Discussing the essentials of Advanced Nursing Practice
Dealing with organizational change is one of the biggest challenges in today’s healthcare system and it takes good leadership to effectively manage change. Change management revolves around handling the complexity of the process which includes planning, implementing, evaluating, and developing strategies to improve the change. In the healthcare environment, change is necessary to enable healthcare providers to adapt to new ways of doing things while promoting best practices and improving patient outcomes. Advancement in nursing education has seen the preparation of highly competent nurses responsible for initiating and managing change in today’s complex healthcare system. These nurses develop seamless and organized care approaches that promote patient-centered care with improvement in quality practices. This discussion appreciates the role of nurse leaders in managing change by identifying an organizational problem and recommending a change to improve quality service delivery to patients.
Purpose and Overview
The purpose of this consultation is to identify a patient-centered weakness in St. Cloud hospital and use the data to propose a change directed towards improving the organizational weakness.
Leadership and management are crucial to the growth and expansion of healthcare organizations today. The healthcare sector is rapidly evolving and the increased use of technology has led to increased competition for quality service delivery. While organizations move towards value-based care, it is important to identify weaknesses and opportunities to better the quality of care delivered to patients. Leaders in the healthcare industry should understand that healthcare delivery has increased in scope and complexity and that change is now inevitable. St. Cloud Hospital, MN is a healthcare organization that has a long-standing commitment to providing compassionate and personalized care to the people of Central Minnesota. To gain an understanding of the strengths and weaknesses of the facility, a consultation with one of the nurse leaders was done.
Data collection about the organization was done using several approaches including information from the nurse leader, information from the organizational website, HCAHPs scores from the Medicare and Medicaid Services, and regional data from the state website. A face-to-face interview was done with a nurse supervisor because of her roles in overseeing process improvement in the facility and expertise to identify areas of weakness in the organization. Well-structured questions focusing on the roles of the nurse leader, strengths and weaknesses of the organization, quality improvement projects, and evidence-based practices in the facility were used during the interview. Secondary data collection was done using the Centra Care website, data from newsroom and noticeboards, and organizational performance from the Hospital compare website. From the consultation process, significant information and data were obtained to form an analysis and recommend change improvement in the organization.
Description of Organization
Founded by the sisters of the order of St. Benedict in 1886, St. Cloud Hospital serves to provide personalized and compassionate care to the people of Minnesota. The organization is recognized as the number one top quality service delivery hospital in the region and it has received national recognition. For instance, St. Cloud Hospital has been named among the top 100 healthcare facilities by Truven Health eleven times (CentraCare, 2020). The reputation of the organization including leadership strength cannot be matched by any other hospital in Minnesota. The quality of services delivered in the organization together with quality improvement practices observed has enabled the facility to get a Magnet hospital designation. St. Cloud Hospital has received Magnet recognition four times and is among the 49 hospitals worldwide that have received the award four or more times (CentraCare, 2020). The reputation of the organization is based on the prestigious distinction of nursing excellence and high-quality patient care provided by nurses and other healthcare providers.
The services delivered in St. Cloud Hospital are dependent on the good leadership and commitment of healthcare workers. St. Cloud Hospital has a huge healthcare workforce composed of approximately 6500 employees and a medical staff of more than 550 physicians. The facility has a bed capacity of 489 and provides care to thousands of patients. The facility is a level II trauma center that provides emergency care services to children and adults including psychiatric patients. Surgical care services are advanced in the facility to include inpatient surgery, outpatient surgery, surgical care unit, and intensive care surgery. According to data from the organizational website, the department has 18 operating rooms that provide surgical care to over 14,000 patients a year (CentraCare, 2020).
St. Cloud Hospital offers numerous services to patients including 24-hour emergency care services. The facility offers a full spectrum of inpatient and outpatient services to meet the growing needs of the population served as follows: Animal-assisted therapy, behavioral health services, birthing services, breast care, cancer care, children’s services, cleft & craniofacial center, diabetes care, digestive care, direct access testing, emergency services, grief & bereavement services, heart & vascular care, home health services, home delivered meals, hospice services, hospitalist program, imaging services, intensive care, interventional neurology, kidney care, laboratory services, link to life, memory care, mental health, neurology, neurosciences, neurosurgery, orthopedics, palliative care, pharmacy, rehabilitation services, sleep medicine, surgery, trauma services, weight management, women’s services, and wound care.
