Introduction

Ethical principles are required to govern how the clinician is going to behave or conduct themselves in presence of a patient. It looks at the right or wrong clinical decision making processes and determine the overall consequences (Klugman, 2016). This paper discusses three ethical principles in nursing, issues and solutions. 

Beneficence

 According to this principle, the clinician and other care providers are usually required to ensure that they have done everything they are supposed to do to benefit the patient in any clinical situation. All the treatment and medical procedures, be it administering medicine or performing a surgery that is recommended is supposed to be with the intention of benefiting the patient. This means that it is important all forms of clinical practice are done to the most good of the patient (Plante, 2016).  For clinicians to ensure the practice of beneficence, it will be important for clinicians to establish and maintain a high level of knowledge and skill, this means that they have to ensure that they are well trained in the most current and best type of clinical practices, they also have to ensure that they have considered their patient’s individual circumstances, including what can work and what cannot work for their patient as what is important for one patient may not work for the other. 

Autonomy

    When it comes to the principle of autonomy, it usually looks at the right of the patient to have the power and authority over what is done to their bodies or their health. In any case what the clinician is supposed to do is to advise or suggest, however when it comes to the application of any medical decisions it should be agreed by both the patient and the clinician, also according to this principle, an attempt to coerce or persuade the patient to making decisions is a great violation of the principle of autonomy (Klugman, 2016). In the end,  it important that the clinician allows the patient to make his or her decision even when the medical provider believes that the choices which the patient is making may not be at the best interest, the patient is supposed to make independent decision as these makes them satisfied with exercising their individual or personal value. 

Non-Maleficence

 The principle of Non-Maleficence is usually referred to the principle of ‘Do Not Harm’. This principle is usually very important and is supposed to be part of the end goal in regard to the decision of the clinician (Klugman, 2016). The principles also usually refers to the fact that the medical providers are supposed to consider if the society or other people are going to be affected by the decisions they made, even when it is done in the benefit of the patient. 

Ethical Violations and how to safeguard it

  Among the most common violations of ethical principles is when clinicians make medical decisions for personal or financial gains without considering their patient’s point of view. Also the clinician may decide to go ahead with a surgery or treatment without the consent of the patient without considering the view of the patient (Plante, 2016).  For example a patient might be frightened by needles  and it is only needles that can give then anaesthesia it is important that in such a situation the clinician works with the patient by respecting the fact that he or she does not like needs  and does not desire to be operated, which is his or her autonomy, the clinician should thus work with the patient to prevent her from getting worse which is the principle of beneficence but must ensure that no harm is done to the patients physical, mental and emotional well-being  which is under the principle of non-maleficence.

References

Klugman, C. M. (2016). Recognizing Ethical Terms, Theories, and Principles. Ethical Competence in Nursing Practice. doi:10.1891/9780826126382.0001

Plante, T. G. (2016). Principles of incorporating spirituality into professional clinical practice. Practice Innovations, 1(4), 276-281. doi:10.1037/pri0000030

Research, EBP, and QI Discussion

The provision of healthcare is increasingly becoming more complex forcing more nurses and other healthcare practitioners to participate in research studies, evidence-based practice (EBP), and quality improvement (QI) initiatives. The goal of nurses in participating in such studies and projects is to achieve patient-centered care that improves the healthcare outcomes of the patients. Various subtle differences exist between research, EBP, and QI projects that make it complicated for nurses to select the most suitable method for evaluating a clinical problem. The paper comprehensively examines these differences to enable nurses to make immense contributions in the nursing field through the development of new knowledge, inventions, and improvements

The difference between Research, EBP, and QI

Quality Improvement: QI initiatives don’t comprise of in-depth literature reviews and are normally specific to one organization. The majority of QI projects aim at correcting workflow processes, improving efficiencies, reducing variations in the provision of healthcare, and addressing problems facing nursing education and administration (Butler, & Prentiss, 2016).

Evidence-Based Practice: EBP projects aim at integrating the best change strategies with patient values and clinical expertise to improve patient outcomes. EBP process entails asking the most suitable clinical question, retrieving the best evidence to address the problem, applying the evidence to nursing practice, and evaluating patient outcomes (Butler, & Prentiss, 2016).

