The Clinical Governance issues and strategy for Neuro-intensive - Essay Example

The Clinical Governance issues and strategy for Neuro-intensive Care Unit: Formal Report to the Director of Nursing Executive Summary Currently,this staff is working in a neurointensive care unit in the hospital. This report is a review of the current status of the unit in terms of clinical governance issues, so a clinical governance strategy can be developed. This author upon reviewing current evidence and following comparison with the current status on the unit, arrives at certain recommendations, which have been presented in the following sections. To summarize, the clinical governance and strategy in safety management in the unit currently are very poor, whereas evidence suggests it to be a high priority. There are many reasons for this, and they include poor staffing, staffmix, skill mix of the staff and resultant workload on the face of high-dependencyhis, and they include oor, where as e, the clinical governance strategy t status on the unit, arri nursing work in the critical care unit. Moreover, the types of patients that this unit treats are all very critical where management needs sometimes more than two nurses for these patients standing by the bed. This is leading to high work load, staff fatigue, and dissatisfaction leading to high attrition rates of experienced staff, and the workforce management commonly is taking place by novice staff who even do not have intensive care unit experience. Therefore, it is difficult to expect from them the kind of technical expertise that is necessary for nursing management in a neurointensive care unit. The position of the nurse clinical educator is vacant, and on the job training is suffering to a great extent, and therefore, in many a cases, errors or omissions are happening due to ignorance (Aari, Tarja, and Helena, 2008, 78-89). Although a clinical governance guideline is in place, it is clear that despite errors or significant incidents occurring, there is inadequate reporting, so it is difficult to expect some strategy to come out, and the nurse manager despite her sincere attempts cannot go beyond certain limits only to keep things running. Given this scenario of poor clinical governance, the safety and quality of patient care is being affected, and quality assurance is poor due merely to the fact that incident and adverse outcomes are not reported and hence not managed. This formal report has analyzed the issues in the unit, found out relevant data, and come up with some realistic recommendations that can be considered for implementation to restore things in the unit back to normal. Quality of care is the watch word in clinical practice, and since the nurses are intimately involved in care of the patients, implementation of principles of quality in care is more important. In the healthcare scenario, strategies to improve the quality of healthcare at present play important roles in the healthcare policies for any provider, since ethically the provider is bound to maintain the standards of quality, is accountable, and deviations have legal implications. There is evidence of variations in quality of care in different settings and of medical errors in most healthcare systems. Combined with this, societal changes have made people more consumerism oriented, and since they expect more accountability from the professionals, the authorities also seek better quality and continued improvement (Kirchhoff and Dahl, 2006, 13-28). A neurocritical care unit is a distinct unit within a hospital that caters to the patients with acute neurological conditions or injuries that are life-threatening and critical for survival. Obviously, such an unit has very easy access to the emergency department, operating room, and imaging facilities. The staff and the workforce are important assets in such units, and the nurses need to be constantly present at the bedside. Therefore, appropriate staffing has been considered to be important and significant determinants of the quality and standards of care provided to the patients. It is literally a critical environment since at every point critical management decisions are to be made, and an error would construe less than optimal outcome where the patient may be affected seriously. Therefore workspace environment plays a very important role in practice, where continuous quality control measures are implemented in order to strategize clinical governance and deliver optimal care. In a neuro intensive care unit, nurse staffing and its levels influence patient outcomes both directly, when the ICU nurse initiates appropriate care strategies and indirectly, by implementing the care strategies of the members of the interprofessional care team. Skill is the most important attribute that a ICU nurse in the neuro setting possess, and it has been said that ensuring an adequate skill mix is an important part of the management of the unit. In an ICU nursing team of such magnitude, there would invariably be different nursing roles who would work as a team, and various guidelines would determine the standards of these roles. Usually a nursing manager would guide clinical practice in such unit. Registered nurses in such a unit would possess formal postgraduate