Nursing care services at St. Cloud Hospital are offered according to the Professional Practice Model (PPM). The nurses use this model to provide patient and family-centered care that involves aspects of shared governance, building working relationships, and provision of exemplary professional practice. The overall rating of the organization is 4 stars compared to the state average of 3.7 and the national average of 3.31 (Medicare.gov, n.d.). Exemplary nursing care is offered by numerous staff comprised of registered and advanced practice nurses. According to the nurse supervisor, the average number of residents per day is 140. In support of patient and family-centered care, patients are allowed to have visitors any time of the day with limitations to special cases. However, due to the COVID-19 pandemic, visiting is currently restricted to immediate family members and is subject to following of the COVID-19 protocols.
St. Cloud Hospital is part f the Centra Care System that serves communities of Central Minnesota. The facility works together with other partners such as Long Prairie, Melrose, Monticello, Paynesville, Redwood Falls, Sauk Centre, and Willmar. Centra Care is currently headed by President Kenneth Holmen. St. Cloud Hospital is headed by Craig Broman who is the Chief Operating Officer and is part of the board of directors governing the institution. Below the Chief Operating Officer is the chief information officer, and the departmental heads. According to the nurse leader, the nursing department is headed by the Chief Nursing Officer who oversees all nursing services. Other departments include the medical services led by the Chief Medical Officer and other medical directors. Other departments identified include the finance, human resource, rehabilitation, and psychology/forensic departments.
Primary Needs of Population
St. Cloud Hospital provides healthcare services to individuals from Stearns County, Minnesota. According to the recent statistics, the county has a population of 161,075 individuals comprising of 87.5 % Whites, 7.8% Black or African American, 2.4% Asians alone, 3.6% Hispanic or Latino, and 0.4% American Indians (United States Census Bureau, 2019). The majority of the population are whites occupying 84.6% followed by the Black or African Americans. The majority of the individuals are learned and have high school graduate or higher, 92%. Healthwise, the county has 7.2% of the population disabled and approximately 5.3% of persons under the age of 65 years have no health insurance. Economically, the median household income in the area is $60,606 with 12.4% of the total population living in poverty (United States Census Bureau, 2019). The majority of people seeking healthcare services in the hospital are from the city of St. Cloud which has a population of 67, 924. The City’s median age is estimated at 29.9 years which is roughly 8 years younger than the national median. The elderly occupy approximately 5% of the total population and equally more youths seek healthcare services in the hospital than the elderly.
The elderly population in St. Cloud makes up 5.3% of the population while individuals between 55 to 74 years occupy 16%. One of the primary health concerns for this population is the increasing burden of cardiovascular disease. Heart disease has been consistently the number one cause of death for the elderly followed by other chronic conditions like hypertension and diabetes. Secondly, obesity is observed to affect the majority of the population. In 2016, reports indicated that 14.5% f the population were smokers and 27.6% represented individuals with obesity or overweight. Additionally, drinking is a common practice in the area whereby 21.4% of the population is listed as heavy drinkers.
Health insurance is an important measure of how healthy a population is and it determines access to healthcare services. About 7.3% of individuals from St. Cloud lack health insurance cover compared to 5.3% in the county. Most of the residents are unaware of the healthcare services accessible and the majority fail to utilize the availability of essential medical services. The same problem is observed in the utilization of community health services where individuals believe healthcare is for the sick. The nurse leader identified a few barriers that contribute to the healthcare accessibility problem including age, location, and cultural challenges. The majority of the people seeking healthcare services in the facility are Whites followed by Hispanics and Black or African Americans.
The majority of the population are youths between the age of 18 and 34 years. This population is faced with healthcare problems such as smoking, drinking, and other forms of substance abuse. Because of these practices, several substance use treatment centers are available in the city to provide treatment and preventive healthcare to the youths. Previous reports indicate that about 11% of the population are frequent substance users with prescription drug misuse being common among the high school dropouts. Forensic patients represent a significant population seeking outpatient healthcare services in the hospital and there is always a challenge of identifying potential substance abusers and those trying to avoid jail time. The increased rate of substance abuse in the region has contributed to increased crime rates and other related public health concerns such as accidents. Statistics indicate that in every 2 hours, someone is a victim of crime in Stearns County. Theft, Burglary, assault, robbery, and rape are among the leading crimes in the area.
