPN nurse is busy organizing for the administration of medications while the registered nurse is dealing with Ed who is having an acute asthmatic attack. The nurse is also in check of another patient complaining of severe headache that has failed to respond to medication and at the same time dealing with a case of acute appendicitis. Based on the workload available that afternoon, it was necessary to have an extra registered nurse to help with managing the patients.

The other problem observed in the case involves a lack of hospital policies dictating the need for calling backup staff when necessary. It is observed that only two nurses are available to provide emergency care to over five patients. I also think that the presence of only one doctor dealing with two other units makes it difficult to coordinate care. The problem of on-call coverage has grown worse over time based on the demand for emergency services in many institutions. Problems like lack of adequate funding make it difficult to have personnel ready to respond to on-call services. As observed, the matron did not provide a satisfactory answer to the registered nurse when a backup call protocol was initiated.

Analysis of the Problem and Causes

Nurses are the linchpins in providing high-quality care to patients in hospitals. The issue of understaffing hinders the nurses’ ability to provide the required care to patients. The biggest challenges facing healthcare are demographic changes that are observed to push the expansion of the workforce and the training of new healthcare workers to fill that gap. Evidence suggests that the shortage of continues rise and currently stands at 7.2% (Ghafoor, 2021). Given the rising demand for healthcare services especially among the elderly, more healthcare workforce should be available to deal with these changes. The causes of healthcare worker shortage are multifactorial; a diminishing pipeline of new nurses due to faculty shortage, significant number of retiring nurses each year, and lack of adequate capital to employ enough nurses at the institutional level all contribute to the problem (Rosenberg, 2021). In the presented scenario, it is evident that the two nurses were overwhelmed by the amount of work available in the medical unit. It was nearly impossible for the RN to coordinate care and attend to all the patients requiring specialized care at once.

Backup and contingency plans are crucial aspects in healthcare institutions. These plans help employees to cope with the increasing number of patients given the shortage of healthcare workers today. Backup plans are available to ensure the safe and efficient delivery of healthcare services to patients at all times (American College of Emergency Physicians, 2021). Despite the awareness of these measures, most institutions only provide backup plans in busy units like the ER. Traditionally, medical staff has volunteered for call panels but the increasing number of patients and problems with payment observed has led to gaps in the subject area. The case scenario described shows have lack of adequate backup systems for staff can lead to adverse events in the hospital. The backup plan mostly is used when an attending provider is scheduled but unable to come in probably due to illness or other justifiable reasons. Secondly, the plan functions to provide coverage when the census on the inpatient services exceeds the safe capacity considering the staff present in a certain unit. The nurse leaders must look at the census level to determine the right time to initial backup calls.

Suggested Solutions

1. The first solution that I would recommend is the improvement of nurse-patient ratios in the medicine unit
2. Timely assessment of the census level and planning for patient care should be done to prevent rushing at the last minute.
3. A backup plan policy should be implemented across all units to ensure attending staff are covered when the patients’ census rises.

Recommended Solution

I would recommend the intervention involving the formulation of a backup plan policy to address the issue of staff shortage in the unit. Departments like the ICU and the ER already have a set minimum of patients that a nurse should attend to at any given time. To ensure quality care is provided, nurses are supposed to handle a certain number of patients and more staffing should be availed when the maximum is exceeded (American College of Emergency Physicians, 2021). In the given scenario, I would expect a backup call to be made when the patient census exceeds a 1:6 nurse-to-patient ratio in the medical unit. I would expect the attending nurse to handle less than four admissions for effective delivery of care. I believe if a backup was present in the facility, the RN would have taken enough time to take a comprehensive history of Mr. James. Inadequate history taking as a result of the rush to attend to several patients probably contributed to the over-sedation of Mr. James leading to respiratory depression. The new plan should also factor in busy days like Mondays and Saturdays that always see massive admissions from the ER.

Implementation

The plan-do-study-act (PDSA) cycle is an iterative four-stage problem-solving model that can be used to implement new change in the organization (Reed et al., 2016). The planning phase involves the recruitment of the employees into the new plan, a description of the current context, and how the new change can solve the existing problem. The nurse leader will involve the administration in planning for the backup system in the unit and educate employees on how it will be carried out. The second stage will involve the implementation of the plan by initiating the backup during busy days and using check sheets to record successful calls. Upon implementation, the study phase will focus on the results like improvement of patient care and other trends pertinent to the backup plan. The employees’ response should be used to gauge the effectiveness of the plan including policies on the number of patients to handle during calls. The last part will involve reflection on the plan and outcomes. Actions will include standardization of the policies if the objectives were met or re-examining of the plan for further improvement.

References

American College of Emergency Physicians. (2021). Ensuring adequate on-call backup in the ED: Problems with on-call coverage contribute to treatment delays and rising hospital costs. https://www.acep.org/imports/clinical-and-practice-management/resources/administration/ensuring-adequate-on-call-backup-in-the-ed/

Ghafoor, Y. (2021). Impact of nurse shortage on patient care. Saudi J Nurs Health Care, 4(4), 114-119. https://saudijournals.com/media/articles/SJNHC_44_114-119.pdf

Reed, J. E., Davey, N., & Woodcock, T. (2016). The foundations of quality improvement science. Future Hospital Journal, 3(3), 199–202. https://doi.org/10.7861/futurehosp.3-3-199

Rosenberg K. (2021). Minimum nurse-to-patient ratios improve staffing, patient outcomes. The American journal of nursing, 121(9), 57. https://doi.org/10.1097/01.NAJ.0000790644.96356.96

Zolot J. (2017). Ohio collaborative model proactively addresses the looming nursing shortage. The American Journal of Nursing, 117(6), 14. https://doi.org/10.1097/01.NAJ.0000520237.83901.d7