Patricia Adams Evaluating Current Practice June 5, 2013 Quality Care Working as a registered nurse with Spectrum Health,

I have had many opportunities to ensure the delivery of quality care. Some opportunities to support the quality initiatives of my organization I have had include: unit based policy and procedure committee chairperson, patient education representative, nursing representative on the patient education council and research assistant for a nurse mentored research study. As part of our individual quality indicators our unit has several specific measures. The quality indicators are used to validate individuals and the organization as a whole. Fluid balance is a vital aspect of the hemodialysis treatment and one of our quality indicators is pre and post dialysis treatment weight. Patients are weighed before and after their treatment and the weight is recorded in the medical record. Our department goal is to ensure that pre and post treatment weights are completed and recorded more than 90% of the time. My pre and post weights have always exceeded the standard requirement. Another quality indicator that is measured at Spectrum Health is medication bar code scanning. Medications are scanned along with the patients wristband to make sure it is the right patient, the right medication and the right time. Our goal is to scan more than 90% of medications. My barcode scanning has always exceeded the standard. Continuing Education Continuing education, both formally and informally, is an ongoing part of my professional identity as a nephrology nurse. Professional certification in dialysis has validated professionalism in nephrology nursing. Recertification requires 25 continuing education credits

specifically related to nephrology. I am also a member of the American Nephrology Nurses Organization. Through this professional organization I complete several online educational offerings and receive their monthly journal. The American Nephrology Nurses Association (ANNA) hosts annual symposiums for nephrology nurses and I have had to opportunity to attend a few of these conferences. As a nurse in the State of Michigan, I complete 25 continuing education credits for license renewal. In addition to the nephrology continuing education credits, I complete a pain requirement, and as part of my involvement in patient education, I have also attended a health literacy conference. I am a member of ANNA Connected, the Acute Care SIG connecting to nephrology peers across the nation. This provides an opportunity for networking within our specialty. My quest for professional development is also evident in my decision to pursue my BSN/MSN degree through Ferris State University. Evaluation of Practice Evaluation of my practice is completed through several processes. Annual performance evaluations are specifically designed to evaluate my ability and performance. It assesses my essential job function and commitments. Through self, peer and manager appraisal I have the opportunity to reflect on my own perception of how I practice and receive constructive feedback on core values, professionalism, collaboration, communication, diversity, accountability, patient and family focus, quality and process improvement. Another method of practice evaluation is a professional development program that rewards engaged direct patient care staff. I have participated in this program since 2007. This incentive program helps retain expert nurses at the point of care. Self-reflection, peer feedback, patient feedback, relationship based care and evidence based practice are additional opportunities for evaluation. Helping Others in the Profession

Working in a specialty area offers opportunities to assist other nephrology staff as well as those outside of our area. Peer mentoring establishes positive and personal relationships and at the same time allows for professional and personal growth. Presenting Hemodialysis and You to new staff offers an overview on nephrology nursing as well as important aspects of caring for the complex dialysis patient. Hemodialysis patient care technicians are vital to the operation of an acute care program. To increase the quality of patient care, certification was recently made a mandatory requirement for technicians at outpatient dialysis centers. Acting as a resource for their educational needs as well as their technical skills is another way of increasing professionalism within this specialty area. A collaborative effort of patient-centered care through effective communication between the bedside nurse, physical therapists, dietitians and physicians is yet another way I am able to benefit other professionals in the delivery of superior quality care to patients. Interdisciplinary Team Work With an increased number of complex nephrology patients with multiple comorbidities, working collaboratively with the interdisciplinary team is of upmost importance. Recently, while I was the charge nurse in dialysis, we had a patient admitted to the hospital after a fall. The patient was scheduled for surgery in the afternoon the following day and needed dialysis prior to surgery. Although the surgeon documented this in his progress note and the consult for nephrology had been completed, the nephrologist had not seen the patient or been notified of this. During morning rounds on the patient he called the dialysis unit and requested an urgent treatment. Coordinating with the nephrologist, dialysis nurse, bedside nurse, surgery and patient transport, I was able to schedule the patient for dialysis and complete the treatment in a timely manner. By collaborating with other members of the health care team we were able to provide

quality care preoperatively. By dialyzing this patient we were able to remove excess fluid that may have led to a negative respiratory status during surgery. We were also able to remove wastes in the blood to decrease the risk of bleeding during the procedure and ensure that the patients potassium level was at safe level. The collaboration of interdisciplinary teamwork is a way to promote high quality, safe patient care. Ethical Decisions in Nursing As a patient advocate, protecting the rights of a patient is a responsibility of a nurse. Ethical situations in which decisions need to be made on behalf of the patient occur in almost every aspect of nursing. As I was caring for a new dialysis patient in her 80s I observed a distraught look on her face. Being a nurse for many years this was a look I had seen before, a look that needed further investigation. Upon further examination I discovered that this patient adamantly did not want dialysis. When a persons kidneys fail there are several treatment choices and one of them is no treatment. As an advocate for this patient I questioned the ordering nephrologist about the choice to order this unwanted treatment. The nephrologist spent a good amount of time talking with the patient and took note of her wishes. He further explained to the patient that her abnormally high labs may cause encephalopathy and that she would need to receive dialysis until they were within normal limits. At that time she would be able to make a clear decision without question of an altered thought processes. After personally supporting many others in this difficult decision of no dialysis treatment, I was able to connect empathetically to her and meet her emotional health needs in addition to her physical needs. Research I have had the opportunity to be a research assistant for nursing research with Spectrum Health. The nurse mentored research study Influencers of motivation-predictor of adherence to

recommended treatment plans has allowed me the opportunity to participate in a research project from its inception. Our original basis for the study was Why dont patients comply to their treatment? In review of the literature, we were unable to locate a tool to measure motivation to adhere. We developed a tool in attempt to measure motivation. Consent was obtained from research subjects who met the inclusion criteria. Data collection was difficult and in conclusion, the study did not find a significant predictor of motivation for adherence to recommended treatment plans. This study has impacted my practice significantly. Enhanced awareness of barriers to adherence and patient perception has helped me care for patients holistically, not just provide a life-sustaining treatment. Do you routinely refer patients to other resources: Are you cost effective in your care? Referral process in nephrology is limited. As a charge nurse, I often collaborate with physicians and care managers to facilitate a seamless transition of patient care from the acute care setting to an outpatient dialysis setting or long term acute care facility. An example of cost effectiveness in our area is in the care of uninsured patients. These patients are unable to receive dialysis as an outpatient because of their lack of insurance and typically present to the hospital with an acute need for treatment. As a charge nurse I collaborate with the emergency department, bed management and nephrologists to provide prompt care. The usual treatment plan is for dialysis two days in a row and then discharge to home. Scheduling them the next morning facilitates an early discharge and an overall cost savings to the hospital Healthy Work Environment In a healthy work environment employees are happier and more productive. The effect of negativism on the workforce is compounding. One morning upon arrival to the unit, I overheard a technician complaining about everything. I could not help but think how easy it is to

get pulled into the negative conversation and how contagious it is. After processing what the technician was saying and thinking of how I could turn this conversation around, I replied, At team Butterworth we are a positive team, talking like that will bring the whole team down just like the Titanic, why dont you join us on the positive team. I then proceeded to talk with other staff in a positive lighthearted way to start out our day. The technician did stop complaining and eventually joined our conversation. The next day at work a peer complimented me. She told me that I did a great job changing the negative atmosphere that could have clouded our day.