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Quality Improvement Analysis ProjectGrace FreemanBon Secours Memorial College of NursingNUR 4144 Professional Role Development: Servant LeadershipOctober 28, 2015’“I Pledge.”The purpose of this paper is to demonstrate the application of leadership principles discussed in lecture to a real-life situation. A quality improvement project being implemented on a known nursing unit was selected as the foundation for suggesting appropriate actions for that unit’s nurse manager. Blanchard & Hodges’ (2008) four domains of servant leadership, derived from analysis of Jesus’ earthly ministry, and Kouzes & Posner’s (2013) five student leadership practices are used to substantiate suggested actions. My clinical Immersion experience is on the Cardiopulmonary Care Unit (CPC) at Bon Secours’ Memorial Regional Medical Center (MRMC). After discussing this assignment with the unit’s Clinical Care Leader, I decided to research the following quality improvement project being implemented there. This year (2015) the Bon Secours Health System updated their “Management of Clostridium Difficile Infection (CDI) Policy and Environmental Disinfecting Guidelines” (Bon Secours Health System, Incorporated [BSHSI], 2015), requiring a change of practice in nursing. While the policy is five pages in length, a sixth page depicting an algorithm for “Nurse Driven Protocol for Patient with Liquid Stool- Diarrhea Management of Clostridium Difficile Infection (CDI)” provides a concise summary of information and a useful tool for daily practice (BSHSI, 2015, p. 6). The algorithm states that if a patient has a “Liquid/unformed stool of unknown etiology” (BSHSI, 2015, p. 6) then enteric contact precautions and hand-washing with soap and water must be enacted. Following actions are determined based on the timing of this occurrence during hospitalization. Occurrence on days 1-3 (admission is day 1) warrants sending “…liquid stool for C Diff PCR per protocol” (BSHSI, 2015, p. 6), with results determining the next action. “C Diff” is the abbreviation for Clostridium Difficile. “PCR” is the abbreviation for Polymerase Chain Reaction, an assay that examines DNA and can be used to detect bacteria (National Human Genome Research Institute, 2015). Continuation of isolation until hospital discharge is warranted by a PCR positive for C Diff. Barring the suspicion of another infectious agent, isolation is discontinued if a PCR is negative for C Diff. (BSHSI, 2015, P. 6)When an occurrence takes place on or after day 4 of hospitalization, a physician’s order is required for a C Diff PCR. Nursing is responsible for notifying physicians with the occurrence of “clinically significant diarrhea” (BSHSI, 2015, p. 6), constituted by “3 or more diarrheal stools in 24 hours without other identified causes…” or “Sudden onset of loose, unformed and/or watery stools with abdominal pain and/or cramping accompanied by fever greater than 100.4 and/or leukocytosis greater than 15,000.” PCR results, as outlined above, determine isolation status. Because there is “…no test for cure…” (BSHSI, 2015, p. 6), only one specimen is submitted. If a repeat test is required, seven days must pass between it and the previous test. “Heart” is the first of Blanchard & Hodges’ (2008) four leadership domains (p. 39). In this domain, motivation is considered pivotal, with a heart propelled by self-interest seen as the most tenacious obstacle to leading like Jesus. How does one align their heart with that of Jesus Christ? Blanchard & Hodges (2008) propose the practice of Exalting God Only (EGO) as the solution (p. 63). This practice entails worshipping God only, depending on God completely, exalting God as your only audience and judge and being aware that God is watching you (Blanchard & Hodges, 2008, p. 63-65). Worshipping God only takes place when one’s heart reveres or is in awe of God alone (Blanchard & Hodges, 2008, p. 63). Worshipping God alone and as ultimate, recognizing His omniscience, obeying his counsel and deriving self-esteem and well-being from reliance on Him comprise a complete dependence on God. He is the source of all life (Blanchard & Hodges, 2008, p. 65). Correspondingly, exalting God as one’s sole audience and judge is exclusive; He is the director of the play of life. Others are positioned as we are and cannot fulfill His role. Therefore, the position of lordship over one’s life is reserved for Him who satisfies the job description. Blanchard & Hodges (2008) rely on the Bible as their source of information for analysis on the life and leadership practices of Jesus. Therefore, To orient one’s heart in this way, it is necessary to read and study the Bible with regularity. This