Stearns County is generally a healthy region ranked eighth in Minnesota and 124th in the United States. However, the population health concerns have a huge impact on the community of St. Cloud and the hospital at large. For instance, several patients seek emergency healthcare services in the facility as a result of drinking, crime, and accidents. The majority of these individuals are uninsured and this costs the healthcare facility and the community a lot. The burden of chronic diseases is observed to cost the organization and the community a lot considering the cost of treatment and follow-up programs. Although St. Cloud Hospital has adequate staff, the amount of work and the population of individuals served is huge leaving a gap for allocation of more nurses and other healthcare providers. There is a need to increase the number of healthcare providers reaching the people in the community including those that have little knowledge about the importance of regular healthcare access. The economic productivity in the region is likely to be affected in the future as the majority of the people continue aging.
Nurse Leader’s Roles
Nursing supervisors provide a critical link between hospital management and the clinical care team. Developing their skills through experience and training, these individuals function as leaders to oversee patient-care operations. During the consultation, an interview was conducted with a nursing supervisor with over ten years of nursing experience in St. Cloud Hospital. The focus of the interview was both on the formal and informal roles of the nurse leader in the institution and how the roles correspond with MSN essentials. As a formal leader, the supervisor works to ensure nurses adhere to the organizational policies and procedures. These include monitoring of working during shifts, interprofessional collaboration during care delivery, and working according to their full scope of nursing practice. The supervisor explained that she closely works with staff nurses and nursing assistants to provide guidance and inspiration during routine nursing care delivery.
Rather than focusing on primary care to the patients, nurse supervisors are directly involved with administrative duties. The nurse leader explained that she is actively involved in hiring and training new staff including the provision of clear directions. Additionally, the supervisor is involved in ongoing staff training upon identification of quality improvement areas. Another administrative role includes budgeting and scheduling of staff to ensure shifts are fully staffed for optimal patient safety. Enforcing protocols and maintaining the safety of staff is also a crucial role for nursing supervisors. The nurse explained that she is actively involved in writing and updating policies and procedures to enhance the safety of nurses while leading by example. The nurse leader emphasized her disciplinary role as a supervisor whereby she is involved in disciplining staff using positive techniques.
To gain more understanding, she was questioned about her role and scope in the organization including informal roles as a nurse supervisor. She explained that she provides clinical leadership, implements processes, and evaluates care delivery to ensure nurses work to achieve organizational goals. She emphasized collaborative patient care to achieve optimal patient outcomes where she performs training to different disciplines on teamwork and interprofessional collaboration. Regarding her informal roles, she expressed concerns on the importance of maintaining a positive working environment motivation, and problem-solving approaches. She takes extra steps to mentor new employees, look into their work-life balance, and provide necessary support during transition especially for new employees.
The described roles of the nurse supervisor align with the roles defined in the Essentials of Masters Education in Nursing. Essential III describes the role of the nurse in quality improvement and safety. Under this role, it is recognized that a master’s-prepared nurse must be articulate in the methods, tools, performance measures, and standards related to quality, as well as prepared to apply quality principles within an organization (AACN, 2011). The nurse supervisor demonstrates alignment with this role as she actively participates in the promotion and improvement of safety within the healthcare organization. She explained that she goes around daily to ensure aspects such as documentation, medication compliance, and following guidelines is done for the protection of patient safety. Additionally, she is an active team player in quality improvement projects in the organization especially those dealing with patient and healthcare worker safety.
The nurse supervisor recognizes the importance of interprofessional collaboration for improving patient and population health outcomes. Essential VII recognizes that the master’s-prepared nurse, as a member and leader of interprofessional teams, communicates, collaborates, and consults with other health professionals to manage and coordinate care (AACN, 2011). The nurse leader ensures the collaborative practice is applied in the institution by promoting good relationships between nurses and doctors. She expressed her role in ensuring nurses and doctors mutually participate in daily rounding including continuous medical education organized by either team.
