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Running head: LEADERSHIP QI PROJECT PAPER

Leadership QI Project Paper

Na Lee Futral

NUR 4144 Professional Role Development: Servant Leadership

Bon Secours Memorial College of Nursing

October 24, 2017

On my honor, I have neither given nor received any help on this work.

I pledge. Na Lee Futral

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Introduction

As hospitals keep growing and evolving, there is a need for continued growth and

improvement from within each unit. In order for quality of care to improve, leaders on the unit

need to be able to communicate and develop shared values with the rest of the unit. Leaders also

need inspire change within their unit, and be able to try new things to improve the quality of

care. Problems that arise on a unit need to be evaluated and efforts must be made to resolve

those problems. Quality improvement, known as QI models, focus on targeting ongoing and

continually improving quality (Marquis & Huston, 2017, p. 621). On the Orthopedic Medical

Surgery Unit, there is a high incidence of falls, and there is continual push to try to decrease the

amount of falls. Accidental falls are prevalent in the hospital; in fact, about 25% of falls in

hospitalized patients result in injury, and 2% result in fractures (Shorr et al., 2012, p.2).

Sometimes patients are having to go back to surgery because of a fall in the hospital.

Nurse Managers, nurses and other hospital staff are continually trying to find ways to

decrease and prevent falls on this unit. Some recent QI projects have included the use of bed

alarms, writing the Schmid Score on the patient board, making sure everyone has slip resistant

socks, more frequent purposeful rounding, and educating patients on how to use the call bell if

they need to get up. This paper will discuss how to utilize the four domains of leadership which

include the heart, head, hands, and habits to implement changes in how the use of bed alarms

will prevent falls on the unit. This QI project will involve making sure that every patient that is a

fall risk, has a bed alarm that is on, to help decrease the incidence of falls. This paper will also

demonstrate how to integrate the five practices of exemplary leadership, which consists of

modeling the way, inspiring a shared vision, challenging the process, enabling others to act, and
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encouraging the heart, to implement this quality improvement project to implement the use of

bed alarms.

Heart Domain

One of the four domains of leadership is the heart of a servant leader. In Lead Like Jesus,

Blanchard & Hodges state that, whenever you have an opportunity or responsibility to influence

the thinking and the behavior of others, the first choice you are called to make is whether to be

motivated by self-interest or by the benefit of those you are leading (2005, pp.31-32). The nurse

manager needs to be motivated by the idea of helping patients prevent falls, and helping other

nurses reduce the incidence of falls during their watch. Leadership on the unit needs to be

transparent and effective, in order to benefit the nurses that work on the unit, and motivate them

to be more aware and more conscious of patients that are fall risks and need to have the bed

alarm on at all times. The nurse manager needs to inspire the right motivation on the unit about

using the bed alarms consistently, to help patients prevent falls during their stay at the hospital

before and after surgery.

Head Domain

The head of a servant leader, examines your beliefs and theories about leading and

motivating people (Blanchard & Hodges, 2005, p.32). It is the responsibility of the nurse

manager to be the visionary for change, and implement those changes. A nurse manager needs

to share her vision for the future on the unit where the appropriate patients have bed alarms on at

all times, without any falls. She needs to model respect for other members of the healthcare

team, have compassion for the patients who are getting hurt from falls on the unit, continually try

to improve service from nurses, and be innovative enough to foster new ideas and help the unit
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as a whole. The nurse manager needs to guide and empower the other nurses on the unit to make

positive changes, and try new ideas on the unit to decrease falls.

Hands Domain

The hands of a servant leader are represented by the actions of the servant leader. If a

nurse manager can combine the right motivation of the heart with proactive beliefs to implement

change, she will become a performance coach. Being a performance coach involves setting

clear goals and then observing performance, followed by praising progress and redirecting

inappropriate behavior (Blanchard & Hodges, 2005, p.33). The nurse manager on the

Orthopedic Unit, needs to define clear, measurable goals, like having zero falls on the unit for

one week. The nurse manager then needs to observe the performance of the nursing staff and

patient care techs, and if the goal is met, recognize and commend positive changes with the

consistent use of bed alarms. If the goal is not met, efforts to decrease falls must be re-evaluated.

Morning huddle is a good time to address falls from the previous shift, and go over what can be

done to prevent falls during the next shift. The nurse manager needs to evaluate staff

performance and then follow up with nurses or patient care techs who are ignoring bed alarms

that are sounding or are continually forgetting to turn the bed alarms on to prevent falls. It is the

job of a good servant leader to provide feedback, give direction and help empower the staff.