is recommended for the CPC’s Nurse Manager and is elaborated on in the discussion of “Habits” below. The humility and confidence that result from exalting God only will win the respect of those working under the leadership of the nurse manager (Blanchard & Hodges, 2008, p. 66-68). One result, but not the motive behind performance, is an increased likelihood that followers’ will more readily cooperate in striving for established goals, allowing more of their energies to be spent in this pursuit. Extending grace and forgiveness overflows from the heart that exalts God only (Blanchard & Hodges, 2008, p. 76-79) and is most clearly demonstrated in times of failure. In the case of the CPC unit scenario, “failures” might look like staff neglecting to act in such a way as to achieve the established vision and goals (Refer to the discussion of “Head” and “Hands” below.). While practical consequences for nursing behaviors are subject to hospital policies and procedures, the Nurse Manager can always extend an attitude of grace and forgiveness to followers, denying the temptation to express any inappropriate negative emotions and actions, while still offering constructive redirection as appropriate. “Head” is the second of Blanchard & Hodges’ (2008) four leadership domains (p. 83). The focus of this domain is the “…leader’s belief system and perspective on the role of the leader” (Blanchard & Hodges, 2008, p. 83). These form the lens through which the leader views themself and their followers. Relationships and interactions are impacted accordingly. In this area, leading like Jesus means adopting his belief system and perspective, which was one of service to God alone manifested as servant leadership (Blanchard & Hodges, 2008, p. 83-84). Blanchard & Hodges (2008) further analyze Jesus’ leadership perspective, identifying visionary and implementation roles as being integral (p. 84). The visionary role consists of establishing an end goal and detailing the way by which to achieve it. Included in this are the establishment and presentation of purpose, a compelling vision of the future and values (Blanchard & Hodges, 2008, p. 85-98). In this situation, the CPC’s Nurse Manager can equate purpose to Bon Secours’ mission “to bring compassion to healthcare and to be good help to those in need, especially those who are poor and dying. As a System of caregivers, we commit ourselves to bring people and communication to health and wholeness as part of the healing ministry of Jesus Christ and the Catholic Church” (Dowling, 2015b, slide 6). To determine their understanding of and agreement with this mission statement, the Nurse Manager is responsible for its clear presentation and facilitating discussion of followers’ perspectives on it (Blanchard & Hodges, 2008, p. 85). Before illustrating a compelling vision of the future, one must envision what outcomes they’re hopeful for if the purpose is lived by and circumstances are positive (Blanchard & Hodges, 2008, p. 88). The resulting vision, or “…ongoing, evolving, hopeful look into the future that stirs the hearts and minds of people…” (Blanchard & Hodges, 2008, p. 88) is then portrayed to those integral in its fruition.Upon consideration, the CPC’s Nurse Manager might arrive at the vision that implementing this policy will decrease the prevalence of C Diff, thereby promoting patients’ health, decreasing unnecessary hospital expenditures, increasing resources available for other uses (perhaps purchasing equipment and or bonuses or raises) and decreasing staff workload. Such a vision would be shared with staff members, using such pertinent details to illustrate it vividly and convincingly. In many ways, the aspect of establishing and presenting a compelling vision in Blanchard & Hodges’ (2008) domain of “Head” (p. 88) reflects Kouzes & Posner’s (2013) leadership practice of “Inspiring a Shared Vision” (p. 54). To exercise this practice, the Nurse Manager performs the same actions as detailed above in that section. Values, an aspect of the leadership domain of “Head,” are concrete principles that constitute a leader’s character and dictate organizational behavior (Blanchard & Hodges, 2008, p. 90). Blanchard & Hodges (2008) cite research stating that emphasis should lie on a maximum of four values listed in order of priority, so as to facilitate focus when conflicting values arise (p. 90). Detailing the practical application of these values is also necessary In this case, Bon Secours’ values can be referenced. While the values of respect, quality, justice, compassion, stewardship, growth, integrity and innovation are all espoused (Dowling, 2015b, slides 7-13), the Nurse Manager might chose those values which most closely