Running head: LEARNING PLAN 2: SAFETY IN PARKINSONS DISEASE 1

Learning Plan 2: Safety in Parkinsons Disease

Rosette Lenon

Ryerson, George Brown, Centennial Collaborative Nursing Degree Program

Patricia Hynes

March 27, 2017

Learning Plan: Part 2

LEARNING PLAN 2: SAFETY IN PARKINSONS DISEASE 2

Student Name: Rosette Lenon

Faculty Advisor: Patricia Hynes
Clinical Placement: Belmont House - LTC
Overarching Goal:

To promote patient safety to residents with Parkinsons disease (PD) in long-term care setting

with a focus on falls prevention, and prevention of aspiration by March 07, 2017.
Relevant Practice Documents from the College of Nurses:

CNO Professional Standards (2002). CNO Competencies for entry-level registered nurse

practice (2009). CNO Working with Unregulated Care Providers (2013)

Sub-goal 1:

I will develop my ability to apply falls management on residents with PD that frequently fall

and continue to fall regardless of falls prevention strategies in place. I will create a specific

chart for these residents that integrate the application of Morse Falls Scale, reviewing the

current fall prevention strategies, and the follow-up care to resident and families, as well as

conduct an in-service to PSWs that share information regarding the head injury routine by

March 7, 2017.
Summary of Activity 1:

My first activity focused on three residents who frequently fall despite the falls prevention

strategies. I applied the Morse Falls Scale, and reviewed evidence-based practice by RNAO

(2011) on the falls prevention strategies in place such as medication reconciliation, timely

medication of anti-parkinson drugs, and physiotherapy. It also includes the follow-up care

provided to resident and families after the fall. On February 2nd, a frequent faller with PD fell

during the night shift and I used my chart to evaluate the current falls prevention strategies in

place and its effectivity in preventing complications from the fall (i.e. timely medication, bed

alarm, mats, cushion on side rails). The follow-up care that I provided was continuing the 48-

hour Head Injury Routine (HIR) protocol, and communicated the residents status to his family
LEARNING PLAN 2: SAFETY IN PARKINSONS DISEASE 3

Summary of Activity 2:

On March 5th, I conducted a brief information session to PSWs regarding what a head injury

routine is. It included information on the purpose of a head injury routine, and the common

assessments conducted by the charge nurse. I educated the PSWs on their role post-fall, such

as following the changes in the care plan (i.e. change in the level of assistance) extensive

care), and to report any changes that is noted when providing care.
Sub-goal 2:

I want to further develop my ability to promote patient safety by preventing aspiration/choking

in residents with PD by creating a concept map on assessment of swallowing abilities, and

differentiating interventions for safe swallowing (i.e. EMST, dietary modifications) and

promote inter-professional collaboration by journaling my participation in a residents family

meeting to present my findings on the residents safety regarding eating by March 7, 2017.
Summary of Activity 1:

I created a concept map focusing on appropriate swallowing assessment (Modified Mann

Assessment of Swallowing Abilities), and the different nursing interventions to prevent

aspirations such as EMST, oral hygiene, advocate for dietary modifications and safe feeding

practices within the unit. On February 16, I completed the assessment tool on a resident with

PD, recognizing her as high-risk for aspirations. I applied safe feeding practices (sitting

upright, calm environment, slow feeding time). Also, I ensured that her dietary modifications

of pureed meals and thickened fluids are appropriate for her current condition.
Summary of Activity 2:

I participated in a care conference meetings where the health care team communicate with the

residents family about their care plan and address any concerns. I spoke about the residents

feeding practices, and reported my assessment findings on their swallowing abilities. My

challenge are lack of confidence in communicating with other HCPs due to feeling inferior.
LEARNING PLAN 2: SAFETY IN PARKINSONS DISEASE 4

Summary & Critical Reflection of Activities:

Activity #1

Creating a chart on promoting safety in residents with PD in regards to falls prevention

helped me prepare for falls-related issues within the unit. The most important change in my

practice was that recognizing that falls prevention has its limitations when it comes to

residents with PD. Residents with PD often have recurrent falls due to cognitive impairment,

freezing of gait, and impaired mobility. My goal of falls prevention shifted from preventing

falls, to preventing injuries due to the advanced stage of PD where the interventions have their

limitations mostly due to the cognitive decline of the residents with PD. In patients with PD, a

nurses role is to critically assess and recognize the slight changes in residents disease

progression and assist in ensuring that the care plan is appropriate for their condition

(Gopalarkrishna & Alexander, 2015). I upheld my role as a nurse as I was able to recognize the

steady decline of residents with PD in relation to their risk for recurrent fall. This was done

through the monthly checks of the falls charts to evaluate the falls prevention strategies and

being familiar with the residents over time. In the residents with PD, strict medication

adherence to anti-parkison medication is the most effective falls prevention strategy as it

decreases the symptoms of instability and gait. From this knowledge, I focused on ensuring

that their medications are given at the right time. The activity made me feel competent in

assessing for falls, the purpose of falls prevention strategies, and also their limitations.

I became proactive in their care, and expanded my leadership role on the unit. I took

leadership in evaluating the current falls prevention strategies, and assessed their

functionalities (i.e. bed/chair alarms are working, mats in place). I recognized the patterns of

previous falls, and relayed the information to the PSWs. I felt that I was at ease in delegating
LEARNING PLAN 2: SAFETY IN PARKINSONS DISEASE 5

appropriate tasks such as reminding to apply bed alarms due to my competence in the

knowledge. In conclusion, I felt that I successfully promoted safety as I developed my ability

in assessing, implementing, and evaluating interventions regarding falls management.

Activity #2

This has transformed my practice as I engaged in a role as an educator, and a leader within my

practice placement. Developing and implementing this education sessions positively impacted

my nursing practice in various measures. The first outcome is that I gained experience in

leading an education session regarding head injury routine. I felt competent in performing a

head injury routine post-fall and was able to critically assess for any sustained complications

from the fall. When a fall occurred on the unit, I was competent in continuing the head injury

routine as it is a 48-hour protocol.

The second outcome is that it developed my delegation skills within the health care

team. I actively incorporated collaboration within the health team and helped to solidify the

roles of nurses, and PSWs post-fall. RNs who are unaware of the accountability of delegated

tasks, they will be unsuccessful in providing appropriate supervision to unregulated care

providers (UCP) who carry out direct patient care activities (Standing & Anthony, 2008).

When I created this activity, I reviewed the CNO standards of delegation to UCPs to ensure

that I am delegating tasks within their scope of practice. A study by Lasaster et a.l., (2016)

states that promoting inter-professional team work has a direct impact on improving patient

outcomes. With my competence in conducting a head injury routine and the PSWs knowing

their role post-fall, the team was organized and knew their role in promoting safety, and

preventing injuries in all aspects of residents care.

Activity #1
LEARNING PLAN 2: SAFETY IN PARKINSONS DISEASE 6

I applied my concept map to a resident with Parkinsons disease that requires full assistance in

feeding and she often pockets her food. Supported by Campbell, Carter, Kring & Martizen

(2016) nurses are in the position to identify patients that are at risk for dysphagia, and have the

tools to assess and implement safety. This impacted my nursing practice because I engaged in

using an assessment tool to a resident with PD. Prior to this activity, I did not have experience

in assessing swallowing abilities. This provided me the opportunity to gain experience in

applying a specific screening tool and has strengthened my assessment skills. In residents with

PD, dysphagia is often insidious and can be overlooked due to its steady decline Kalf, Swart,

Bloem & Munneke, 2011). Feeding the same resident weekly allowed me to see the steady

decline in late-stage Parkinsons disease. I was able to recognize the apparent symptoms but

also recognized the insidious symptoms such as the decrease ability to cough, and increased

time of feeding that may pose them at a greater risk for aspirations.

My practice has enhanced in terms of leadership in this activity. I felt that I was

directly advocating for the residents care. It not only ensured that they are eating safely but

also that their dietary plan remained appropriate for the resident. I successfully provided clear

instructions and reminded the PSWs and volunteers about safe feeding practices. Through this

activity, I was confident in communicating and delegating the PSWs on proper feeding

practices. Leadership was an area that I wanted to improve on because I recognized thats

nursing is also heavily reliant on being able to coordinate the care through delegation, and

leadership. This impacted my practice as I felt successful in taking on a leadership role on

maintaining safety. I plan to continue to develop my skills in leadership and delegation

throughout my nursing career.

