Part A: PLAN (Nursing Ethics Education and Support)

A. Quality improvement project

Ethical situations and dilemmas are present in all types of nursing. After meeting with

the chief nursing officer (CNO) of Spectrum Health Continuing Care (SHCC), it was identified

that the nursing employees were lacking the knowledge needed to accurately identify ethical

situations. When ethical situations were identified there was no place for the employees to go

with this information. This was a large concern for the CNO and it was in her strategic plan to

start working on this in the next year. There are two stages to her plan. Education for the

nursing employees about what ethical situations are is the first step. The second step was to

create an algorithm for employees to follow when they encounter these ethical situations.

SHCC is a large facility with many different service line units and home care areas. For

this project I will be focusing on one unit that has expressed the most interest in dealing with

medical ethics. The unit identified is the Neurological Rehabilitation unit. With this unit

identified I will be working with the neurological rehabilitation team and providing them with

the education needed to recognize ethical situations. I will also create the algorithm needed for

the staff to know what to do when the ethical decisions present themselves.

The education plan will be a problem-based learning plan with some Power Point

references for the employees. I will educate employees with the help of the systems medical

ethicist Dr. Michael Wassenaar. Case studies will be presented to the employees to help them

identify ethical situations that have been witnessed in the organization before. Some of the

ethical case studies will touch on how to manage patients with drug abuse and pain, end of life

cases, poor family support and abuse, working conditions for nurses doing home care, and

others. There will be a pre-survey and post-survey evaluating the ethical knowledge of the

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employees before the education and their knowledge after the intervention. Part of the education

will also include the algorithm developed for the employees to follow when an ethical situation

presents itself.

B. Evidence to support the need for this project.

While working with the CNO for SHCC she has identified certain ethical situations that

have affected her employees. The problem is that her employees didn’t know they were ethical

concerns until after the situation was out of control. After they were identified as concerns there

was no place to go and no direction on what to do. This was alarming to her and she needs to

change this in the organization.

Nurses report a high frequency of ethically sensitive situations in their professional

activities (Leuter, Petrucci, Mattei Tabassi, & Lancia, 2012). In nursing school students are

focused on learning what they need to know to pass the licensure exam, whatever space is left in

their head, they might fit in some ethics (Tschudin, 2013). According to a study by Vynckier, et

al. (2014) their study revealed that current ethics courses failed to meet basic objectives of ethics

education. The poor consistency in nurse’s ability to follow ethical reasoning and ethical

practice, even between countries, indicates that nurse educators, and leaders should develop

nursing ethical competencies (Dierckx de Casterle, Izumi, Godfrey, & Denhaerynck, 2008). A

comprehensive ethical education plan has been identified as a way to improve the nurse’s ability

to manage ethical situations with patient care (Leuter, et al. 2012). Research supports not just

having an education plan but continued education on medical ethics. After testing, students

failed to achieve learning outcomes related to ethics, so it is recommended that they are place in

the clinical setting for ongoing learning (Walton, Jeffery, Van Staalduinen, Klein, & Rothnie,

2013).

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The best way to educate the employees is using a problem-based learning (PBL) plan.

When teaching ethical content using a PBL plan vs. a conventional lecture format the students

expressed greater satisfaction with PBL (Lin, Lu, Chung, Yang, 2010). There was no significant

difference between the end educational retention between the two programs (Lin, et al., 2010).

There was also no statistical significance between PBL and small group discussion learning

(Heidari, Adeli, Taziki, Akbari, Ghadir, Moosivi-Movahhed,… Damanpak-Moghaddam, 2013).

If there are not significant difference in how the education is retained then choosing the one the

students expressed greater satisfaction with is the logical choice to use.

Just having an educational plan isn’t enough. Once the ethical dilemmas are identified

the nursing employees need to have an outlet and support to deal with these situations. Nurses

are willing to use an ethical consultative service. In one study 90.3% of nurses responded that

they would use a consultative service to help them with ethical dilemmas (Leuter, et al. 2012).

This indicates there are enough ethical situations that happen which make nurses feel this service

would be beneficial (leuter, et al. 2012).

Nurses come from a many different educational backgrounds, including AND, BSN,

MSN or even DNP. With these varied education backgrounds they are all tough differently

when it related to ethics. Having a comprehensive bedside ethical education plan, like the one

described above, could have positive effects on relationships with the interdisciplinary team,

better communication with patients and families, and less stress and burn out caused by ethical

dilemmas (Blacking, 2011). This is the main goal of this whole project.