Master’s prepared nurses are required to demonstrate a Master’s level nursing practice while caring for patients. Master’s level nursing involves the use of a nursing intervention that influences healthcare outcomes for individuals, populations, or systems (AACN, 2011). The nurse must demonstrate an understanding of nursing science and readily integrate this knowledge into practice. To demonstrate the application of this role, the nurse supervisor utilizes clinical reasoning and uses decision making skills to influence positive care delivery to the patients. For example, the nurse explained that punishment to employees is always positive to encourage a change of behavior rather than creating enemity between staff. Additionally, the nurse encourages the use of evidence-based practices to improve quality within the institution.
Characteristics of the Organization
St. Cloud Hospital derives its mission from CentraCare and it is focused to improve the health of every patient, every day. One of the strengths of the organization identified during the interview is strong leadership. The organizational leadership is focused on the mission and vision allowing for employee commitment and the provision of personalized care. The nurse supervisor explained that St. Cloud is a healthcare partner that understands the patient and is ready to walk them through their most exciting moments or biggest challenges in life. Additionally, the institution has recently tried to implement changes using the top-down approach to enable focus on patient care and reduce costs. This is a managerial strategy to cope with the difficulties of the COVID-19 pandemic and a way of changing the old organizational structure. Through its strong leadership, the organization is now among the top 100 hospitals in the US and has attained several awards for being the best hospital in ST cloud Minnesota.
The nurse supervisor identified a few organizational weaknesses that are hindering the delivery of quality care. She talked about staffing issues during the weekends that have resulted in problems such as increased fall rates and increased waiting times in the emergency department. The facility does not have enough float pool to cover all call outs and the few available staff do overwork. Efforts to increase the number of registered nurses and nursing assistants are underway. The major concern that is observed is an increase in patient falls in the inpatient units. The elderly population is greatly affected by this problem and following the restricted availability of relatives in the wards due to COVID-19 protocols, immediate action needs to be taken.
Various quality improvement projects and evidence-based practice implementations in the facility are ongoing. Recently, the department of psychiatry/forensic services launched EBP to help patients transition back into the community after discharge. Implemented practices include assertive community treatment, family psycho-education, and integrated treatment for co-occurring disorders for psychiatric patients. Additionally, each intervention utilizes evidence-based treatment modalities depending on the patient’s condition. For instance, family psycho-education for post-traumatic stress disorder (PTSD) patients involves the use of present-centered therapy. The other evidence-based practice used in the facility is SBAR communication to enhance communication between nursing teams and other healthcare providers. Six months ago, the use of the SBAR checklist to enhance communication in the emergency department was launched and currently, the project managers are collecting feedback regarding the effectiveness of the practice.
A quality improvement program is a set of focused activities designed to monitor, analyze, and improve the quality of processes to improve the healthcare outcomes in an organization. St. Cloud Hospital has several quality improvement programs that have been implemented in different departments. In the intensive care unit and operating rooms, a hand hygiene measurement system is in place to help reduce patient and healthcare infections. The system which is electronically driven analyzes the rate of hand hygiene performance in the two departments against the set target by the end of the year. Another quality improvement program that has demonstrated improved results is the use of a board-level commission to improve safety, communication, and transparency. The commission which consists of selected healthcare members replaces critical leaders in the organization who lack time to monitor processes in the institution.
Recommendation for Organizational Change
The healthcare problem identified by the nurse leader is an increased rate of patient falls related to staffing issues, especially on the weekends. As the administration continues to make necessary changes to improve staffing, the use of hourly rounding can serve to reduce the fall rates in the institution. I recommend the use of an hourly rounding checklist by nurses to help identify patients at risk while responding to the patient’s needs on time. Falling during hospitalization remains regrettably common across hospitals and it results in serious injuries or even death. Walsh et al (2018) explain that adults especially those in medical and surgical units fall 3.5 times per 1000 patient days and approximately 26.1% suffer serious injuries. Several approaches such as staff education, the use of wrist bands, scheduling toileting, and installing bed alarms have yielded insufficient results to solve the problem. However, hourly rounding including assessment and mitigation of fall risk has proven to be effective.