pertain to the scenario. For example, the values of respect, quality, stewardship and growth might be highlighted as their definitions directly correlate with the situation at hand. To concentrate energies when pursuing the vision, three-four goals must be established (Blanchard & Hodges, 2008, p. 97). Their meaning is derived from the vision. In part, establishing goals means defining and determining understanding of behaviors desirable in pursuit of the vision. Until satisfactory comprehension is determined, it is necessary to reinforce definitions through repetition.When translated into actions, what do the agreed upon values look like? The answers to this question act as standards by which to measure accomplishments (Blanchard & Hodges, 2008, p. 91). In this case, the Nurse Manager might include examples such as respect (treating people well) (Dowling, 2015b, slides 7-13) translating into greater than or equal to 95% compliance with the new C Diff policy over the course of six months, quality (service improvement) as patient satisfaction survey responses of greater than 90% satisfaction regarding nursing interactions related to implementing the new C Diff policy, stewardship (responsible use of resources) as billing related items to patient accounts greater than 90% of the time, and growth (service development and improvement) as increased policy compliance over the course of six months, to name a few. The aspect of examining values in Blanchard & Hodges domain of “Head (2008, p. 90) and Kouzes & Posner’s (2013) leadership practice of “Modeling the Way” significantly overlap (p. 24). Thoughtful, thorough reflection to identify personal operational principles (values) is fundamental to “Modeling the Way.” If not already done in this case, the Nurse Manager can dedicate time and energy to this pursuit, examining their mindset and actions (through internal reflection and external discussion), identifying those major characteristics by which they operate. “Modeling the Way” also entails disclosing these principles to followers and inviting them to discuss their own values and how they do or do not correspond to those of the leader and organization (Kouzes & Posner, 2013, p. 24). It is important to affirm those values agreed upon by all. On the part of the Nurse Manager, behavior consistent with espoused beliefs is also imperative to earning the respect and allegiance of followers. Often, this looks like “practicing what is preached,” (Kouzes & Posner, 2013, p. 24) but can sometimes require standing up for one’s beliefs when challenged.In Blanchard & Hodges (2008) domain of “Head,” the aspect of implementation entails “…empowering and supporting…” (p. 84) one’s followers in carrying out the agreed upon vision. Here, servant leadership can take the form of training and developing followers to successfully accomplish established goals (Blanchard & Hodges, 2008, p. 99). Here too, the fabric of the leader’s heart is exposed and exercised. In this case, some applicable forms of staff training and development that the Nurse Manager can promote include inviting Infection Control to provide in-services on the new policy, initiating its discussion in “Huddle,” testing the staff for understand (ex: performance of HealthStream module and test), observing staff’s adherence to the policy both on the unit and via documentation, providing staff with opportunities to voice their experiences and offering feedback, guidance and continued support. “Hands” are the third of Blanchard & Hodges’ four leadership domains (Blanchard & Hodges, 2008, p. 119). Having the hands of a servant leader equates to being a performance coach (Blanchard & Hodges, 2008, p. 121) Three major subcategories of performance coaching are “…performance planning, day-to-day coaching, and performance evaluation” (Blanchard & Hodges, 2008, p. 121). Performance planning focuses on establishing goals and acting as a guide to promote their achievement. To some extent, Blanchard & Hodges (2008) leadership domains overlap. Some of the actions suggested above are applicable to this domain as well. For example, in a sense, when establishing behaviors that correspond with values, performance planning (goal setting) occurs. If need be, additional determination and detailing of behaviors conducive to realizing the vision can take place in this domain. Day-to-day coaching entails noting followers’ actions as they relate to the vision, being supportive and celebrative (cheerleading [Blanchard & Hodges, 2008, p. 123]) of jobs well done and providing guidance to adjust and improve those actions that are misdirected (Blanchard & Hodges, 2008, p. 121). In the given scenario, the Nurse Manager may fulfill this aspect of