C. Where will this project take place?

This project is going to take place at Spectrum Health Continuing Care (SHCC). The

original discussion was how to develop this for the whole system, but the CNO identified one

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unit that needed this project more and thought it was a good place to start. The unit that I will

focus on is the Neurological Rehabilitation unit run by the Director of Nursing Nanci Steinbach.

The environment is an inpatient unit that provides rehabilitation care for patients who have

suffered a neurologic event. This includes stroke, traumatic brain injury, and other neurologic

diseases. The main care team includes an attending physician, nurses, and rehabilitation

specialists.

The unit consists of 58 beds in a combination of private and semiprivate rooms. The

nurse to patient ratio is around 1:10 to 1:14 depending on the time of day. The nursing

employees perform care related to medication passing, wound care, dialysis, tracheostomy care,

and other nursing clinical judgment practices. The nurse’s works closely with the CNAs who

perform basic activity of daily living care that the patients need. They also work closely with the

rehabilitation specialists. The rehabilitation specialists include physical therapists, occupational

therapists, and speech and language pathologists. The patient and family are at the center of the

care they provide. The intent is to rehabilitate the patients back to baseline, or as close as

possible so they can live a fulfilling life.

D. Who is involved in this project?

The facility involved in this project is SHCC, the Neurological Rehabilitation unit. The

preceptor for this project is going to be Deb Cress, MSN, RN, NE-BC. She is the CNO for

SHCC. Her contact information is: phone: 616-486-2404, email: deb.cress@spectrumhealth.org.

Deb Cress has worked her way from a bedside nurse in the ICU to the CNO of SHCC during her

long and successful nursing career. She has been a leader through large mergers and changes in

the nursing profession. I personally worked for her a few years ago and I learned many

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leadership skills that have helped me in my career. I look forward to learning more from her in

her new position as CNO.

Deb has also helped me by providing me a list of resources to help develop this program.

Nanci Steinbach is the Director of Nursing for the Neurological Rehabilitation unit and she is

going to assist me in identifying the top missed ethical dilemmas and how to educate the

employees. Also Dr. Michael Wassenaar, the system medical ethicist for Spectrum Health, will

help develop the algorithm the nursing employees can use when they encounter an ethical

situation. Please see attached signed preceptor agreement in Appendix A.

E. QSEN graduate level competencies.

a) Teamwork and Collaboration

K. Identify system barriers and facilitators of effective team function. There are

many barriers to these ethical concerns. The first barrier that needs work relates

to identification of ethical concerns. The second large barrier is no structure for

reporting ethical concerns. I will work with staff and leadership to help break

down barriers and show the importance of having strong ethical education and a

way to manage concerns that are identified.

S. Lead or participate in the design and implementation of systems that support

effective teamwork. The algorithm I will produce with help me meet this

competency. Designing a tool to help staff know where to go with ethical

concerns, that everyone agrees on, will help with teamwork and support the

employees.

b) Safety

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K. Summarize methods to identify and prevent verbal, physical and psychological

harm to patients and employees. Part of the ethical education will be directly

related to these topics. Discussion will occur around how identifying ethical

situations and getting the help needed will reduces these problems for the patients

and employees.

F. ANA Scope & Standards of Practice for Nursing Administration.

a) Standard 11: Collaboration. Knowing how to collaborate with many different health care

members will be essential. Working with Deb Cress, and Dr. Wassenaar, will only be the start.

Also collaborating with the rest of the nursing team to provide this education is necessary.

b) Standard 12: Ethics. Ethics is the basis of this project. Educating on how to identify ethical

situations and what to do next using an algorithm is at the heart of this project.

c) Standard 14: Resource Utilization. The reason this work hasn’t been done before is because

of a lack of resources. With myself doing a large part of this work I am adding to the resources

needed to create the education and support needed. I will also be looking at the ability of the

current medical ethicist to see or address these ethical concerns. If he is not available all the time

we may need to form a committee to review the cases and then bring the most difficult one’s to

the medical ethicist for further review and guidance. This will be what is spelled out in the

algorithm being developed.

G. Please see diagram 1 below titled “Root Cause Analysis for Ethics Education”

The fishbone diagram shows the different concerns related to why this education is

needed and why it hasn’t been done before. The group sat down and discussed the concern of

why nurses were unable to act or bring up ethical situations. Four main barriers were identified

and broken down by the group. The barriers are related to physicians, nursing staff,

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administration, and the whole health system, and are identified in the diagram. Under each of

the four main barriers there were barriers that if acted on would help the main concern. If the

areas identified are fixed then there should be a successful implementation of this program. The

fishbone puts this in a visual diagram for everyone to see.