Research: this is a systematic investigation that consists of research development, evaluation, and testing to answer a particular research question (Butler, & Prentiss, 2016).

Application of these Concepts in Practice

There are various ways I can apply research, EBP, and QI projects as a registered nurse. For instance, I can apply research to carry out a systematic study to examine some of the strategies for preventing catheter-associated urinary tract infections (CAUTI). I can implement EBP in my organization to prevent chemotherapy extravasation for the patients receiving vesicant therapy. The major steps in EBP include (1) formulation of clinical questions that can be addressed by research evidence, (2) search for and retrieval of evidence, (3) appraisal and synthesis of evidence, and (4) integration of the evidence with own clinical expertise, local context, and patient preferences (Denise & Cheryl, 2018). Finally, I can use QI initiatives to improve wound care in my facility.  

Topic Search using Two Different Databases

 

There are various observations I made from using both PubMed and Google Scholar to search for the results of congestive heart failure. I realized that PubMed only indexes biomedical literature for peer-reviewed articles only whereas Google Scholar contains indexes of books, articles, abstracts, theses, and court opinions from various disciplines and sources such as academic publishers, professional societies, online repositories, and universities among others. Only a small fraction of the sources in PubMed are available as free full text when compared to Google Scholar.

EBP Models

EBP models provide frameworks for designing and implementing EBP projects in nursing environments (Denise & Cheryl, 2018). The Iowa model is fundamental in distinguishing two types of stimulus: problem-focused triggers and knowledge-focused triggers. The identification of the problem is critical as it helps in gathering massive support from the nurses, especially if they have encountered the problem on several occasions (Denise & Cheryl, 2018). The first major step in the Iowa model involves determining whether the identified problem is a priority for the organization, and I think, in this case, congestive heart failure is a priority considering its mortality and morbidity cases. The synthesis and appraisal of evidence are also of importance to the Iowa model (Denise & Cheryl, 2018). The last stage involves implementing and evaluating the change to determine its efficiency. On the other hand, the John Hopkins Nursing Evidence-Based Practice (JHNEBP) focuses on clinicians and this allows rapid implementation of the best available practices. The model follows a three-step process: practice question, evidence, and translation (McEwen & Wills, 2019). In my opinion, the Iowa model is more comprehensive and will be better for implementing EBP change for preventing congestive heart failure among the general population.

References

McEwen, M., & Wills, E. M. (2019). Theoretical basis for nursing (5th edition). Lippincott Williams & Wilkins.

Butler, E., & Prentiss, A. (2016). Empowering Nurses through Evidence-Based Practice (EBP), Quality Improvement (QI), and Research.

Denise, F. P., & Cheryl, B. (2018). Essentials of nursing research: Appraising evidence for nursing practice. Lippincott Williams and Wilkins pp-26-27.

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Root Cause Analysis and Failure Improvement Plan

Root Cause Analysis

The problem that occurred in this case scenario is the death of Mr. B, a patient who arrived in the hospital complaining of severe pain in the hip region and the left leg secondary to a fall. The death of the patient occurred following a series of intervention that took place prior to his transfer for advanced care in the tertiary facility. The patient sustained brain death during the intervention and hip reduction procedure. There are a series of event that occurred during the entire process that could have led to the brain death of Mr. B. First, a complete history of Mr. B was not taken prior to commencing the procedure of hip reduction. The history was important in understanding the treatment that the patient was on the probable effects that the drugs might have on the new drugs to be administered. The physician instructed the administration of diazepam and then hydromorphone without considering the possible drug interaction between the two sedative drugs and the opioid-oxycodone.