qualifications with varying levels of critical care experiences in the neuro intensive care unit. 2. Summary of Key Issues and Current Strategies 2.1. Staffing This unit caters a population of 2.5 million, and a neurological intensive care unit serving this population should have at least 5 to 7 dedicated critical care beds for neurological patients to allow a safety factor of 1.33. In this unit there are only 10 beds, and this makes a situation where all the beds are occupied all the time. This unit, however, is sited in close proximity to the operating theater, imaging, and other intensive services. Other facilities in this unit are optimal in the sense that staff it is equipped with minimum support facilities including staff station, clean utilities, dirty utility, store room, patients ensuites, patient bathroom, linen storage, disposal room, sub-pathology area. However, due to constraints in space, provision of these has cut into the actual bed space and care areas. This cannot be changed, however, working is better accomplished when each patient gets 20 square meter of area. There is provision for one hand wash basin per two adjacent beds, and this would be sufficient for minimum infection control guidelines in our facility. Apart from these, each bed space has been provided with piped medical gases of oxygen and air, suction, and adequate electrical outlets, data points, and task lighting, which are sufficient for bedside procedures. A qualified team is very important for executing care to these patients. Evidence from current literature is very sparse in terms of recommendations in a neurointensive care unit staffing, and comparing the practical deficits in our unit to that is needed in any intensive care unit work environment can provide adequate guidelines. Qualified and skilled staffing is of essence in this type of care, and there must be a flexible level 3: level 2 bed ratio staffed as one. There is currently no provision of level 1 intensive care beds for neurological disorders, and this can be contemplated to solve the problems related to staffing in terms of skillmix and staffmix. Usually, in this unit three types of patients are cared for, and these belong to the categories of neurosurgical, head injury, and other critical neurological disorders. In this given situation, nurse staffing is an important issue that this unit suffers from. The staff establishment that refers to the number of nurses required to provide safe, efficient, and quality care to the patients, and in all parameters, such as nurse: patient ratios, nursing competencies, and skill mix, this unit is below the standard requirements (Bolton et al., 2007, 238-250). 2.1.1. Current nursing staff profile, including skillmix and staffmix It has been recommended that the ratio remains 1:1, however, in practice this often turns out to be 1:2 or sometimes factually 1:3. There are several reasons for this. The first and foremost reason is lack of skilled staff and faulty rostering without considering the workload of a skilled and experienced nurse. Although the authority is trying to augment this deficiency by adding other types of clinical or support staff to the workforce and sometime novice nurses, this lack of appropriate skillmix is compromising quality and increasing the workload on the skilled staff. Due to no attempts on the part of authority to employ a clinical nurse educator and the skill training being mostly hospital based training certificates, the new joinees are taking a lot of time to achieve requisite skills, and therefore vital clinical decisions in work place is being mostly dependent on 2 or 3 skilled and experienced nurses. This is making their working hours prolonged, since the nurse manager is requesting them to comply depending on the critical nature of particular patients. This has led to serious attrition rates in employed nurses leading to crises in the staffing issues. 2.1.2. An analysis of current nursing workload in relation to the ward/activity Currently, in our unit, the minimum requirement of 1:1 nurse patient ration is not being met, and sometimes depending on patient acuity and skill mix issues, the necessity becomes higher where each patient may need two nurses. For resource reasons, the staff mix can be determined as 1 experienced and skilled to 1 novice, but due to staff shortage, many novice nurses are allocated one patient. These nurses need to be supervised due to highly technical nature of the work in the neurointensive care unit, but due to workload, the experienced nurses are often failing to attend or supervise them. Many patients are on ventilators, agitated, unconscious, comatose, and very critically ill. These patients need at least one skilled nurse and help from others to maintain, monitor the gadgets, and decide accordingly, which is never the case in this unit. The current skillmix is not at all ideal, since the number of registered nurses with formal specialist critical care qualifications with experience in neurointensive care unit practices is only 3. In comparison the recommendation is 75%, this unit has only 10%. Resource problem considered, this should be at least 50% of the total staff to handle the issues in the unit. There must be a clinical coordinator and ACCESS nurses (Hasin et al., 2005, 1676-1682). The present nursing manager can handle her work efficiently. The positions of clinical nurse educator and clinical nurse consultants are vacant, the novice nurses need to be trained and certified, and new recruitment should increase the number of the skilled nurses to at least 10 for this unit from the current number of 3. This is important since this current nursing shortage in this unit can be covered by a rich RN skillmix. Good and quality care in the intensive care unit setting needs a pragmatic staffing pattern, and shortage of nurses contribute to lack of time to provide adequate care. In many cases, the nurses cannot provide time to a patient or a family without being taken away from the care of another patient. Lack of time attributed to shortage in skilled nurses in this unit is the most frequent barrier to provide a standard care (Rischbieth, 2006, 397-404). Moreover, there is evidence that staffing, skillmix, and staffmix support care processes in a positive manner by creating a healthy work environment, which results in job satisfaction. The essential environmental attributes have been studied to be very closely related to the quality of work. These attributes are work with peers who are clinically competent, collegial relationship between team, clinical autonomy, nurse manager support, perception that staffing is adequate, and support for education. Most of these are lacking in this unit, and the first step toward that would be adequate staffing. To be specific, the best care is possible only when around the clock coverage by one person at a time on the job requires 4 to 5 qualified persons on the pay roll considering a 40-hour work week, vacations, weekends, and holidays. In this unit given this acute staff shortage, this is currently being managed by calling in senior regular staff RNs on their days off, calling in regular staff early, and juggling the current staff to make do. Floating the RNs from other critical care units is the next alternative that is most used, and they have no idea what they will do in an entirely foreign setting, but it is better than floating RNS from the noncritical areas, where staffing is the most important concern not quality or addressing adverse events (Schmalenberg and Kramer, 2007, 458-468). 2.1.3. An analysis of any current issues in relation to nursing recruitment and retention, including job satisfaction Staffing and staff shortage in this neurointensive care unit is the most important issue in relation to recruitment, retention, and job satisfaction. In this relation the rostering format is very important that decides retention. Inability to provide flexibility in rostering practices given this acute shortage of staff is affecting the retention of the staff. The traditional shift pattern in this unit is 8 hour morning and evening shifts with an optional 10 hour night shift, which remains optional never. Now the shortage is so acute that authorities tried to implement 12-hour shift without consulting the nurses. With the loss of shift overlap time, this is taking away the time from the in-unit educations sessions. The professional dissatisfaction and lack of professional development has further been accentuated by the absence of educator in the unit. Although this 12 hour shift would provide improvement in social and personal life, most often for the skilled nurse this is not the case, and they are ending up coming early or going late due to unit requirements, called by the nurse manager. Moreover working long hours can reduce the high level alertness that is necessary in this unit. Therefore, the problem may be summarized as lack of available skilled, trained, and experienced nurses for this unit to be recruited, very high attrition and very poor retention rates, and gross deficiency in satisfaction are working together to make matters of this unit worse. Many incidences are there in this unit, of burn out syndrome that may affect the quality of care leading to miss, near-miss, or even critical incidents. The leadership has failed to project the unit as a place to the prospective candidates where work would not cause emotional exhaustion, depersonalization and would provide the very necessary sense of personal accomplishment in work in the unit. More over mainly due to these reasons, many nurses have quit, and there is evidence that workplace environment and workloads are two determinants of retention and job satisfaction (Stone et al., 2006, 1907-1912). This has further been enhanced by the baseline work-related stress in this intensive care unit. Moreover there is absence of preventive strategies such as support in patient care and support from the care manager is apparently lacking. This could lead to not only deficiency in job satisfaction, but also decreased quality of care, reduced safety awareness while caring for these critical patients, and absenteeism further accentuating the shortage (Poncet et al., 2007, 698-704). 