Habits Domain

Habits are how a person renews her daily commitment as a leader to serve rather than to

be served (Blanchard & Hodges, 2005, p.33). A nurse manager continually faces stress, but

how she deals with pressure is a good indicator of her character. Some of the habits include

solitude, prayer, study and application of scripture, accepting and responding to Gods love, and
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involvement in supportive relationships. Nurse managers face challenges daily, and if something

is not going well, they need to motivate themselves and keep pushing to make positive changes

on the unit. They need to have their own support systems that they can depend on that are

always there for them. The nurse manager may have an unexpected fall on the unit one day, but

she needs to keep on persevering through the bad days to get to more good ones.

Model the Way

Nurse managers should set a good example, by demonstrating actions that fit well with

shared values on the unit. The leaders on the unit should, create standards of excellence and

then set an example for others to follow (The Five Practices, n.d.) If nurse managers are helping

the patients on the unit by getting them up to go to the bathroom, they to ensure that they

remember to set the bed alarm again, once the patient is back in bed. If there is a bed alarm that

sounds in the middle of the hallway, the nurse manager should stop what she is doing and go

check on the alarm to see what is going on. She needs to demonstrate that hearing a sounding

bed alarm is a priority on the unit and needs to be followed up with. More than just telling others

on the unit what to do, the nurse manager needs to model what she expects of others that she

works with.

Inspire a Shared Vision

The nurse manager needs to get other nurses and hospital staff to envision a unit with no

falls. She needs to inspire others who work with her to think big, and imagine the unit becoming

more successful along with the hospital. It is also the job of the nurse manager to encourage

those around her to think about other exciting possibilities for the future by making positive

changes on the unit. She needs to get everyone on board with the idea of zero falls, less patient
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complaints, and less lawsuits. Other people who have been working on the unit for a while may

be skeptical of all these great changes, but it is the job of the nurse leader to get everyone

invested and excited about this shared vision.

Challenge the Process

In order to challenge the process, nurse managers need to continually look for new and

innovative ways to change and improve the Orthopedic Unit. If some beds are not equipped with

bed alarms, the nurse manager needs to push for beds with bed alarms from the hospital

administration. If the unit is not equipped with enough staff to help patients up out of bed when

they need help, the nurse manager needs to push for more nurses and support staff to be hired on

the unit. If the hospital administration is slow to respond, then the unit needs to advocate for the

safety of its patients, and provide the hospital with data to support the need for more beds with

bed alarms, and more nurses and staff to help patients ambulate to the bathroom. The nurse

managers need to have adequate data and information about the incidence of falls and lawsuits

that affect the hospitals as well. The nurse manager should also continually look for ways to

improve the unit by trying different staffing ratios, and experimenting with several combinations

of fall prevention on the unit. By taking these risks, the nurse manager will either see effective

positive results, or will have gained an opportunity to learn from those mistakes and try

something else.

Enable Others to Act

For this QI project, the nurse manager needs to get others on the unit to work together

collaboratively to create an environment of trust. She needs to enable each nurse as a vehicle to

implement change independently, but also work collectively with other nurses to decrease falls
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as a whole on the unit. The nurse manager needs to develop trust with each nurse knowing that

she will do her part to evaluate the patient as a fall risk and then making sure to remember to turn

on the bed alarm after ambulating them to the bathroom, getting a chair alarm for when the

patient is sitting, and turning the bed alarm again when returning to bed to lie down. Other

interdisciplinary team members like physical therapists, also need to be encouraged to work

together with the nursing staff and the patient care techs, to turn the bed alarms when returning

the patient to bed. The nurse manager also needs to give each nurse on the unit more power and

autonomy, and enable them to work more independently. She cannot go around micro-managing

each member of her team, or they will think she does not trust their competency and become

resentful of her and her leadership.

Encourage the Heart

When the unit decreases the number of falls during the week, the unit should be praised

and encouraged to keep up the good work. If a nurse has had zero falls for an entire week, she

needs to be recognized for her excellence and consistent good work at morning huddle. Group

members can clap and cheer for each other to recognize their contributions to the units goals. If

her patients have zero falls for the entire month, she should be rewarded and recognized with a

small gift card. If the unit as a whole has zero falls within a month, the unit should be rewarded

with a pizza party. A good nurse manager knows that celebrating victories will motivate the unit

to continually work hard to improve the unit.

Professional Practice Implications

Falls in the hospital happen because patients are trying to move on their own without

adequate assistance. Since the Orthopedic Medical Surgical Unit is understaffed, bed alarms are
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thought to reduce falls by alerting personnel when at-risk patients attempt to heave a bed or

chair without assistance...bed alarm systems may (also) reduce the need for physical restraints

(Shorr et al., 2012, p.2). In a study to test the effectiveness of bed alarm use to prevent falls in

hospitalized patients, Shorr et al.s research showed that there was no statistically significant

effect on the number or rate of falls, injurious falls, or patients restrained on intervention

compared with control units (2012, p. 7). Implications from this study are that, if the unit is

short staffed, then nurse managers need to hire more nurses and support staff, like patient care

techs to do more purposeful hourly rounding like ambulating the patient to the bathroom

regularly.