During the procedure of reduction, the patient was not put on any oxygen supplementation or ECG monitor. According to the conscious sedation policy of the hospital, every patient must be put on continuous blood pressure monitors, ECG and pulse oximeter throughout the procedure until the patient is declared stable. To some extent the policy was ignored because from the time the reduction procedure began up to the time the Ed team left for the respiratory distress patient, Mr. B was not on any monitor except the automatic blood pressure monitor and pulse oximeter. The patient was left under the watch of his son who had no medical background or any awareness of the changes in the vital signs. When the Mr. B’s son reported about the alarm ringing, the LPN noted the reduction of the oxygen saturation to 85% and instead of intervening; the LPN reset the alarm and did not report to the RN or the physician. The response team was only alerted after the blood pressure had seriously fallen and the oxygen saturation was far below normal.

It can therefore be concluded that the series of events that took place prior to the transfer of Mr. B lead to his death. The use of large doses of sedative drugs, the lack of vital signs monitoring and poor intervention plans all contributed to the death of the patient. The brain death could have occurred due to excessive sedation or limited oxygen supply secondary to reduced blood pressure. The ventricular fibrillation occurred to the rapid heartbeats and tachycardia that occurred due to the compensatory response by the head to the seriously reduced blood pressure. The fact that the ED department only had one RN and one physician could also have contributed to the events that led to the death of the patient.

Process Improvement Plan

The improvement plan should begin with the change theory that can be employed in this situation which is the Lewin’s Change Management Theory. The theory tries to explain the human behaviors that relate to change and change resistance patterns (Sutherland, 2013). There are three stages in this model. Unfreezing, change and refreeze requires previous practices to be forgotten and redirected. The unfreezing stage of the theory enables organizations to understand the difficulties that relate to the problem identified and the strategies to be developed to achieve the process of change.  The first step in the model is to Unfreeze by debriefing the situation with all the staff to find out what they felt went wrong. Did they follow policies, did they take shortcuts etc. The second step is to change by increasing the number of staff in the emergency department from one RN to three or more and an additional physician and more LPNs. The staff should all obtain training on advanced trauma and cardiac life support and the conscious sedation module. Strict adherence to the hospital polices should be ensured to prevent the re-occurrence of the case where the conscious sedation policy was ignored during the procedure of hip reduction of Mr. B. By increasing the number of the RNs in the setting, the possibilities of having an inadequate history as in the scenario will be avoided and the patients will be monitored more closely as well as necessary interventions conducted in due cause.

The LPNs working in the setting should be more empowered and accorded necessary communication skills that enable them to report any problems promptly before anything worse happens.  The third and final step is to Refreeze and that would involve running a mock code or emergent situation to ensure the staff have let go of the old way of thinking and ensure they have adapted to the new policies. This would be followed with periodic in-services for re-education and refreshing of the policy. 

Failure Mode and Effects Analysis

The entire emergency department team including the nurses, doctors, laboratory technicians and other members will be involved in the FMEA. The steps that will be involved in the FMEA will include the identification of the probability of an event occurring, being aware of the possible severity of the event, detection, dormancy, indication and finally the risk level (Neal, 2013). Severity is the consequences of the failure mode set towards the improvement plan. To understand the consequences, an analysis can be conducted to identify any previous failures and the consequences. Detection involve the creation of awareness of the possibility of failure occurring and the steps to be undertaken. The occurrence step is applied when failure has occurred and the improvement plan is being implemented.

The professional nurse plays a very significant role as a leader in quality care promotion and influencing the activities of quality improvement (Needleman, 2009). The nurses contribute directly to quality improvement by communicating the area of the hospital that needs changes so as to achieve the desired quality. The nurses are more involved with the patients and they understand the conditions of the patient more and therefore they are aware of the level of adequacy of supplies and the requirements needed by the patients. The nurses are also in constant contact with the patient relatives who form the base of external stakeholders who possess a lot of information of the areas of the hospital that need change.

Reference
Neal, R. (2013). Modes of Failure Analysis Summary for the Nerva B-2 Reactor. Washington DC: Wiley Series.

Needleman, J. (2009). The Role Of Nurses In Improving Hospital Quality And Efficiency: Real-World Results. Health Affairs, 28(4), 625-644.

Sutherland, K. (2013). Applying Lewin’s Change Management Theory to the Implementation of Bar-Coded Medication Administration. Canadian Jounal of Nursing Informatics, 50-62.