2.1.4. An analysis of professional development strategies to meet current and projected clinical practice needs There is currently no professional development program for the staff in our unit. It has been noted earlier that senior positions responsible for on the job education are lying vacant for a considerable period of time. With the skilled staff shortage in the unit, it is mandatory that some kind of in-house critical care courses be undertaken for the nurses who are unskilled. The neurointensive care unit nursing care is a matter of high level precision with all equipments that increasingly use medical technology to deliver the care. Many nurses work without being oriented to these machines, how to read the data, and how to utilize those data to make a clinical decision. The lapse appears so large that any fault in this process would create safety issues, where many incidents may happen. If clinical governance is necessary, more necessary is the training and professional development to use the ancillaries in the unit. Present curricula of the specialist nursing role do provide adequate content to serve their roles, but it needs orientation to the currency of knowledge and correlating them to clinical skills. A clinical skills development program is the need of the hour, and currently there is no continuing education input to understand and implement the very rapidly changing knowledge base for neurointensive care nursing and innovative regimens of treatment through the use of medical technology. There is evidence that failure to correlate with academic learning and practical clinical care may lead to severe job dissatisfaction, which may lead to care without involvement and hence diminution in quality standards. Moreover an error made in ignorance is not an error. There is a perceived need for these nurses working in this neurointensive unit to maintain current, state-of-the-art knowledge across the broad range of clinical states that they encounter in practice, and there must be someone constantly on the vigil to detect erroneous practice and to demonstrate the right way of doing things at the bedside. There are no unit-specific orientation program, no formal programs of assessment, and no demonstration of clinical competence through a structured identification of educational needs depending on the mandatory requirements of the unit. These are adding to the job dissatisfaction of even those who are experienced and skilled and consequently leading to many incidents that need to be reported (Donaldson, Brown, and Aydin, 2001, 20-29). 2.2. Current Clinical Governance and Risk Management Strategies This units activity and environment is highly risk laden, and given the skill mix of the staff there should be someone who looks after the potential risk issues and risk management. Currently, the manager of the unit is looking out for potential error, harm, safety issues, and potential medicolegal vulnerability. It is very alarming to note that ignorance is the main reason why the most of the staff in this unit do not acknowledge their own vulnerability to error, and that in itself is a violation of the safety principles. Many are fatigued with the work load, and most think that they not violate any safety issues out of fatigue. For this reason, this author collected data from two types of errors. These were errors reported by physicians and nurses immediately after an error discovery and activity profiles on 24-hour records. It took quite some time to collate the data, but over a period of 4 months a total of 554 human errors were reported by the medical staff. There was an average 178 activities per patient per day and an estimated number of 1.7 errors per patient per day with the number of potentially detrimental errors for the unit was on average twice a day, nurses had many more activities per day, and they contributed to equal number of errors as the physicians. In summary, this unit commits a number of potential errors that can be prevented. 2.2.1. Safety 2.2.1 Safety This unit has well delineated policies, procedures, and guidelines in terms of safety issues. This is well written, simple to read, and in a consistent format. This is supposed to be evidence based, but it has not been updated for quite a few years. There is a protocol in place for reporting. The most common problems that are encountered in the unit are drug errors, infections risks, lack of timely information, misinformation, or rudeness of staff. According to policy, the manager needs to intervene proactively in such situations. The other issues in the unit are falls risk and pressure ulcers and self extubation when the patient needs to be intubated. According to policy, when such events occur, there is need to fill a format and to send the report to the contact person. Moreover, violation of such issues needs prudent documentation as soon as possible following the incident. It is required to explain the incident and its possible outcome to the family and the patient, and in this regard this unit currently follows the principles of open communication. However, due to staffing shortage the root cause analysis does not happen effectively to explore in details the sequence of events and system failure that participated in the incident. Moreover, there is no system in place where defensive principles can be applied in a proactive manner to prevent such incidences, many of which go unreported in the current state of affairs. 