Running Head: QUALITY PAPER 1

Jessica M. Harris

Quality Improvement

Professional Role Development: Servant Leadership

NUR 4144

March 21, 2018

Dr. Ellcessor

“I pledge…” - Honor Code

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Quality Improvement: Bladder Management During Labor

The fields of medicine and nursing are constantly changing; therefore, it is important for

nurses and doctors to be able to change and adapt with it. In the past, laboring patients with an

epidural were automatically given an indwelling catheter for continuous bladder emptying. If the

patient was to delivery vaginally, the indwelling catheter would be removed immediately prior to

pushing. If the patient was going to have a cesarean section, the indwelling catheter would

remain in until the epidural had worn off and the patient was able to void on her own. There has

been research that suggests that the practice of inserting an indwelling catheter in laboring

women with an epidural can increase the risk of developing a catheter associated urinary tract

infection (CAUTI). It has been recommended that it is better to use an intermittent catheter, or to

straight catharize, on a as needed bases to reduce the risk of urinary tract infections in laboring

patients.

It is important as a nurse manager to be abreast of the latest research in improving patient

outcomes and then implementing and teaching these changes in practice to staff, including

nurses, doctors, and patient care technicians. Nursing mangers can help create dramatic change

in patient outcomes by informing staff of new policies and procedures. Laboring patients are an

important and special group of patients because you are treating the patient and the unborn

child(ren). It is imperative to protect this special group of patients from the risk of infection.

At Saint Francis Medical Center (SFMC), the New Life Center, or Labor and Delivery

unit, has implemented a new policy that requires nurses to intermittently catharize laboring

patients with epidurals, instead of placing an indwelling catheter. Indwelling catheters are now

only placed if the doctor has specifically ordered it or if the patient is going to have a cesarean

section. This policy is part of the unit’s quality improvement (QI) project, as they are trying to
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keep their CAUTI’s down. This paper will be discussing the QI project implemented at SFMC

L&D unit: intermittent catherization instead of indwelling catheters in laboring women with an

epidural.

The Four Domains

In the book, Lead Like Jesus, authors Ken Blanchard & Phil Hodges discuss the four

domains that can help us, as servant leaders, lead like Jesus. These four domains are: heart, head,

hands, and habits (Blanchard & Hodges, 2005). Each of these domains can be implemented and

modeled by the nursing manager to help lead her unit as a servant leader in the implementation

of the QI projects on the unit.

The heart domain constitutes the motivation or intent and the head domain is a person’s

beliefs, values, and vision. The nursing manager can help influence her fellow coworkers and

staff by staying humble. Blanchard & Hodges describe humility, “As a leadership trait, humility

is a heart attitude that reflects a keen understanding of your limitations to accomplish something

on your own” (2005, p. 66). It is an important trait in a servant leader to be humble, and as a

nursing manager, realizing how important the members of your staff are to the implementation of

your vision of having less CAUTI’s. “Effective leadership begins with a clear vision, whether for

your personal life, your family, or an organization” (Blanchard & Hodges, 2005, p. 85). As the

leader of the unit, it is the nursing managers job to help foster a shared vision of how the unit

should operate. Having a shared vision, can help facilitate the intermittent catherization QI

project on the unit, and therefore reduce CAUTI infections on the unit.

The hands domain is the work, which encompasses the process, practice, teambuilding,

and lastly, evaluation. The nurse manager can work with her staff to change their indwelling
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catheter practice to intermittent catheter practices. She can implement a teambuilding approach

and then evaluate how effective the intermittent catheter practice on laboring patients with an

epidural has decreased CAUTI’s on the unit.

The habits domain constitutes how a person stays grounded. This could be through

solitude, prayer, the study and application of scripture, the acceptance of God’s unconditional

love, and being involved in supportive relationships. This could mean that the nurse manager

makes sure that she is grounded before coming into work and talking to her staff about the

changes in policy. The nurse manager could also teach her staff the process of grounding and

how beneficial it can be to incorporate it into nursing practice.

The Five Practices of Exemplary Leadership

There are five practices of exemplary leadership: modeling the way, inspire a shared

vision, challenging the process, enabling others to act, and encouraging the heart (Ellcessor, PPT,

2018). Each of these practices incorporates one or more of the domains: heart, head, hands, and

habits. By utilizing these practices and incorporating them into her leadership, the nursing

manager can help foster change on her unit.

