Nurses are the cornerstone for the care and treatment of patients during a hospital stay. The quality of nursing care is an important factor in determining whether or not a patient has a good experience during his/her illness and can potentially impact the medical outcome. Because of the importance of nursing care and the potential for a high degree of variability between nurses, units, and facilities, the American Nurses Association has created a national database of nursing quality indicators (NDNQI). The database contains data collected from thousands of facilities across the United States and allows for the identification of connections between a defined set of nursing quality indicators and patient outcomes. Analyses involving the NDNQI have demonstrated the important role nurses play in patient outcomes and are used to improve patient care and safety (Montalvo, 2007).
Multiple NDNQI indicators are involved in the scenario described. Mr. J is an elderly retired rabbi with mild dementia who has been hospitalized following a hip fracture resulting from a fall in his home. Given his history of prior fall, mild dementia, and current treatment with pain medication, Mr. J is at risk for falling during his hospitalization. Patient falls and patient falls with injury are NDNQI outcome measures that are affected by nursing quality. Patients at increased risk of falling need to be monitored closely to prevent falling while hospitalized. Any change in their physical or mental condition needs to be noted as soon as possible, so that measures can be taken to keep them safe. The nursing staff taking care of Mr. J appear to be aware of his fall risk and are diligent about keeping him in restraints to limit his movements. The need for Mr. J to be in restraints at all times, however, is not clear. Mr. J is described as drowsy, but is otherwise cognitively appropriate. Other factors, such as nursing staffing levels, may be affecting the decision to keep Mr. J restrained. Nursing hours per patient day is an NDNQI indicator, and it may be that patients in his unit are restrained more than necessary simply because there is not enough nursing staff available to adequately ensure patient safety.
Restraint prevalence is also an NDNQI outcome measure that not only may indicate a staffing issue but also the potential for increased incidence of negative outcomes, such as hospital-acquired pressure ulcers. Data on the prevalence of hospital-acquired pressure ulcers is included as part of the NDNQI, and it is a reflection of the quality of nursing care provided at a facility. Hospital-acquired pressure ulcers result from failure to reposition immobile patients at regular intervals. Restrained patients, such as Mr. J, are at an increased risk of developing pressure ulcers, as they are unable to reposition themselves. Mr. J’s daughter noticed a red, depressed area, similar to a severe sunburn, over his lower spine when he was moved. This description is consistent with a Stage I pressure ulcer, and, at the very least, indicates that he is at risk for developing a problem. The response of the CNA when it was pointed out to her is concerning and suggests issues with the nursing care in the unit, such as lack of training and/or a working environment that has the potential to compromise patient care. Such factors are tracked by the NDNQI, as they directly impact the quality of the patient experience and outcomes. If the CNA did not recognize the significance of the physical finding on Mr. J’s spine, then it indicates the need for further education on the identification and prevention of pressure ulcers for the nursing staff. Analysis of the prevalence of restraints and prevalence of hospital-acquired pressure ulcers for the unit and the entire facility can help identify if an overuse of restraints is leading to more patients developing pressure ulcers, and if additional training in the prevention and development of pressure ulcers is needed for the nursing staff (Agency for Healthcare Research and Quality [AHRQ], n.d.). Identifying the deficiencies and scope of the problem will allow any deficiencies to be addressed and result in an overall improvement in the quality of patient care.
The scenario further describes an ethical issue involving Mr. J’s special dietary needs during his hospitalization. A kosher diet was ordered for him, but several days into his stay, his nurse noticed he was receiving non-kosher meals. His nurse correctly informed the nursing supervisor of the problem, who then discussed the issue with the kitchen supervisor, who then discussed it with the kitchen staff. Beyond that point, the situation was handled very poorly. The family should have been notified of the error by the nursing staff at the time of discovery, rather than finding out about it from the dietary worker the next day. The nursing supervisor should not have instructed the nurse to keep quiet about it, and the nurse should not have been dismissive of the patient’s religious practices when questioned by his daughter. Respect for patients and their families are an important component of quality nursing care. If I was the nursing shift supervisor, there are a variety of ways I would resolve this problem. I would have notified Mr. J’s physician of the error. Since he is Jewish, he may have some insight has to how to best approach discussing the problem with the patient and his family. Also, I would contact pastoral services for the facility and see if they could assist, as well. Since this seems to be a recurrent facility-wide problem, it would be important to work with the kitchen supervisor and administrators to identify how patients who have kosher meals ordered for them regularly receive non-kosher meals. Sensitivity training for the nursing staff is clearly needed, as indicated by the nurse’s response and the staff’s general lack of exposure to Jewish patients. Many resources are readily available on the internet, and I would identify materials for the nursing staff to read (Guidelines for health care providers interacting with Jewish patients and their families, 2002).
- Agency for Research Healthcare and Quality. (n.d.). Preventing pressure ulcers in hospitals. Retrieved from http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/puover
- Guidelines for health care providers interacting with Jewish patients and their families. (2002). Retrieved from https://www.advocatehealth.com/documents/faith/CGJewish.pdf
- Montalvo, I. (2007). The National Database of Nursing Quality IndicatorsTM (NDNQI®). OJIN: The Online Journal of Issues in Nursing, 12 (3), Manuscript 2. doi: 10.3912/OJIN.Vol12No03Man02