Running head: QUALITY IMPROVEMENT: FOLEY CARE 1

Quality Improvement: Foley Care

Kirsten Larson

Bon Secours Memorial College of Nursing

NUR 4144

Dr. Ellcessor

October 17, 2017

I pledge. Kirsten Larson

QUALITY IMPROVEMENT: FOLEY CARE 2

The medical field constantly makes changes to promote better patient care and outcomes.

Individual units in individual hospitals implement their own quality improvement projects to

enhance the patient care and create a better work environment. These quality improvement

projects can range from things as simple as hand hygiene to strategies to reduce the nurse

turnover rate. With all quality improvement projects, good leadership can make the difference

between success and failure.

Catheter-associated urinary tract infections (CAUTIs) have been on the forefront in

recent years. The U.S. Department of Health and Human Services has instituted national goals

for reducing healthcare associated infections which include catheter-associated urinary tract

infections (Krien, Kowalski, Harrod, Forman, & Saint, 2013). In response, hospitals and other

medical facilities have researched strategies on reducing UTIs associated with indwelling

catheter use. Facilities have instituted strategies to limit the use of indwelling urinary catheters as

a means to reducing urinary tract infections. However, not all catheter use can be avoided.

Because of this, facilities have developed best practice guidelines for caring for indwelling Foley

catheters once they have been placed. Some hospitals have created bundles to aid this process

with a focus on early removal and proper cleansing around the insertion site (Krien et al., 2013).

Now that research has identified the best means to reduce CAUTIs when indwelling catheters are

necessary, it is up to individual facilities to implement them. On the Oncology unit at St. Marys

Hospital, the nurse manager has identified routine Foley care as a quality improvement project.

Using the leadership theory of Servant Leadership, nurse managers can effectively implement

and maintain Foley care strategies.

QUALITY IMPROVEMENT: FOLEY CARE 3

Heart Domain

In order to successfully lead as a servant leader and accomplish change, the nurse

managers motivation cannot be self-serving. According to Blanchard and Hodges, a self-serving

leader looks at the world as a give a little, take a lot proposition and put their own agenda,

safety, status, and gratification ahead of that of those affected by their thoughts and actions

(2005, p. 41). To implement routine Foley care successfully, the nurse manager should not be

focusing on reducing CAUTIs for better reimbursements or on how their reputation would be

effected by the change. It is easy to cave in to the pressure of the leadership above them and

implement strategies because of that. However, in this case, the nurse manager should be

motivated out of a sense of what is right for the patients. The motivation the nurse manager

brings to a situation affects the attitudes of the rest of the nursing staff towards the change.

Head Domain

In servant leadership, the head domain refers to the values and beliefs of the leader about

the role of a leader. The servant leader recognizes that they lead by creating a vision and serve in

the implementation. The nurse manager can lead by setting the course and the destination

(Blanchard & Hodges, 2005, p. 84). By envisioning a reduction in the occurrence of CAUTIs by

implementing routine Foley care, the nurse manager is living out the belief that servant leaders

have a visionary role. The nurse manager further lives out their belief on the servant aspect of

servant leadership by supporting and enabling the units nursing staff to carry out the change.

This also involves empowering others. The nurse manager only does so because they believe that

it is their role as a leader to assist their staff. Other values and beliefs of the nurse manager can

also come into play. These may include a belief of responsibility to the patients and the general
QUALITY IMPROVEMENT: FOLEY CARE 4

population as a whole to reduce infections. A nurse managers values determine how they act

(Blanchard & Hodges, 2005).

Hands Domain

The hands domain refers to the actual work of the servant leader. There are three

activities that a servant leader uses to become a performance coach and successfully lead others

to accomplish their goals or vision. According to Blanchard and Hodges, these activities are

performance planning, day-to-day coaching, and performance evaluation (2005, p. 121).

Performance planning involves determining goals that help advance the unit towards achieving

their vision. Day-to-day coaching requires the nurse manager to consistently observe the nursing

staff at work, encourage them to follow the new guidelines or practice, and reward the staff as

they achieve their goals. The last activity requires the nurse manager to discuss with staff

members about their progress. The work of the manager following servant leader model stems

from their motivation and beliefs.

Habits Domain

It is easy for a servant leader to become caught up in the work of creating a vision and

enabling others to help implement the vision. The servant leader can easily become overwhelmed

and exhausted by the constant busyness and by focusing exclusively on the tasks at hand. The

habits domain of servant leadership are strategies designed to prevent servant leaders such as

nurse managers from becoming overwhelmed and burnt out. Habits such as solitude, prayer,

intimate community, and seeking accountability help rejuvenate servant leaders and keep them

on track (Blanchard & Hodges, 2005). They can also be done with the nursing staff to promote a

sense of teamwork and provide moments for reflection that encourage the staff and motivate

them.
QUALITY IMPROVEMENT: FOLEY CARE 5

Five Practices of Exemplary Leadership

The nurse manager utilizing the servant leadership model can develop and implement

changes using the Five Practices of Exemplary Leadership. According to Marquis and Huston,

the Five Practices of Exemplary Leadership fosters a culture in which relationships between

aspiring leaders and willing followers can thrive and increases the leaders ability to lead

others to get extraordinary things done (2017, p. 51). The Practices of Exemplary Leadership

include modeling the way, inspiring a shared vision, challenging the process, enabling others to

act, and encouraging the heart. Many of these practices tie in with one or several domains in the

servant leadership model.