The practice of modeling the way utilizes the head domain. By modeling the way, the

nurse manager can set an example of how her staff should use an intermittent catheter when a

patient is laboring with an epidural. Inspiring a shared vision deals with the heart domain. The

nursing manager can inspire her staff and enlist them to help decreased CAUTI infections in the

patients on their unit by intermittent catheterization. The practice of challenging the process is

both the hands and heart domain and it can be best reflected in the QI project of changing how

the unit deals with bladder management in patients laboring with an epidural. The studies have
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shown that intermittent catheterization is better than indwelling, so by challenging the old

process at the hospital, the nurse manager and staff can help change outcomes for the patients on

the unit.

The practice of enabling others to act utilizes the head and hands domains. By enabling

her staff to act, the nurse manager is empowering her staff to help reduce infections in the

patients on the unit. The nurse manager can also empower her staff to remind one another about

the change in procedure for bladder management in laboring patients with an epidural. The

practice of encouraging the heart operates under the habits domain. By encouraging her staff, the

nurse manager can foster a sense of good will, by recognizing how hard her staff is working to

change their practice. She could create an audit and see just how much they have decreased

CAUTI’s since changing their bladder management practices and pass on this accomplishment to

her staff.

Professional Practice Implications

There has been extensive research on how best to decrease CAUTI’s in women that are

laboring with an epidural, as well as when they are postpartum. Due to this research, SFMC has

changed their policy on how best to manage the bladders of laboring women with epidurals.

There are some professional practice implications for bladder management of laboring women

with an epidural. “Intermittent catherization is recommended for multiparous women and those

in the active or transition phase of labor” (Hiller, Farrington, Forman, McNulty, & Cullen, 2017,

p. 484). It is thought that intermittent catherization, instead of indwelling catherization, leads to

a decrease in CAUTI’s. Wilson, Passante, Rauschenbach, & Yang state, “Intermittent

catheterization only as needed appears to be best practice for bladder management for laboring

women with an epidural” (2015, p. 234). This means that while a laboring woman has an
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epidural, the staff should be using intermittent catheters for bladder management until the patient

is ready to deliver, as well as, after delivery until the patient can safely get up to use the

restroom. If the laboring woman ends up needing a cesarean section, the staff will place an

indwelling catheter in when the patient is back in the operating room.

Outcomes Evaluation

There has been some push back from staff regarding this policy change. For the most part

intermittent catherization of laboring patients with an epidural is being done on the unit, unless

that patient is going for a cesarean section, as those patients are still receiving an indwelling

catheter. There have been instances when the nurse or physician have requested an indwelling

catheter placed, due to continued trauma from frequent intermittent catheterizations. The nurse

manager, charge nurse, and clinical care lead are often asking the nurses if they are performing

the intermittent catheterizations and making sure that they are documenting them appropriately.

Additionally, if the physician or nurse has requested the indwelling catheter, the nurse manager,

charge nurse, or clinical care lead nurse, ask the nurse to make sure there is an order from the

physician documented in the patient’s chart. There is room for improvement, but this policy is

important in reducing CAUTI’s in laboring women and when they are postpartum.
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References

Blanchard, K. H., & Hodges, P. (2008). Lead like Jesus: Lessons for everyone from the greatest

leadership role model of all time. Nashville, TN: Thomas Nelson.

Ellcessor, DNP, RN, RNC-OB, B. (2018, February 20). Five practices of exemplary leadership

[PowerPoint slides].

Hiller, A., Farrington, M., Forman, J., McNulty, H., & Cullen, L. (2017). Evidence-based nurse-

driven algorithm for intrapartum bladder care. Journal of PeriAnesthesia Nursing, 32(5),

483-489. doi:10.1016/j.jopan.2017.03.003

Wilson, B. L., Passante, T., Rauschenbach, D., Yang, R., & Wong, B. (2015). Bladder

management with epidural anesthesia during labor. MCN, The American Journal of

Maternal/Child Nursing, 40(4), 234-242. doi:10.1097/nmc.0000000000000156