NU270 PrepU: Quality Improvement (week 11)
An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next?
Analyze and Plan - Evaluation may be the last phase of the system development lifecycle, but it represents an essential step for nurses to be involved in before circling back to Analyze and Plan based on the results of the evaluation. This step is important to complete before making updates or improvements to a system already in place. Once this step is completed, the other steps of the system development lifecycle would follow.
The second step in implementation of evidence-based practice includes systematic review. To complete a systematic review of the literature, what must the nurse do?
Summarize findings from multiple studies that are related to a particular nursing practice. - A systematic review suggests that the nurse has reviewed multiple studies regarding a particular nursing practice question or topic. Asking the question about a clinical practice would come in the first step. A recommendation for best practice comes after synthesizing all of the data collected by the systematic review. Meta-analysis is concerned with doing a statistical analysis across studies.
Which characteristic is the most important indicator of high-quality nursing practice?
The nurse considers the individual needs of clients. - The personal, compassionate, caring side of a nurse is the most important indicator of quality nursing care. Considering the individual needs of the clients demonstrates the nurse's belief in the importance of the client. Being organized and efficient, following policies and procedures, and ensuring accurate medication administration are important parts of nursing care but are mainly task oriented.
Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?
The nurse locks out client information, except to those who have been authorized through appropriate security measures. - Locking out client information except to those who have been authorized through fingerprints or voice activation is correct. This action enhances confidentiality and protects electronic data in health care agencies. Less frequently changing access numbers and passwords could allow staff who have left the agency to compromise the system. Removing the automatic save and screen saver for data that have been displayed for prolonged periods could allow unscrupulous individuals onto the system. Providing unlimited data access to the multidisciplinary team so personnel from various departments can retrieve the data could allow all staff access to information that does not impact their jobs.
A nurse manager is using the AACN PEARL tool as a resource in a hospital setting. Which statements describe examples of the chief focus of this resource? Select all that apply.
The nurse uses PEARL to find tools to improve client outcomes., The nurse uses PEARL to share critical learning with staff., The nurse uses PEARL to plan change initiatives for the unit. - AACN PEARL is an acronym for Practice, Evidence, Application, Resources, and Leadership. This is an online collection of evidence-based tools and resources that facilitate implementation of interventions to improve client outcomes and simplify the process of sharing critical learning with peers, staff nurses, and hospital leadership. This tool does not help formulate diagnoses for clients, improve communication with clients, or improve management skills.
Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?
To improve quality of care - The primary reason to fill out an incident report is to improve the quality of care. Incident reports are not designed to be a means for disciplinary action. Incident reports are designed to identify actual or potential risks that can be addressed to improve quality of care. Incident reports are not intended to initiate litigation or document everyday occurrences.
Which statements are true about informatics in nursing practice? Select all that apply.
Utilization of information services helps to support decision making. Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. - Traditionally, documentation consisted of timely and accurate charting. However, the QSEN updated definition is expanded and calls for using information and technology to communicate, manage knowledge, mitigate error, and support decision making. Nurses should value technologies that support error prevention and care coordination.
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
limiting abbreviations to those approved for use by the institution. - In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.
Which guidelines define and regulate what the nurse may and may not do as a professional?
nurse practice act - Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.
An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? Select all that apply.
"We've noticed that this system really helps to save us valuable time." "Using the system is highly intuitive." "This system fits nicely into how we work." - The National Institute of Standards and Technology defines usability as "the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use" (NIST, 2017). Sometimes the way screens are formatted can be confusing, making it a real challenge to perform nursing tasks in a way that makes sense. Making clinical systems easy to use, intuitive, and supportive of nurses' workflow is what usability is all about. A system with effective usability can save time, reduce errors, and improve end-user satisfaction. A system that makes it challenging to complete tasks or screens that contain large amounts of information do not promote usability.
A nurse is using an evidence-based practice tool to plan care for a patient with acute abdominal pain who is admitted to the health care facility. Which tool would the nurse most likely expect to use?
