Quality and Safety Education for Nurses (QSEN) is imperative because it equips them with knowledge and skills concerning patients care and healthcare system. The faculty of QSEN has defined six competencies: safety, informatics, patient centered care, quality improvement, teamwork and evidence based practice (Cronenwett et al., 2007). These competencies assist in alleviation of problems like negligence, patients mishandling and inappropriate documentation.
The case study and QSEN
During the clinical practicum, I witnessed a devastating event. This is because it affected the patient’s quality of care as well as continuity of nursing management. An Operating Room Nurse left blood in a patient’s room after transferring him to my unit, which was cardiac care. Additionally, the Operating Room Nurse did not hand over the patient to the Cardiac Care Unit Nurse. Therefore, the cardiac care unit nurse was unaware of the patient existence, his condition, management and possible transfusion.
The aforementioned case relates to the following QSEN competencies patient-centered care, teamwork, safety and quality improvement. Patient centered-care competency states that the nurse should respect the needs of the patient (Cronenwett et al., 2007). The Operating Room Nurse neglected the patient’s needs because she left blood in the patient’s room without informing the Critical Care Unit Nurse yet the patient was for transfusion. The lack of reporting the patient’s progress to the Critical Care Unit Nurse indicates the negligence of patients needs. Cronenwett et al., (2007) explain that teamwork and collaboration involve open communication. From the analysis of the case study, there was no collaboration in the management of the patient. This is because the Operating Room Nurse did not hand over the patient to either the Critical Care Unit Nurse or I.
According to Cronenwett et al., (2007), quality improvement entails the use of data to enhance the quality of health care. From the above case study, the lack of documentation interfered with the patients care. This is because the Operating Room Nurse did not leave behind the patients notes. Finally, the above case study relates to the competency about safety. The safety competency states that the nurse should ensure that the patient is free from harm (Cronenwett et al., 2007). The Operating Room Nurse was exposing the patient to harm by leaving blood in the room. This is because it increased the probability of the patient missing the transfusion.
The nursing practice
The preferred nursing practice that addresses the above case is the use of a hand over sheet while transferring a patient from the operating room to the critical care unit. The Operating Room Nurse should accompany the patient with a hand over sheet describing the surgical operation performed, medication used, the findings, the vital signs before and after the operation, the postoperative drugs, investigations and procedures. The Operating Room Nurse should hand over the patient and the sheet to the Critical Care Unit Nurse. Besides, she should tell the Critical Care Unit Nurse the condition of the patient and the management. According to Taylor et al.,(2007), the nurse should prepare a detailed handover sheet before transferring a patient from one unit to another.
The rationale of using a hand over sheet is to facilitate continuity of care (Taylor et al, 2007). If the Operating Room nurse had handed over the handing over sheet to the Critical Care Unit Nurse, it could be easy to continue with the patient care. This is because the Critical Care Unit Nurse could have known what was done to the patient as well as the anticipated care. Additionally, handing over sheet protects the patient from harm (Taylor et al, 2007). If the Critical Care Unit Nurse had the handing over sheet, she could have known that the patient required transfusion. As a result, she could have found the blood in the patient’s room and proceeded with the transfusion.
The current guideline for educating nurses about hand over focus on the health care professionals and the patients care. According to Patterson et al., (2010), nurses should be taught about the handing over process. It should entail the formation of a handing over sheet prior to transfer of a patient followed by verbal hand over to the Critical Care Unit Nurse (Patterson et al., 2010). The nurse should receive training about handing over policies. Patterson et al., (2010) explain that lack of documentation of patients care is a crime. Finally, education guideline about handing over process includes the different types of the procedure, which are verbal, electronic, audio and written (Patterson et al., 2010).
The rationale of educating nurses about the handing over process is to equip them with knowledge about comprehensive and holistic patient care (Patterson et al., 2010). This is because many nurses are not aware of the handing over process thus risking the patient’s life. The Operating Room Nurse risked the patient’s life by transferring him to the critical care unit and not informing the Critical Care Unit Nurse about his condition. Another rationale of educating nurses about the importance of documentation is to help them realize the consequences associated with it (Patterson et al., 2010). The Operating Room Nurse did not prepare a handing over sheet because she did not know its relevance. Lastly, the rationale of educating nurses about the types of handing over process is to empower them with alternatives in case of a crisis like pressure of work (Patterson et al., 2010). The Operating Room Nurse could have handed over the patient to the Critical Care Unit Nurse verbally. This could alleviate the problem of patient negligence.
The nursing research
In order to address the issue at hand, nurses should conduct researches about barriers to the handing over process. The research should focus on the nurses, the patients and the health care facilities because they interfere with handing over process. For example, the criticality of condition of another patient can force a nurse to bypass the handing over process to attend to the other patient (Meissner et al., 2007). Understaffing can trigger the skipping of handing over process because the nurse is overwhelmed by work (Meissner et al., 2007). Finally, the nurse cannot prepare a handing over sheet if the health facility does not have the appropriate stationeries.
The importance of conducting researches about handing over is to come up with factors contributing to the ineffectiveness of the process. This is because the determination of these factors will assist in developing strategies that address the issue (Meissner et al., 2007). For instance, the health care facility can supply stationeries to facilitate the development of handing over sheets. Meissner et al., (2007) reports, handing over sheet prevent the loss of data that may have an impact on the patients care. For example, it is unlikely for a nurse who has a handover sheet to forget that a certain patient require a specific procedure.
In conclusion, handing over process is important because it facilitate quality care. Therefore, nurses should strive to learn and practice handing over process after transferring a patient from the operating room. Finally, nurses should conduct researches about handing over process, as this will assist in formulation of strategies that address the issue.
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnston, J., Mitchell, P., et al. (2007). Quality and Safety Education for Nurses. Nursing Outlook , 55 (3), 122-131.
Meissner, A., Hasselhom, H., Estryn-Behra, M., Nezet, O., Pokorski, J., & Gould, D. (2007). Nurses perception of hand Over in Europe: Results from the European Nurses. Journal of advanced Nursing , 57 (5), 535-542.
Patterson, E., & Wears, R. (2010). Patient Handoffs: Standardized and Reliable Measurement Tools Remain Elusive. Journal of Quality and Patient Safety , 36 (2), 51-61.
Taylor, M., Ye, K., Knott, J., Dent, A., & McBean, C. (2007). Handover in the Emergency department: Deficiencies and Adverse Effects. Emergency Medicine Australasia , 19 (5), 433-441.