H. Change and leadership theory.

The main change theory I am going to use is the influencer model (Patterson, Grenny,

Maxfield, McMillan, & Switzler, 2008). The basics of the influencer model are related to 6

categories that are identified to help with change. If a leader can use 4 of the 6 categories then

their chances for making a successful change increases dramatically. The 6 categories are: make

the undesirable desirable, surpass your limits, harness peer pressure, find strength in numbers,

design rewards and demand accountability, and change the environment. The more categories

used the better chance the change will be successful (Patterson, et al. 2008). The first category I

will work on is changing the environment. I will do this by changing the culture with education.

The second category will be to harness peer pressure. This will be accomplished by using the

unit leaders and charge nurses to do the right thing and make the ethics calls when appropriate.

If the employees see this happening then they are more likely to do the same. The third category

will be to find strength in numbers. If we educate all or most of the staff then the whole team

will be on the same page and will help advocate for the patients and themselves. The last

category I will focus on will be to design rewards and demand accountability. I will accomplish

this by giving unit leaders the tools to hold employees accountable for reporting ethical concerns

and then rewarding them when they do. I am not going to just use a change theory. I also need

to use a strong leadership theory too.

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I have chosen the authentic leadership theory to help lead this change. Leading a change

can be very challenging. Having strong leadership skills are necessary. Many research articles

focus on transformational leadership as a strong leadership style. The American Nurse

Credentialing Center (ANCC) also recognizes transformational leadership as a core competency

for Magnet designation (American Nurse Credentialing Center, 2008). Authentic leadership is

very similar to transformational leadership except for one aspect I feel is very important. The

difference between authentic leadership and transformational leadership is authentic leaders are

anchored by their own deep sense of self and know where they stand on important issues, values,

and beliefs (Shirey, 2006). Once they know that about one’s self then they can lead a successful

team. Authentic leaders bring their real self into leadership so they appear to the employees

more genuine (Waite, Mckinney, Smith-Glasgow, & Meloy, 2014). An authentic leader is one

who is perceived as open, optimistic, and resilient (Waite, et al. 2014). I will use the theory of

authenticity to portray these characteristics when meeting and educating the staff. If the

employees believe I am authentic and that I am acting in the patient’s and their best interest, the

proposed plan will be more successful. Using a nursing leadership theory shows strong

leadership. Strong nursing leadership leads to a strong nursing environment (Shirey, 2006).

I. How will you assess whether your improvement project worked? Will informatics

technology be used?

There will be a few ways to assess if the ethics education has made a difference. I will

provide the employees with a survey before the education. This will be used to identify their

current knowledge about ethical situations. After the education I will provide them with the

same survey asking them about their new knowledge of ethical situations. This should help

measure the effectiveness of the education. Part of the education will also include how to access

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the algorithm related to obtaining support when confronting ethical situations. The long-term

measurement of the effectiveness of this project will be how many times nurses access the

algorithm and get an ethics consults. Currently they have not had any ethic consults so the

baseline data is zero.

Information technology might be used in the project as a method of requesting an ethics

consult. The current electronic medical record (EMR) system SHCC uses is Cerner. There are

capabilities to have automatic consults built into the system when a need is identified. Currently

nurses can request care management or social work using this system. If there were ethical

dilemmas identified by the nursing employees and they entered them into the EMR, than one

barrier to obtaining the consults would not exist. This would be a long-term goal of the project

and one the CNO does not think would be done in the time frame identified for this class.

J. Predict what you think will happen as a result of your improvement project.

What I think will happen is an increased awareness of ethical concerns that the current

nursing employees already encounter but don’t currently recognize. There will be a significant

increase in the post-test scores when compared to the pre-test. This will show that the education

was effective. With better identification they will also have new support to deal with these

ethical concerns. I would anticipate that the nursing employees would consult the ethics team

around 5 times a month to help with ethical concerns. This should result in better care for the

patients and better satisfaction for the nursing team.

K. Please see grid below.

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Title of Quality Improvement Project: Nursing Ethics Education and Support

Goal 1 with QSEN/ANA Support Sub-Objectives to meet Goal Activities to meet Each Sub-objective Timeline for eachGoal 1: Develop an education program with the intent to help the nursing staff identify ethical situations.