Algorithm - Evidence-based practice tools used for planning care include care maps, multidisciplinary action plans, clinical guidelines, and algorithms. Algorithms are used more frequently in acute situations to determine a particular treatment based on patient information or a response. Care maps, clinical guidelines, and multidisciplinary action plans help facilitate coordination of care and education throughout hospitalization and after discharge.
The nurse is working at a facility that is applying for Magnet® Recognition. The nurse knows that compared with other hospitals, Magnet® hospitals have which direct effect on client care?
Better patient outcomes - Magnet® hospitals have better patient outcomes than facilities without the recognition. Magnet® hospitals have higher nurse retention and job satisfaction scores, but these do not have a direct effect on client care. Magnet® hospitals have shorter, not longer, patient stays.
An informatics nurse is evaluating a new clinical information system for usability. The nurse notes that the system requires the user to complete a maximum of 3 steps to complete a task. The system also provides shortcuts to frequent users of the system. The nurse would determine that which concept of usability is being addressed?
Efficient interactions - Efficient interactions is demonstrated by actions that facilitate efficient user interactions. An example is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users. Consistency involves the ability of the users to apply prior experience to a new system so that the lower the learning curve, the more effective their usage, and the fewer their errors. Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user.
A group of nurses are participating in being the first group of staff to use a new electronic pain assessment tool. The group is discussing whether or not the system is easy to use. During the discussion, the group mentions that "the shortcuts provided are really helpful and save valuable time." The informatics nurse specialist interprets this statement as reflecting which concept?
Efficient interactions - The statement reflects efficient interactions. One of the most direct ways to facilitate efficient user interaction is to that minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user. Effective use of language involves the use of concise, unambiguous language with terminology that is familiar and meaningful to the end users in the context of their work.
The nurse manager is concerned about the large number of teenage mothers being seen in the obstetrics clinic. How can the nurse manager use the transformational leadership style to address the concern?
Enlist volunteers to help develop a community outreach project that will educate teenagers on methods to prevent pregnancy. - Transformational leaders create revolutionary change and inspire others to become involved with their cause or concern. Enlisting others to make a change in the community is an example of transformational leadership. Creating new policies to distract attention from the problem and talking individually to each teenager does not inspire others to become involved in the change. Conducting research may be a step taken when developing the community outreach project; however, conducting research does not involve others getting inspired to be a part of the change.
Which nursing intervention would best demonstrate evidence-based practice in maternal-child health care?
Family-centered pediatric care - Evidence-based practice has become the standard that nurses are to strive for in caring for their clients. By involving the family in caring for ill children, the child and the family are better served and have improved outcomes. Parental interaction is encouraged for preterm infants to foster bonding. Children and adults need to be separated on inpatient units to ensure that the caregivers have a clear understanding of each client's needs, since children are not small adults. Centralized care has proved to be most beneficial to client outcomes by providing resources and specialists in one location.
A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which statement demonstrates the principle of accountability?
Filling out an occurrence report and notifying the healthcare provider - Accountability means that when an error occurs, the nurse takes the proper actions to address it. In this instance, the nurse should fill out an occurrence form for follow-up and notify the provider, as the error may change outcomes in the client's condition. Administering the missed medications with the other evening medications may double up the dose or cause unexpected adverse effects with the other medications. Telling the client that the medication will be administered the following day is not acceptable, as the nurse is suggesting next actions without the provider's knowledge. Documenting in the chart in a narrative about the occurrence does not allow for the health care provider to be notified and aware of a change in the client's condition.
The National Center for Health Statistics uses data from healthcare agencies to issue quarterly and annual reports on performance related to goals for improving the health of the U.S. population. Which initiative is targeted with improving the health of all Americans?
Healthy People 2030 - The Healthy People 2030 campaign provides an overall action plan to improve the health and quality of life of people living in the United States. The initiative includes leading health indicators for measuring the overall health of the U.S. population. The Joint Commission is an independent agency that accredits and certifies healthcare organizations and programs in the United States. The AHRQ is the organization that developed standardized quality indicators used to measure healthcare quality at the federal, state, and local levels. Quality indicators are not an initiative; they are standards for measuring healthcare quality.