To ensure effective implementation of the recommended strategy, the PDSA cycle will be used to organize activities. To plan for the change, the administration will select a committee responsible for initiating hourly rounding in the hospital. Training of employees about the new strategy while utilizing the AHRQ protocol will follow. The protocol contains items such as pain, medication, toileting, and checking the hospital bed that is performed for every patient (AHRQ, 2013). The second phase will involve the implementation of hourly rounding during shifts. Specific attention will be given to the individual needs of the patient and the identification of risk factors for falls. The study phase will involve recruiting nurses and assistants to serve as champions on the floor. Leaders in each department will monitor fall rates and provide feedback to nursing teams. The last step will involve making necessary changes for the intervention, analyzing reduction in fall rates, and formulating organizational policies regarding the new change.
Rationale for Recommended Change
Patient falls are common healthcare problems that have a huge impact on the patient and the organization. They have a huge financial cost to the patient and can lead to prolonged hospital stays. Compared to patients without falls, patients with serious fall-induced injuries stay 6.9 days longer and have hospitalization costs that are $13,806 higher (Walsh et al., 2018). These costs become a problem to the community especially when the elderly population is involved. It reduces productivity because family members have to stay in the hospital to look after their loved ones. For patients insured under Medicare services, the hospitals absorb the costs of falls and this translates to decreased quality of care. While the patients can be affected by the falls directly, healthcare organizations suffer a great deal because reimbursements are dependent on quality measures such as falls rate. Additionally, catastrophic injuries, such as death, can trigger investigations by regulators or result in legal claims.
The recommended change is to use an hourly rounding checklist with mitigation of fall risk to identify patients at risk for falls. Hourly rounding is a proactive method that demonstrates the utilization of the patient-centered care approach whereby crucial elements such as pain, personal needs, position, and placement are assessed (AHRQ, 2013). The hourly rounding integrates fall prevention activities with the rest of the patient’s care and helps to increase awareness of the risk to the patient and family members. Prevention of falls in the institution can help save costs and improve patient satisfaction in several aspects. For example, patients will be able to understand their care upon leaving the healthcare facility, and it will help increase the HCAHPS scores on timely receiving of care upon request. Consequently, more patients will be satisfied with the quality of care delivered in the institution and recommend the hospital to other healthcare consumers.
Measures to Evaluate
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey will be the national benchmark to measure the change in the organization. The aspects that will be analyzed include patients who report they received help as soon as they wanted and the recommendation of the hospital to other consumers. According to the previous scores, patients who reported that they “Always” received help as soon as they wanted has a score of 71% compared to the state average of 76% and a national average of 70% (Medicare.gov, n.d.). The goal is to increase the scores from 71% to 75% within a period of six months.
Upon implementation of the new change, the study phase in this evaluation will involve comparing the observed scores after implementation with the quarterly HCAHPS scores for the organization. To act effectively, improvement of the scores after the second quarter will indicate the success of the program and this will lead to the incorporation of the change into the organization’s practices. If the scores will not improve, the recommendation will be reviewed and necessary changes made before running the cycle again.
Agency for Healthcare Resaerch and Quality. (2013). Preventing falls in hospitals: Tool 3B. Scheduled rounding protocol. Retrieved from
American Association of College of Nursing (AACN). (2011). The essentials of master’s education in nursing. Retrieved from
CentraCare. (2020). Caring for you in St. Cloud: St. Cloud Hospital. Retrieved from https://www.centracare.com/locations/centracare-st-cloud-hospital/
Medicare.gov. (n.d.). Hospital profile: Survey of patients’ experiences: St Cloud Hospital. Retrieved from
United States Census Bureau. ( 2019). Quick facts: Stearns County, Minnesota. Retrieved from https://www.census.gov/quickfacts/stearnscountyminnesota
Walsh, C. M., Liang, L. J., Grogan, T., Coles, C., McNair, N., & Nuckols, T. K. (2018). Temporal trends in fall rates with the implementation of a multifaceted fall prevention program: Persistence pays off. Joint Commission Journal on Quality and Patient Safety, 44(2), 75–83. https://doi.org/10.1016/j.jcjq.2017.08.009
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