Activity #2
LEARNING PLAN 2: SAFETY IN PARKINSONS DISEASE 7

I participated by sharing my findings regarding the residents feeding practices. I

felt competent in providing information as I interpedently assessed the residents swallowing

abilities and their feeding practices. New graduate nurses are more likely to promote inter-

professional collaboration through a supportive work environment (Pfaff, Baxter, Jack &

Ploeg, 2014) With my experience, a supportive preceptor and team made me feel at ease in

collaborating. They were receptive in allowing me to participate in the care conference. This

has impacted my practice as I felt a part of the collaborative process to improve patient safety.

One of the challenges I faced was the feeling of inferiority to the team because of my

role as a student nurse. Self-confidence is found as a prominent factor in engaging in inter-

professional collaboration Pfaff, Baxter, Jack & Ploeg (2014). I lacked self-confidence in my

role as a nurse as I felt that there will be another health care provider that has a greater breadth

of knowledge, causing me to feel incompetent in my knowledge. To overcome this barrier, I

actively sought out opportunities where I am communicating with the team. I became more

confident integrating with the team. This has positively impacted my nursing practice as I plan

to uphold inter-professional collaboration as it made me gain a better understanding of the

patients care plan and ultimately, lead to a higher quality of care.

References

Allen, N. E., Schwarzel, A. K., & Canning, C. G. (2013). Recurrent falls in Parkinson's disease:

A systematic review. Parkinson's Disease, 2013, 1-16. doi:10.1155/2013/906274

Campbell, G. B., Carter, T., Kring, D., & Martinez, C. (2016). Nursing bedside dysphagia

screen: is it valid? Journal of Neuroscience Nursing, 48(2) 75-79.

doi:10.1097/JNN.0000000000000189

College of Nurses of Ontario (2002). Professional standards, Revised 2002. Toronto, ON.

Retrieved from http://www.cno.org/globalassets/docs/prac/41006_profstds.pdf

LEARNING PLAN 2: SAFETY IN PARKINSONS DISEASE 8

College of Nurses of Ontario (2009). Competencies for entry-level registered nurse practice.

Toronto, ON. Retrieved from

https://www.cno.org/globalassets/docs/reg/41037_entrytopracitic_final.pdf

College of Nurses of Ontario (2013). Working With Unregulated Care Providers Toronto, ON.

Retrieved from http://www.cno.org/globalassets/docs/prac/41014_workingucp.pdf

Gopalakrishna, A., & Alexander, S. A. (2015). Understanding Parkinson Disease: a complex and

multifaceted illness. Journal of Neuroscience Nursing, 47(6), 320-326. doi:

10.1097/JNN.0000000000000162.

Kalf, J. G., Swart, B. J. M. d., Bloem, B. R., & Munneke, M. (2012). Prevalence of

oropharyngeal dysphagia in parkinson's disease: A meta-analysis. Parkinsonism &

Related Disorders, 18(4), 311-315. doi:10.1016/j.parkreldis.2011.11.006

Lasater, K., Cotrell, V., McKenzie, G., Simonson, W., Morgove, M. W., Long, E. E., &

Eckstrom, E. (2016). Collaborative falls prevention: Interprofessional team formation,

implementation, and evaluation. The Journal of Continuing Education in

Nursing, 47(12), 545-550. doi:http://dx.doi.org/10.3928/00220124-20161115-07

Pfaff, K., Baxter, P., Jack, S., & Ploeg, J. (2014). An integrative review of the factors influencing

new graduate nurse engagement in interprofessional collaboration. Journal of Advanced

Nursing, 70(1), 4-20. doi:10.1111/jan.12195

Standing T.S. & Anthony M.S. (2008) Delegation: what it means to acute care nurses.

Applied Nursing Research, 21(1), 814. doi: 10.1016/j.apnr.2006.08.010.