Modeling the Way

According to Marquis and Huston, modeling the way requires the nurse manager to

clarify their values and become aware of their actions to ensure that their conduct reflects their

values (2017). In the implementation of routine Foley care, the nurse manager needs to

effectively communicate their value to the nursing staff. Because the nurse manager is acting

from self-less motivations, the value behind the implementation of Foley care is patient safety. In

order for the nurse managers behavior to truly reflect their values, the nurse manager has to be

consistent in their efforts to improve patient safety in a variety of areas. Also, by communicating

the reason behind the change, the staff is more likely to be supportive of the change.

Inspire a Shared Vision

Inspiring a shared vision occurs when the nurse manager creates a vision and strategies

that motivate the nursing staff to participate in the change (Marquis & Huston, 2017). In New

York City, a community hospital used a nurse-led process to reduce the use of Foleys which

reduced the rate of CAUTIs in the facility (Quinn, 2015). The nursing administration formed
QUALITY IMPROVEMENT: FOLEY CARE 6

councils with nurses from various backgrounds to implement their strategy. By involving

bedside nurses to champion the change, nurse managers can inspire the nursing staff to become

integral parts in implementing the new process of routine Foley care. Effective communication

on the part of the nurse manager is crucial for inspiring a shared vision.

Challenging the Process

Marquis and Huston define challenging the process as identifying opportunities and

taking action (2017, p. 51). One hospital in Delaware created an improvement team to

investigate all unit CAUTIs, research criteria for long- and short-term use of Foley catheters,

identify barriers and successes, debrief on each unit-acquired infection, and plan and implement

a path forward (Smakulski et al., 2015). The improvement teams job itself was to challenge the

process by identify opportunities for growth and then implementing strategies such as education

both in person and through alternative media. A nurse manager could develop their own

improvement team to identify openings for education on standardized Foley care and who would

assess and educate staff members as needed.

Enable Others to Act

Enabling others to act promotes trust and collaboration (Marquis & Huston, 2017). This

may involve working with managers and nursing staff from other units to work toward the same

goal. The study conducted by Krein et al. found that inconsistent policies on Foley catheters

throughout the hospital created a significant barrier to reducing urinary catheter use. In this

particular study, the nursing staff in the emergency departments were not aware of the protocol

regarding the use of indwelling catheters (Krein et al., 2013). In regards to Foley care, it is

important to be consistent throughout the hospital on standardized Foley care and how often it

needs to be done. It is very common for nurses to float to other units when they are short-staffed.
QUALITY IMPROVEMENT: FOLEY CARE 7

If the hospital is not consistent on the Foley care policy nursing managers on individual units

will have a harder time implementing routine Foley care and will constantly be educating nurses

floated from other units. This is why it is important to include bedside nurses and nursing

administration from different units throughout the hospital in the implementation of routine

Foley care and in the development of an improvement team.

Encourage the Heart

Encouraging the heart involves the celebration of achievements and goals. The nurse

manager recognizes and appreciates the work of the nursing staff in progressing to their goals

and gives verbal or written signs of approval. In the study conducted by Smakulski et al.,

individual staff members were recognized for their achievement and the entire unit was rewarded

for the months in which no CAUTIs occurred (2015). Encouraging the heart not only involves

the nurse manager rewarding and recognizing staff but also the nursing staff itself recognizing

individual. This promotes better teamwork and pride in the units achievements. Verbal and

written recognition, and gifts can be simple but powerful ways to encourage the nursing staff as

they implement routine Foley care.

Implications for Professional Practice

Nurses are responsible for maintaining a healing environment and for the promotion of

patient safety. Requiring routine Foley takes the nurses role in infection control further. It is a

simple way of reducing a healthcare-associated infection that could lead to complications that

further compromise patient health. Because routine Foley care is founded on evidence based

practice, the profession of nursing gains credibility when it puts its own research into practice

and promotes its control over how care is provided. Routine Foley care requires nurses to work

with other members of the nursing staff to ensure that Foley care is performed. Nurses have the
QUALITY IMPROVEMENT: FOLEY CARE 8

ability to delegate certain tasks to unlicensed personnel who are properly trained to perform that

task. When nurses are unable to perform Foley care themselves, they are responsible to delegate

the task to the appropriate people and evaluate the care given. This requires teamwork between

the unlicensed personnel and nurses.

Outcome Evaluation

Implementing routine Foley care will reduce the rate of catheter-associated urinary tract

infections on the Oncology Unit at St. Marys Hospital. Because there will be fewer infections,

the use of antibiotics may also decrease. Overall costs to the patients and to the hospital will

decrease. It is cost effective for hospitals to reduce CAUTIs since the Centers for Medicare and

Medicaid will no longer reimburse medical facilities for the treatment of hospital acquired

CAUTIs (Quinn, 2015). Because many patients on the Oncology actively receive chemotherapy

during their admission or are on neutropenic precautions, reducing the rate of CAUTIs will

decreases the likelihood of these patients dying from a hospital-acquired infection during their

stay.
QUALITY IMPROVEMENT: FOLEY CARE 9

References

Blanchard, K., & Hodges, P. (2005). Lead like Jesus. Nashville, TN: Thomas Nelson

Krein, S. L., Kowalski, C. P., Harrod, M., Forman, J., Saint, S. (2013). Barriers to reducing

urinary catheter use: A qualitative assessment of a statewide initiative. JAMA Internal

Medicine, 173(10), p. 881-886. doi: 10.1001/jamainternmed.2013.105

Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing:

Theory and application (9th ed.). Philadelphia, PA: Wolters Kluwer

Quinn, P. (2015). Chasing zero: A nurse-driven process for catheter-associated urinary tract

infection reduction in a community hospital. Nursing Economic$, 33(6), p. 320-325.

Smakulski, M., Brodwoski, M., Prouse, K., Stover, S., Manley, D., Seckel, M., & Mattison, K.

(2015). EB89 foley: Focus on linking evidence to your practice. Critical Care Nurse,

35(2), p. e43-e44.