2.2.2. Effectiveness of care The effectiveness of care, therefore, is deteriorating in terms of outcome and patient and family satisfaction. Very highly skilled care is necessary, and that is lacking. Inadequate staffing is leading to miscommunications between the nurse and physicians. A lack in understanding of the necessary protocols is leading to inaccurate implementation. All these factors are contributing to incidences of complications and as a result prolonged stay. Many cases have been reported where unmanned patients have fell down leading to secondary injuries or a wrong medication had been given in a wrong dose. Lack of time is leading to insufficient contact precautions leading to spread of infections and even death. Quite a few patients have ended up having pressure ulcers due to failure to implement appropriate posture management has led to pressure ulcers. Not infrequently, few patients have extubated themselves while they needed to be in ventilator, and re-intubation had to be done. Keeping aside the job satisfaction of the nurses and satisfaction of the patients with care, if these issues are considered as parameters to measure the effectiveness of care, this unit is failing in that count. 2.2.3. Incident and adverse outcome management As mentioned earlier, the incident management after the incident involves a reporting, investigation, and assessment following the specific guideline and protocol. The root cause analysis however states that despite the safety and error reporting systems, there is a gap in understanding that leads to the common medical errors. Therefore identification and analysis of the reported errors based on commonly performed tasks and individual involved need to be done. Since communication failures are the most important identified reason in this unit that needs to be taken care of. Furthermore from experience, the other reasons are dispensing problem, human knowledge error, hand-off error, technical failure, or scheduling issue. Incidents are reported in the hospital safety-report forms. There are many unreported errors which result from system failure, and the nurses are encouraged to report such. Adverse outcome management is usually taken on a serious basis with a priority. The consultant physician is immediately contacted and all senior personnel are involved in the decision making as soon as discovery. Usually the focus remains on systems and processes, not on individuals committing the error. As has been mentioned earlier, the manager takes the leadership to discuss and disclose the event and its consequences to the family and the patient, if he is able to understand. 2.2.4. Ensuring quality of care Although it is known that consistent compliance with evidence-based guidelines can significantly improve patient safety and quality of care, it is clear that this unit lack in these areas. One of the reasons is that many of the staff are not guidance compliant in facilitating implementation in the clinical setting. This area has significant room for improvement as far as it is applicable to this unit. The impact of individual nurses beliefs and attitudes toward guideline compliance needs to be strengthened, but a system approach is necessary to accomplish this. The reasons for this are system ambiguity in the forms of task, exception, responsibility, method, or expectation and staffing issues. It is also to be noted that the major issues in critical care such as management of airway, oxygen therapy, and monitoring are frequently suboptimal leading to increased morbidity and mortality of the patients. 3. Recommendations 3.1. Staffing The recommendation is to arrange for appropriate staffing in the unit with 1:1 ratio. At least 75% of the recruitment must be skilled and postgraduate nurses experienced in neurointensive care unit work. There is significant evidence that nurse staffing and adverse events are associated phenomena. On the job education, skills training, guideline appraisal, and orientation of the new recruitment are mandatory. Rostering must be realistic to allow all the staff adequate time to reflect on their practice and continue education and at the same time allowing their social life. These will lead to professional development and high staff retention. Stopgap arrangements to get staff from other pool must be stopped to allow the development of teamwork and learning and to reduce adverse events. The starting point to solve the staffing issues in our unit should be establishment of minimum base staffing levels in the patient census approach, using the number and classification of the patients within the unit to determine the number of nurses to be restored on duty in a shift. The unit manager can calculate the number of full-time equivalents that are necessary to implement the roster, and the working week should not exceed 38 hours. To this end, historical data from previous years of patient throughput and patient acuity can be utilized, so the future requirements can be calculated. It is also recommended that consultation with an established unit of the nearby tertiary care unit be made in order to ascertain their experiences. The ultimate and final staffing pattern should be decided by the actual clinical practice setting, acuity of the patient, and the knowledge and expertise of the available staff. A patient dependency scoring tool may be utilized to guide these staffing decisions rather than randomly assigning the roster. It has been demonstrated that the use of nurses other than registered nurses within the critical care setting can be one potential, solution for this shortage. Substitution of one grade of staff with a lesser skilled, trained or experienced grade of staff has been shown to reduce adverse events in the critical care setting (Rose et al., 2007, 434-443). 