Practicum: Objectives, Project, Achievement, Audience, and Results Capstone Project

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¶ … Practicum: Objectives, Project, Achievement, Audience, and Results

The site of my Practicum was Village Hospital (VH), a young hospital that recently opened in 2008. The objective of the practicum was to develop and disseminate an evidence-based practice (EBP) congestive heart failure (CHF) protocol that would support nurse-sensitive outcome data. Nurses need clarification and instruction on basic CHF discharge. They need information related to CHF core measures in order that nursing staff documentation should align to the specific performance measures demanded by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare & Medicaid Services (CMS) standards. With the current explosion of skill mix on the unit, it is a challenge for nurses to keep up with the latest CHF guidelines.

My first step, consequently, was to complete a literature review of 15 peer reviewed journal articles on evidence-based practice demonstrating that CHF patients are, usually, ill-prepared to manage their disease, and that simple changes in nurses' instructions to patients could better help patients cope, thereby reducing readmissions and associated healthcare costs.

My secondary objective in generating this literature review was that it would assist me in developing or revising an effective EBP pathway that will serve as a beneficial clinical tool for nurses to expand their practice in the cardiac areas of specialty. I discussed this with the mentor who gave me valuable advice.

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Further tasks that I accomplished towards that end were semi-structured interviews with the staff. Village Hospital (VH) nursing faculty demonstrates different levels of expertise in treating patients associated with Congestive Heart Failure. All the RNs interviewed had at least 3 years of experience in general medical/surgical practice and a small amount of clinical experience with CHF patients. I realized that staff were, largely, unfamiliar with EBP and needed additional information on the topic. I reported the outcome of this interview to my mentor and to the manager of Medical -- Surgical.

Capstone Project on Practicum: Objectives, Project, Achievement, Audience, and Results Assignment

My consequent oral delivery to nurses (using the literature review) was aimed toward teaching them how to provide evidence -- based care to patients with CHF. I explored the CHF clinical pathways and looked at the system's existing CHF clinical pathway. I reviewed the existing policy of the standards of care with patients diagnosed with CHF and reviewed the attached care map. I found that the care map was inundated with extraneous medical facts and lacked information regarding the current EBP. I was also discontent with its user friendliness.

Another Practicum task involved my designing an EBP clinical pathway. The design of the pathway will decrease the length of stay (LOS) to 4.0 days compared with 6.2 days before the new pathway's inception. Clinical outcomes in the pathway are aimed at improvement in documentation of left ventricular function, prescribing appropriate medications, and counseling smoking cessation. A copy of the pathway was given to the leadership staff and approval was received. The design of the clinical pathway is user friendly and will be readily accessible to the staff. A copy of the approved pathway is also in the practicum portfolio.

Finally, I developed and administered a pre and post evaluation assessment tool that will assess the RNs existing knowledge and new knowledge in caring for CHF patients, and then presented the EBP PowerPoint presentation to the RNs.

The results of the pre and posttest evaluation suggested that between 70% of the staff had initial knowledge of the proper core documentation before the presentation. My presentation raised that variable to 90% of RNs who showed significant improvement in their knowledge as a result of my lecture. As a last step, I created and distributed an evaluation questionnaire to the nursing staff evaluating the resource tool and the teaching method.

Part II Identification of how the MSN Terminal Objectives were Incorporated and Applied during my Practicum

My 10 years clinical experience working with CHF patients greatly contributed to success of my efforts. The literature review certainly helped, but it seems to me that my extensive experience contributed to my ability in understanding and being better able to deliver the innuendoes of the review better than a newcomer to the field would have been able to do. In fact, it was my extensive experience that contributed to the passion for this specific theme: I had seen too many cases when patients lacked proper care and/or instruction when diagnosed with CHF, and it was this feeling and passion in willing and attempting to relay my experiences that led, I think, to a better oral delivery and to greater effect of dissemination of the literature review. In other words, the two together: the work of my completing this review and my experience culminated in a successful practicum outcome.

Regarding the completed literature review itself, the only change I would make next time, would be to uncover more nursing peer-reviewed articles on the matter (and to teach myself Excel beforehand!). Nonetheless, I found the act of generating the review helpful since it enhanced my knowledge on the subject and would better help me to instruct colleague and students. The acquired information will also help me assist relevant other community members in guarding their health (particularly since CHF is prevalent in my community).

The analysis of the incidence of the Institute's patients who had been diagnosed with CHF and ultimately discharged with core measures not being met (October 2008 through June 2010) shocked me. I discovered that VH was not always compliant in meeting the standards of care set forth by the federal government, and that this delinquency in documentation cost the facility hundreds of thousands dollars. Ironically, VH aims to implement cost-effective strategies that will get its numbers in-line with the national average. Yet its failure in meeting discharged core measures cost them significant dollars. Reviewing the data also gave me insight into how the data is collected and the process of how managers are held accountable for their report cards. I learned how to apply statistical evaluative procedures to assessment data, and determined that were I the one to conduct research at VH, I would select a larger and more diverse sample so that the findings will more accurately reflect the population. Analyzing the audit and compiling the review actually helped me understand the broader implications of my work. I feel that I can apply this learning to helping other registered nurses ( RNs) understand their own task better, thus enhancing their motivation.

The nurse manager and mentor agreed with my observations noting that RNs on the unit, lacked sufficient information on the appropriate EBP documentation for patients discharged with CHF, and that many of them would indeed benefit from additional information on the topic. The discussion with mentor and nurse manager was instructive to me in that it demonstrated how little nurses knew on the subject and indicated to me the importance of collaboration with relevant personnel in order to generate ideas, obtain advice and receive feedback on one's learning curve.

My semi-structured interviews with the staff at VH were also a valuable learning experience in that many members of the staff expressed and evidenced intimidation and reluctance to voice their views, particularly since I am their supervisor during working hours, and they felt that I would draw conclusions about their work ethics. During the following set of interviews that occurred, at differing days and times, in the cafeteria, the staff relaxed. I attributed this to the informality of the environment, and learned that perception and approach (Rogerian non-judgmental stance and active listening as well as genuinely wanting to understand the other, namely empathy) were the most important factors when trying to elicit another's opinions. The value in the experience I gained from this learning strategy assisted me with the different types of assessment and the various formats that could be used when teaching adult students.

The entire research, including the speech and discussion provided me with greater understanding regarding why the RNs (1) were not using the EBP tool, (2) failed to grasp that the care map assisted them with meeting standards of care, and (3) would not assist me in developing a clinical pathway tool that was user friendly. I learned that you can reduce the complexity of EBP by integrating all research on a given topic into a single, meaningful whole, and also that the clinical pathway must be kept simple and readily available, particularly given the time pressures and stress that the average RN encounters during her average day. This time me that before interviewing staff another time, I would first peruse the available tools and then formulate my questions. I also realized that more substantive information about the integration of CHF clinical pathways with full documentation of the impacts of integration on CHF population should be published.

The discussion (both with staff and later with mentor and manager) was extremely valuable in that it will not only assist me in my instructional strategies, but also showed me that knowledge transformation -- or modification (i.e. critically assessing one's current knowledge… [END OF PREVIEW] . . . READ MORE

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