A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply.
Improvement in health care quality Greater client engagement Reduction in privacy breaches of client information - Meaningful use would be reflected by improved quality, safety, efficiency, and reduced health disparities; engagement of clients and family; improved care coordination and population and public health; and maintenance of privacy and security of client health information.
During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which activity should the nurse perform related to documentation?
Include the time and date of the incident in the report. - When completing an incident report, the nurse should include the date and time of the incident, the events leading up to it, the client's response, and a full nursing assessment. To control the risk of litigation, the nurse should not highlight the mistake in the client record or attach a copy of the incident report. Because the report is a legal document, it should not contain the name of the nursing assistant.
What is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered?
Nursing care now uses EBP as a means of ensuring quality care. - The facilitation of EBP involves identifying and evaluating current literature and research, as well as incorporating the findings into client care as a means of ensuring quality care. The other answers are incorrect; they were used even before EBP became a major force in the delivery of nursing care.
Nurses in an ICU noticed that their clients required fewer interventions for pain when the ICU was quiet. They then asked a researcher to design a study about the effects of noise on the pain levels of hospitalized clients. How does this demonstrate the ultimate goal of expanding the nursing body of knowledge?
Nursing research helps improve ways to promote and maintain health. - Nursing research expands knowledge to learn improved ways to promote and maintain health. The other answers are incorrect because they are not the primary purpose of nursing research.
Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?
Omitting clients' responses to nursing interventions - Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health histories and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.
An informatics nurse specialist is involved with implementing strategies to improve the performance of the clinical information system being used. As part of this process, the nurse specialist is working on updating the plans of care in the system to reflect changes to a procedure based on new evidence. The nurse is also working to streamline the display screens to reduce the need to document the same information in three different areas. The nurse specialist is addressing which aspect of the system?
Optimization - Optimization commonly includes strategies to improve processes, maximize effective use, reduce errors, and eliminate workflow inefficiencies. Updating and streamlining reflect such strategies. Usability refers to the ease of use of the system. Standard terminology refers to the use of specific data entry elements that allow the development of reports and data. Interoperability reflects the ability of the system to share data across health care systems.
An informatics nurse is part of a team that is testing a new electronic health record system. The testing involves large groups of health care providers who will be using the system. During this testing, the system stalls and fails to respond when large numbers of providers are using the system at the same time. Which phase of testing is being conducted?
Performance - Performance testing is more technical and ensures proper functioning of the system when there are high volumes of end users or care providers using the system at the same time. Can it handle the load? Function testing uses test scripts to validate that a system is working as designed for one particular function. Integration testing uses test script to validate that a system is working as designed for an entire workflow that integrates multiple components of the system. User acceptance testing occurs when the nurse (or other system end user) "test-drives" the new system or new functions of the EHR to ensure it's working as designed.
The nurse manager overhears comments made between two nurses. The first nurse repeatedly makes comments that focus on the second nurse's skin color and race. The second nurse is observably offended. Which action by the nurse manager to address the behavior of the first nurse would promote a quality practice environment?
Speak to the first nurse, pointing out that the comments constitute harassment and will not be tolerated. - The nurse manager has a responsibility to intervene and advise the first nurse that the comments are considered harassing and inappropriate and will not be tolerated in the work environment. This discussion should be clearly documented and the situation closely monitored in case the nurse makes similar comments in the future. The other options do not address the situation appropriately and will not lead to the behavior stopping or to ensuring a harassment-free work environment.
A client has been admitted in the emergency care unit with conditions of respiratory distress and pneumonia. The client's condition worsens and requires mechanical ventilation. While visiting this client in the hospital, the family observes members of the health care team washing their hands upon entering and leaving the room. By implementing recommended hand hygiene measures, which organization's goals is the health care team supporting?