Goal 2: Create ethics algorithm the employees can follow to gain the support they need to address the ethical situation (QSEN/ANA support below)

1.1 Research the best way to educate nursing staff on ethical dilemmas and their identification.

1.2 Develop an education plan based on the evidence.

2.1 Meet with Dr. Wassenaar to go over his work and resources.

2.2 Create a paper-based algorithm about what to do with ethical situation.

2.3 Educate the staff on the algorithm.

1.1 Do a literature search to find the best way to educate nurses. Then find the best ethics data that will be relevant to the continuing care setting or even the neurological rehabilitation unit. Use current situations to tell stories of incidents in their setting

1.2 With the use of evidence I will use patient case studies in a problem-based learning style to communicate the ethical information. I will use a combination of Power Point as well as interactive discussion. I will also use Dr. Wassenaars expertise to help with the education.

2.1 Meet with Dr. Wassenaar and learn about ethics. Research stories and pull from his knowledge and experience to find the most relevant information that can help the patients and nursing and how this will help develop an algorithm

2.2 Work with the key stakeholders to create an algorithm. Then place this algorithm in the education plan.

2.3 Use the algorithm in my teaching plan and use the post-test to see if the employees understand the process.

1.1 10/1/2014-1/15/2015

1.2 1/15/2015-2/15/2015 create education and work on goal #2

1.3 2/12/2015 start setting up class times2/19/2015 communicate class times to employees

1.4 3/1/2015 do a pretest of the staff3/14/2015 start education for two weeks4/1/2015 have staff do a post survey4/14/2015 compile the data for review4/30/2015 go over data with the CNO and count number of ethics consults

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Title of Quality Improvement Project: Nursing Ethics Education and Support

Goal 2 with QSEN/ANA Support Sub-Objectives to meet Goal Activities to meet Each Sub-objective Timeline for eachGoal 3: Implement the education program to the nursing employees.

3.1 Teach the nurses based on best evidence and relevant ethical dilemmas they might encounter.

3.2 Evaluate the effectiveness of the education by survey and the number of ethical consults reported to the ethics team.

3.1 With the help of CNO we will identify the resources available to assist and support the nursing staff when they have identified an ethical dilemma. Breaking down system barriers will be key when trying to reallocate resources

3.2 Use PowerPoint presentations and case studies to go over ethical situations and how to use the algorithm when these situations arise.

3.3 Have the staff fill out a pre and post survey at the time of the education to see if it has made a difference in their understanding of ethics in nursing. Also giving them the tools to consult the ethics team and tracking the number of times this is done.

2.1 1/15/2015

2.2 1/19/2015 have a meeting with key stake holders

3.1 1/26/2015 add this to the education

3.2 2/12/2015 combine the education plan and algorithm together and start implementing the education plan.

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Goal 1 QSEN/ANA Support ContinuedMeets QSEN Competency: Teamwork and Collaboration

K. Identify system barriers and facilitators of effective team function: There are many barriers to these ethical concerns. The first barrier that needs work relates to identification of ethical concerns. The second large barrier is no structure for reporting ethical concerns. I will work with staff and leadership to help break down barriers and show the importance of having strong ethical education and a way to manage concerns that are identified.

S. Lead or participate in the design and implementation of systems that support effective teamwork: The algorithm I will produce with help me meet this competency. Designing a tool to help staff know where to go with ethical concerns, that everyone agrees on, will help with teamwork and support the employees.

This QSEN competency will be very important for the implementation of this project. Ethics is not a single discipline concern. Many different disciplines play key roles in identification of ethical dilemmas and then the plan that follows. Knowing how to collaborate with others, lead others, and see the system view will be important to understand when working on this project

Meets QSEN Competency: Safety K. Summarize methods to identify and prevent verbal, physical and psychological harm to patients and staff: Part of the ethical

education will be directly related to these topics. Discussion will occur around how identifying ethical situations and getting the help needed will reduces these problems for the patients and employees.

This QSEN competency will be very important to the direct care nurses. The education should provide them with methods to identify ethical dilemmas, which can cause nursing staff to feel psychological harm for themselves. Nursing burnout is a common problem and helping them to identify concern and give them tools to address these ethical concerns will help.

Standard 11: Collaboration. (American Nurses Association, 2009, p.79) Working closely with the medical ethicist will be important when rolling out this program. We will need to work together to make sure the education fits the needs of the employees and is accurate in the message. Working with the unit DON and CNO will help me learn leadership skills and how to collaborate with their own nursing employees as well.Standard 12: Ethics. (American Nurses Association, 2009, p.80) The most important standard for this project is ethics. Assuring a process is identified to address ethical issues is a very clear standard set by the ANA.Standard 14: Resource Utilization. (American Nurses Association, 2009, p.82) The reason this type of project hasn’t been done before is because of a lack of resources. Understanding how to develop a program like this with the current resources will be a challenge but a learning opportunity.

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Diagram 1. Root Cause Analysis for Ethics Education

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Appendix APreceptor agreement letter.

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