the domain by providing individual staff with verbal praise and or tangible rewards for achieving a certain benchmark in such areas as documentation and patient satisfaction. Perhaps it is more reasonable to reserve tangible rewards for when the group as a whole achieves certain benchmarks, but individual verbal recognition can always be given. Recognizing the act of celebration as pivotal to continuation of success is imperative. Benchmarks can also serve as a guide by which to determine the need to initiate discussions to discover contributing factors to lack of adherence and what measures can be taken to facilitate success. The components of support and celebration inherent to the aspect of day-to-day coaching in Blanchard & Hodges’ (2008) leadership domain of “Hands” (p. 121-123) is mirrored by Kouzes & Posner’s (2013) leadership practice of “Encouraging the Heart” (p. 120). Clearly articulating the vision and coaching followers’ constant pursuit of it, being expectant of personal and followers’ best performance, maintaining an outlook of hopefulness, celebrating the achievement of goals, offering feedback and promoting team cohesion constitute “Encouraging the Heart” (Kouzes & Posner, 2013, p. 120). By performing those actions exemplifying the day-to-day coaching of “Hands” (Blanchard & Hodges, 2008, p. 121-123), the Nurse Manager will also “Encourage the Heart” (Kouzes & Posner, 2013, p. 120). In Blanchard & Hodges’ leadership domain of “Hands,” recognizing and understanding the learning stage of individual followers (novice, apprentice, journeyman and master) and tailoring interactions so as to further their progression is of great value (Blanchard & Hodges, 2008, p. 126; Dowling, 2015a, slides 10-13). On the part of the Nurse Manager, strategic performance of this subcategory is crucial to the realization of the vision and requires cultivating a thorough understanding of the unit’s staff (Blanchard & Hodges, 2008, p. 124)Lastly, in their leadership domain of “Hands,” Blanchard & Hodges (2008) emphasize the importance of meeting with those carrying out the vision and appraising the effectiveness of their efforts over longer periods of time (121). This is performance evaluation. The Nurse Manager can accomplish this aspect of the domain by scheduling incremental formal (During this process, the Nurse Manager is performing constant mental evaluation.) individual and or group evaluations. It may be most beneficial to perform a series of formal evaluations (ex.: every two months) leading up to and in preparation for more cumulative evaluations (ex.: every six to twelve months). Such topics as the extent to which goals and benchmarks have been met and positive and negative contributing factors should be discussed. This is also an opportunity to celebrate accomplishments and further discuss behavior needing improvement, providing further intervention if necessary. In all domains, the servant leader strives to equip followers to perform in a constructive manner which will lead to successful accomplishment of goals in this domain (Blanchard & Hodges, 2008, p. 122).“Challenging the Process,” a leadership practice outlined by Kouzes & Posner (2008, p. 80), parallels “Hands’” aspect of performance evaluation, among others (Blanchard & Hodges, 2008, p. 121-122). “Challenging the Process” can be summarized as the leader’s search for and embrace of challenges, pressing and equipping others to leave their comfort zone and pursue the seemingly unattainable heights, approaching these in manageable segments, practicing and facilitating communication and collaboration and the willingness to make and learn from mistakes (Kouzes & Posner, 2013, p. 80). The Nurse Manager demonstrates this leadership practice by (Kouzes & Posner, 2013, p. 80) by performing the actions used to exemplify Blanchard & Hodges’ (2008) aspects of the leadership domain of “Hands” suggested above (p. 119-124)Kouzes & Posner’s (2013) leadership practice of “Enabling Others to Act” (p. 98) is closely aligned with Blanchard & Hodges’ (2008) leadership domain of “Hands” as well (p. 119-124). “Enabling Others to Act” views teamwork as essential to success, facilitates the creation and sustenance of a respect-filled, trusting environment conducive to this, work to empower individual team-members, promote team growth through delegating essential project components and allowing a wide range of decision making and publicly celebrate individual and team achievements (Kouzes & Posner, 2013, p. 98). In the case of the CPC unit, the Nurse Manager’s fulfillment of any actions descriptive of aspects of Blanchard & Hodges’ (2008) leadership domain of “Hands” (p. 119-124) also “Enables Others to Act” (Kouzes & Posner, 2013, p. 98).