This study demonstrated that if bed alarms are not as effective as thought, maybe there

needs to be a change in practice of how nurses respond to alarms going off. Sometimes nurses

are so caught up in taking care of their own patients or charting that they do respond to bed

alarms with the sense of urgency that should be taken. Nurses, patient care techs, and the

physical therapy team also need to work together to consistently make sure that the alarms are

on. Some patients may object to the bed alarms because they think the noise is aggravating, but

nurses need to do a better job educating and explaining that these alarms are on for the patients

own safety, since they may be weak following an injury or surgery.

In another study from Hempel et al., the research showed that the most effective fall

prevention were unique approaches combining a number of different components and care

processes aiming to prevent falls, such as risk assessment, visual alerts indicating risk, patient

and family education, care rounds, bed-exit alarms, and post-fall evaluations (2013, p.492).

The implications from this study are that nurses only exclusively using bed alarms may not

effectively prevent falls. Nurses need to change their practice and utilize the Schmid fall risk
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assessment tool, and maybe put the score on the patient white board to alert other hospital staff.

Nurses and nurse managers also need to teach better education on fall prevention, and include

family in education about not ambulating a patient without a nurse present. Nurses tend to

document hourly rounds, but they really need to set eyes on their patients just to make sure the

patient is comfortable, and to make sure the call bell is within reach just in case something does

happen. With up to six patients per nurse on busy Orthopedic units, nurse managers need to

make sure that the nurses on the unit are not overwhelmed with their patient load, and make sure

that they are supported.

Outcomes Evaluation

The nurse manager is hopeful that she can motivate her unit to make adequate

changes and make sure to prevent as many falls as possible. The goal of the unit would be to

decrease the incidence of falls to zero falls. This could be evaluated by examining chart audits to

see what safety devices are being used and what safety precautions and interventions are being

implemented with each patient. The nurse manager could also make the unit more aware of falls

or the lack of falls, by creating a visual board for the staff.

Another positive outcome for the unit would be to see more near misses in falls, than to

see actual falls. The outcome of this goal could be evaluated by looking at Quantros reports,

which help look at incident reports. Quantros safety and risk management tools also help

report, track, and monitor adverse events in real time (and) quickly perform root cause

analysis and investigations (Quantros, n.d.). A near miss would mean that someone is

preventing a fall and implementing proactive measures to decrease falls. A near miss would also

demonstrate that there was enough staff present to catch and prevent the fall before it happened.
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Documentation of near misses and falls on the unit are crucial in implementing

interventions that work and interventions that do not work. Evaluating the outcome of a QI

project is important to see if interventions like the use of bed alarms is effective on the unit.

Even if the research does not completely support the use of just bed alarms to decrease falls in

the hospital, no one would know if these measures were effective or not, if no one took the risk

of experimenting and exploring different options to decrease falls. Nurse managers need to

determine the efficacy of an intervention by analyzing outcomes.

Conclusion

Nurse managers and nurses need to work collaboratively together to achieve desired

goals for the unit. Nurse managers need to continue to encourage and support the nurses on the

unit to try new things, be innovative in practice, and experiment to try to approach problems in

different ways. They need to support their nurses with adequate staffing, support personnel, and

the right equipment to succeed. They should always be analyzing patient outcomes from

different interventions and continue to implement different QI projects to see what is the most

successful for their unit. Great leadership comes from a good balance of trust, teamwork, and

collaboration, and nurse managers need to continually push and motivate those they work with to

always make improvements and to keep growing as a unit.

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References

Blanchard, K. H., & Hodges, P. (2005). Lead like Jesus: lessons from the greatest leadership

role model of all times. Nashville, TN: Thomas Nelson.

Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., Ganz, D. A.

(2013). Hospital Fall Prevention: A Systematic Review of Implementation, Components,

Adherence, and Effectiveness. Journal of the American Geriatrics Society, 61(4), 483

494. http://doi.org/10.1111/jgs.12169

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

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

Quantros Safety & Risk Management. (n.d.). Retrieved October 24, 2017, from

https://www.quantros.com/d/SRM_brochure.pdf

Shorr, R. I., Chandler, A. M., Mion, L. C., Waters, T. M., Liu, M., Daniels, M. J., Miller, S.

T. (2012). Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in

Hospitalized Patients: A Cluster Randomized Trial. Annals of Internal Medicine,

157(10), 692699. http://doi.org/10.7326/0003-4819-157-10-201211200-00005

The Five Practices of Exemplary Leadership Model. (n.d.). Retrieved October 24, 2017, from

http://www.leadershipchallenge.com/about-section-our-approach.aspx