Discussion Question
A med-surge teaching unit has a morning routine where the aides do a set of vital signs with an electric BP cuff and enter them in the computer from 7-7:30 am. This is done while the nurses are getting report and ensures that all patients are seen during the shift transition hour and evaluated. As a new nurse you have been trained to do a manual BP and apical rate for any patient with a cardiac history before meds are given. You note that the difference in your vital signs and those of the aides range from a few points to 20 mmHg spread. You are frustrated because you don’t know if you can trust the aides you are working with or the equipement.
1. From a systems based perspective, what are the quality improvement concerns?
2. How would you analyze and diagnose where the system quality can be improved?
3. How would you identify and prioritize change?
4. Where does evidence based nursing practice fit in?
5. After a planned change is instituted, how would you evaluate the outcome?

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A med-surge teaching unit has a morning routine where the aides do a set of vital signs with an electric BP cuff and enter them in the computer from 7-7:30 am.  This is done while the nurses are getting report and ensures that all patients are seen during the shift transition hour and evaluated.  As a new nurse you have been trained to do a manual BP and apical rate for any patient with a cardiac history before meds are given.  You note that the difference in your vital signs and those of the aides range from a few points to 20 mmHg spread.  You are frustrated because you don’t know if you can trust the aides you are working with or the equipement.
1. From a systems based perspective, what are the quality improvement concerns?
2. How would you analyze and diagnose where the system quality can be improved?
3. How would you identify and prioritize change?
4. Where does evidence based nursing practice fit in?
5.  After a planned change is instituted, how would you evaluate the outcome?

Discussion
1.   From a system based approach the areas that need quality improvement are the need for a correct BP and apical rate from a computer and from a nurse, which one is correct? Which one needs improvement? With either of these done incorrectly and the use of cardiac meds it could be a huge issue for the patient and the hospital .Quality improvement should begin with knowing the system(computer) you are working with and knowing if it is in good working order and if there were other issues with this model in the past “the professional Rn of the twenty-first century will not be effective in the role without a solid base of knowledge related to the impact of nursing informatics, computers ,and information technology on the nursing practice, patient care and patient outcomes”(pg141) knowing your staff . As a nurse we must need to know if our aides are qualified to handle their position and if they are qualified to do tasks assigned to them efficiently and without errors.
2.   So to analyze this situation the first steps should be to analyze the errors and the discrepancies. First thing should be to implement a plan of care such as the PDSA model (pg.506) “what are we trying to accomplish” this model will help with, doing, studying and acting on a problem that may arise in the hospital, such as this issue. In the planning stage (diagnosing), a multidisciplinary staff could be assigned, possibly a few nurses on different shifts being aware of the machines and the aides and taking notes to compare to other shifts. With this information it could be possible to see errors done by either the computer or the aides and possibly see where the issue lies. Another way of protecting our clients is the magnet hospital way. If our hospital or facility isn’t a magnet hospital we could follow their lead in safety by researching their methods on safety protocol. “Magnet hospitals are known for better patient and staff safety outcomes” (pg.81)
3.    In still following the PDSA model, the next phase would be the doing phase(pg.507).(Identify and prioritize) In this phase it could be essential to analyze the information and take steps to get better results, in this phase we could see if the issue was from machine ,and if it was go about ways to better update the machinery or replace it or have it serviced ,if it was with the aides ,we could monitor them and hope that with help they improve or we could send them for more teaching to get their skills up to par or in worst case scenario ,replace them with a better qualified staff. We could also instruct our aides that with any cardiac patients that we the nurses would obtain the BP and apical results ourselves before giving cardiac medications.
4.   Evidence based nursing comes into play in this scenario because EBN is “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served” (pg.122). With these values and this scenario a nurse can determine by the research that the best care for these patients would be provided. In the research nurse could determine if the machines or the staff was at fault then use this information to determine the correct plan of care for their patients. The stages of knowledge, persuasion, decision, implementing, and confirmation could be seen in this scenario, by implementing the phases and getting the appropriate outcome the professional nurse would use evidence based nursing and a potential problem could be alleviated.
5.    To evaluate the outcome the nurse could then go into the studying and acting phase of the PDSA model (pg.507). In this phase, possibly the machines were corrected or the staff trained or let go and the new staff would be monitored. In these phases the nurse would then use more data to see if the issue has been solved and continue on the path of change or see if the issue has not been solved and implement a new course of action. In this phase all patients on medications for heart issues would be evaluated by staff and the data collected would be beneficial to the outcome.