“Habits” are the fourth and final of Blanchard & Hodges’ four leadership domains (Blanchard & Hodges, 2008, p. 153). One’s focus on and commitment to the vision are strongly impacted by their habits (Blanchard & Hodges, 2008, p. 154). Engaging in solitude, prayer, study and application of Scripture, acceptance and response to God’s unconditional love and involvement in supportive relationships are the habits of a servant leader modeled by Jesus Christ. The primary means by which the Nurse Manager can accomplish this domain is by designating specific, consistent time to read the Bible and pray each day. Attending a church that preaches the Bible and establishing mentors in the faith with whom to discuss one’s relationship with Jesus and its application to the working world are proactive as well. The implementation of revisions made to the C Diff policy will affect professional nursing practice in a number of ways. For example, nursing is responsible for recognizing patients who meet the criteria to enact the C Diff algorithm (BSHSI, 2015, p. 6). Familiarization with the policy and algorithm so as to recognize appropriate situations in which to act is therefore necessary. In order to know if a patient is having loose stools and with what frequency, the nurse must be monitoring and documenting all bowel movements of all patients. Nurses will need to introduce bowel habit awareness to and enlist a partnership with patients at an early stage in their admission. Patient teaching so as to provide a context for these actions will also be necessary. Here, the nurse will need to use discretion so as to avoid causing paranoia, while promoting health.Another example is that nursing is responsible for enacting the C Diff algorithm for patients meeting certain criteria. Should a patient have loose stools with a certain frequency, nursing will need to initiate contact precautions, collect and send a stool specimen for testing and contact the patient’s doctor. All of these tasks take time, which can be costly on a busy nursing unit. Nurses may need to further sharpen their time management and prioritization skills so as to maintain patient safety while meeting all hospital expectations. Likely, (especially at first) this will add stress to already stressful positions resulting in higher job dissatisfaction and may result in compromised patient care in other areas. In turn, patient dissatisfaction with nursing interactions and care and staff turnover rate may increase (also posing a compromise to patients’ well-being) while positive patient outcomes may decrease. On the CPC, the implementation of this policy will improve patient outcomes in multiple ways over time. It will promote early identification and treatment of cases of C Diff. In turn, this will result in a better prognosis for the specific patient and may decrease their healthcare-related costs as well. Those who might otherwise have been impacted by the spread of undetected C Diff (other patients) will benefit as well (Dubberke et al., 2014, p. 628). The hospital will not be held responsible for their acquisition of this infection, thus decreasing related costs and freeing up funds to finance other areas within healthcare. Over time, decreased instances of C Diff may result in the redistribution freed time to other responsibilities of on the part of nursing. This may improve patient care, outcomes and satisfaction. Nursing staff may be increasingly satisfied with their jobs, the turnover rate decreased and patient care further enhanced. ReferencesBlanchard, K. & Hodges, P. (2008). Lead like Jesus: Lessons for everyone from the greatest leadership role model of all time. Nashville, TN: Thomas Nelson. Bon Secours Health System, Incorporated (2015). Management of clostridium difficile infection (cdi) policy and environmental disinfecting guidelines. In Policy manual: Infection control. Retrieved from Dowling, T. (2015a). Module ii: The hands of a servant leader [PowerPoint slides]. Retrieved from Dowling, T. (2015b). Module ii: The head of a servant leader [PowerPoint slides]. Retrieved from Dubberke, E.R., Carling, P., Carrico, R., Donskey, C.J., Loo, V.G., McDonald, C., Maragakis, L.L., Sandora, T.J., Weber, D.J., Yakoe, D.S., & Gerding, D.N. (2014). Strategies to prevent clostridium difficile infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(6), 628-645. Kouzes, J. & Posner, B. (2013). The student leadership challenge: Student workbook and personal leadership journal. San Francisco, CA: The Leadership Challenge. National Human Genone Research Institute (2015). Polymerase chain reaction (pca). Retrieved from ................
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