The Joint Commission - One of The Joint Commission National Patient Safety Goals (NPSGs) prioritizes the reduction of health care-associated infections. The NCSBN prioritizes matters related to public health, safety, and welfare, including the development of licensing examinations in nursing. The IOM emphasis relates to ensuring that patient care is safe, effective, patient centered, timely, efficient, and equitable. The AHRQ highlights patients' satisfaction with care.
The neuroscience nursing unit has developed a set of step-by-step directions of what should occur if a nursing assessment reveals the client may be exhibiting clinical manifestations of a cerebrovascular accident (CVA). Which statement about clinical practice guidelines are accurate? Select all that apply.
The development of evidence-based practice guidelines require a research review from different studies to develop the most accurate diagnostic method to implement. When developing a CVA set of step-by-step directions, the nursing unit should ask for assistance from experts in the neuroscience field. The potential users of the guidelines should pilot test it for further feedback. A meta-analysis could be utilized to combine evidence from different studies to produce a more accurate diagnostic method. - Clinical practice guidelines are systematically developed and intended to inform practitioners in making decisions about health care for CVA clients. They should be developed using research and review by experts in the clinical content. Potential users should also participate and provide feedback prior to implementation. The purpose of the guidelines is to review EBP articles and develop new practice guidelines rather that continuing practicing primarily on "how it has always been done before." Once developed, the guidelines must be continually reviewed and changed to keep pace with new research findings. A meta-analysis could be utilized to combine evidence from different studies to produce a more accurate diagnostic method or the effects of an intervention method.
A nurse is filing a safety event report for an older adult client who tripped and fell when getting out of bed. Which action exemplifies an accurate step of this process?
The nurse details the client's response and the examination and treatment of the client after the incident. - An unintentional injury or incident that compromises safety in a health care agency requires the completion of a safety event report (incident report). The nurse completes the event report immediately after the incident and is responsible for recording the circumstances and the effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The physician is not responsible for filling out or signing the safety report unless she witnessed the incident. The nurse reports factual information, not opinions.
Facility policies on wound dressing selection refer the nurse to a dressing algorithm. The nurse anticipates that the algorithm will include:
a step-by-step decision-making tree for dressing selection. - Algorithms are step-by-step methods for solving problems. An example would be a decision tree for selection of wound care dressings based on type of wound.
A client went missing from a long-term care facility and an emergency code was called. After a search of 1 hour, the client was discovered in a utility room that should have been inaccessible. When responding to this event, staff should:
fill out an incident report, with the goal of preventing a similar event in the future. - Incident reports are primarily used to facilitate improvements, not to determine culpability. A client's health record requires skill to document the necessary behavior and results and allows for adapting nursing care planning; a client health record must not discuss aspects particular to the incident report or facility issues. Holding a meeting will likely be necessary or helpful, but does not replace the need to document the event in the form of an incident report.
A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation?
identifying risks and ensuring future safety for clients - Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action and they are not commonly used to communicate within the interdisciplinary team.
When caring for a client with alcohol dependence who is prescribed a benzodiazepine, which side effects is it most important that the nurse monitor for?
sedation - The side effects of benzodiazepines are sedation, confusion, restlessness, bradycardia, tachycardia, urinary retention or incontinence, and drug dependence. The nurse should observe the client for excessive sedation and should use benzodiazepines cautiously in clients with impaired kidney or liver function. Insomnia, increased thirst, and anxiety are common side effects in drugs used in recovery from chemical dependence, but are not most commonly associated with benzodiazepines.
A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error?
unauthorized entry - This action is an unauthorized entry. A nurse shouldn't document for another nurse, except for an authorized entry in an emergency. Omission is a documentation error in which information is missing from the medical record. In this scenario, the day-shift nurse omitted documenting the administration of pain medication. A late entry refers to an entry made later than it should have been. The nurse should identify a necessary late entry as a "late entry" and document the reference date and time. An improper correction is an entry corrected in an improper manner, such as by erasing, using correction fluid, or obliterating the error with a marking pen. The nurse should always follow the facility's documentation guidelines.