3.2. Safety The staff must be trained in safety issues and the unit policies to prevent incidents in order to ensure patient safety. They must understand the importance of prevention of events before it occurs. The reporting system must be included in the culture of the unit with a no-blame approach, to make sure that the person committing an error gets a fair treatment. The managers must take the lead role to find out the root cause and act in a proactive manner to explain, communicate, protect, and support the staff within the legal framework of safety issues and issues with negligence. The manager must also take care to keep in place well-defined protocols and direct the teams to co-ordinate activities involving the stakeholders in the decision making process. With a team developing, a patient-centred culture and effective communication and coordination through open and collaborative problem solving would lead to the organizational success in safety implementation. A senior manger would need to be rostered on call and would be available for advice for 24/7, with these managers being trained to know how to respond to incidents. Frequent rehearsals on major and foreseeable events must be made within the team along with the accentuation of the learning that all staff in a highly demanding setting like this ICU are vulnerable to commit errors, and errors have serious legal consequences from the accountability point of view (Stockwell and Slonim, 2006, 199-210). 3.3. Effectiveness of care Although the measurement of effectiveness of care delivered in the unit has traditionally been measured by incidence report, adverse events, extent of reporting, and patient satisfaction, the current evidence suggests that the root causes of adverse events that need clinical governance approach are actually related to concerns about staffing, nursings influence on patient safety and health care outcomes, and issues related to work environment. Thus it is important to implement a nursing-sensitive performance measure that address all the domains of nursing activities in this unit, such as staffing, technical issues, system failure, documentation burden, and burn out. The lack of on the job education and professional performance satisfaction are important issues that need to be addressed. The most current scientific and empirical evidence suggest improvement of care quality if these issues are solved (Needleman, Kurtzman, and Kizer, 2007, 10s-43s). 3.4. Incident and adverse outcome management Many errors occur in the unit, and despite concentrated efforts, the patient safety has not improved markedly. This occurs due to difficulty recognizing and reporting events that commonly occur in the complex and dynamic environment of this unit. In many cases these do not happen due to time pressures or fear of punishment alone, in fact most occur due to the fact that the staff has become accustomed to such errors. That is a problem with attitude that can be worked upon on an individual basis, but other failures such as miscommunication, unawareness, and system failure in terms of ambiguity can be averted with intensive efforts. For this, it is necessary that the authority direct their attention from the traditional classification system of errors, and recognize system failure that can contribute to patient safety violations. This would also need more diverse and innovative reporting methods. Informal peer support programs and training of peers where colleagues debrief others with an experience should be in place to facilitate incident and adverse outcome management. The experienced staff must volunteer themselves for training and providing assistance to the less experienced ones. Best practice protocols guided by evidence must be in place to target prevention (Elder et al., 2008, 25-30). 3.5. Ensuring quality of care The quality of care can only be accomplished by strict adherence to protocols, knowledge of current evidence, and an able leadership. With patient-centered approach in the unit, a planned approach to educate the staff about new techniques, awareness of patients safety and activity levels, and improvement of knowledge about the patients condition can be used to improve quality of care. The training programs should consider factors that can affect the quality of care and techniques to prevent them. Compliance of the leadership staff is an important stimulator for compliance of the staff. Quality improvement drives based on evaluation of care and educations have both been seen to reduce the rates of incidents and to improve the quality of care. The incident reports and its root cause analysis can be used as tools in such training (Stockwell and Slonim, 2006, 199-210). Reference Aari, RL., Tarja, S., and Helena, LK., (2008). 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