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Case Management Plan for a terminally ill Patient


Developing a case management plan for a terminally ill patient which is a 65 year old man who is dying from Congestive Heart Failure. 

  • Describe the model of case management you will utilize.
  • Identify actual resources in your local community that is available to your holistic plan of care.
  • Describe what resources are lacking in your community and how you might be able to retain these resources for the patient.
  • Discuss who will be involved in the plan and their roles as well as their time-frames of involvement.
  • Explain clearly how each member of the team will document the plan of care.
  • Describe the role of the case management in the end of life care.
  • Explain how case management will be evaluated in the end.
  • Discuss how you or the team will protect themselves from litigation.

Sample paper

Case Management Plan for a terminally ill Patient

Model of Case Management to Utilize

The model of case management to utilize in this scenario is the Triad Model of Case Management. In applying the triad model of care, the responsibility of the management is subdivided into separate roles. The specific approach to use in this case is the patient, family, and the professional triad. The triad mode utilizes the expertise or knowledge of the entire management team. The model is essential in advancing an interdisciplinary team approach in care management. Three major disciplines are involved in the process, which include social work, utilization management, and the nurse case manager (Cohen & Cesta, 2005). The model is important in that it helps nurses and others involved in care management to identify critical system issues that affect patients in the continuum of care.

The Triad Model of Case Management can enable nurses to alter the course of caregiving with regard to the care recipient and the caregiver by providing each with the freedom to make key decisions in the professional care (Cohen & Cesta, 2005). The triad model is essential in helping nurses to develop collaborations with patients as well as their families to deliver a type of care that enhances mutual relations between the nurse and the client. One of the key strengths of the triad model is that it ensures unique attention is given to each of the case management. On the other hand, fragmented care may arise especially if there is no proper coordination among the care team. The triad model ensures that even by giving assistance to the patient, he/she does not lose autonomy or independence. It is also important for nurses to involve caregivers in decision-making.

Actual Resources in the Local Community that is Available for the Holistic Plan of Care

In utilizing the triad model in patient care, the nurse must explore all the available resources, such as human, financial, and material resources. All these resources should be used to enhance the quality of patient care and in providing the client with personal freedom or independence required. The nurse must ensure that the patient receives necessary resources and at the appropriate time. The nurse determines the materials, equipment, and supplies that the patient needs in order to be more comfortable. After evaluating the client material needs, it is the responsibility of the nurse to ensure that the patient receives the material resources. The materials available in the community to support an individual suffering from congestive heart failure include CPAP machine, oxygen supplies & oxygen therapy devices, sequential air device, a cardiovascular system, renal system, and other life support equipment.

Human resources are also available in the local community and are vital for the holistic plan of care. The human resources available include the nurses providing care as well as those involved in the healthcare team. Family members play a key role in providing care to terminally ill patients. The nurse is responsible for training then family members on various areas of care that may be necessary for the particular patients. The financial resources are also key in the holistic plan of care. It is worth noting that the triad model of care is more expensive compared with other models such as the dyad model. The client finances the total costs incurred in healthcare. Insurance options such Medicaid and Medicare services can help to reduce substantially hospital bill for clients. The health insurance options range from government-run health insurance programs to private health insurance programs, most of which provide comprehensive care to clients.

Related: Nursing Sensitive Indicators

Resources that are lacking in the Community and Ways of Retaining the Resources for the Patients

The Triad Model of Case Management faces a number of resource constraints in its implementation. One of the key challenges is lack of properly trained medical professionals to care for the terminally ill patients. Medical education largely neglects the training of end-of-life care to nurse practitioners. According to Woo, Maytal, & Stern, (2006), only 18 percent of medical students claimed to have received formal training on how to care for terminally ill patients. In addition, about 40% of the respondents felt inadequate to impact younger clinicians with skills about care for the terminally ill patients. As such, there is need for highly trained medical personnel to help the terminally ill patients. Moreover, the study reports that majority of nurses experience a personal discomfort when dealing with the issue of death. In some cases, nurses and physicians may feel that they have failed in doing their work.

A solution to the problem above involves availing proper training to clinicians on end-of-life care. Clinicians should play a critical role in providing care and support to terminally ill patients. The clinicians should focus on approaches that aim at improving the quality of life of patients, rather than taking approaches that aim at curing or prolonging the life of the terminally ill patient. Another resource that is lacking relates to insufficient compensation of clinicians involved in end-of-life care. Medicare services compensate clinicians based on a relative value scale (Woo, Maytal, & Stern, 2006). This means that those involved in performing invasive procedures are likely to attain higher earnings compared to those involved in non-invasive procedures such as end-of-life care. This leads to demoralization of those involved in care of terminally ill patients. In order to attract more clinicians in the area of end-of-life care, there is need to bridge the payment disparity that currently exists. Raising the salaries of those involved in end-of-life care can attract more professionals in the field.

Those involved in the Plan and Time frames of Involvement

There are a number of key participants in the case management plan for the terminally ill patient. The first person involved in the plan is the nursing professional responsible for providing expert care. The nurse determines the materials and the equipment needed by the patient to lead to comfortable life. The nurse offers individualized care to the patient such as prescribing medication for pain alleviation and in enhancing the self-care ability to the patient. The nurse is responsible for helping the patient maintain independence. This is especially in situations where the patient requests for independence. The nurse is supposed develop and maintain a plan of care that suits the patient’s specific needs. Another role of the nurse is to provide guidance to family members on the needs of the patient. The nurse is involved right from diagnostic stage to the late stages when the patient passes away.

The family of the 65-year-old patient is also involved in the care plan. The family plays a critical role in improving the quality of life of the patient. Although clinicians help family members in making critical decisions in end-of-life care, the family has the right to make final decisions, such as where they prefer the death to take place. The family has the right to choose their degree of involvement in end-of-life care. Family members can help in communicating with the patient as well as providing personal care. This depends on whether they wish to provide such care to the patient. The family is involved right from the beginning until the very end of the entire process. It is also important to involve a religious leader. This is because most patients rely on spirituality for support and comfort during their final days. The religious leaders should be involved from the time of diagnosis, and upon the patient’s request.

How Each Member of the Team will Document the Plan of Care

Each member of the team has a critical role to play in documenting the plan of care. Clinicians are responsible for the provision of hospice care. This involves care of the terminally ill patient with regard to the physical, social, emotional, and spiritual aspects. The main goal of the hospice program is to ensure that patients experience minimal pain, restriction or discomfort while in their last days. The nurse has four critical roles to play. First, the nurse is responsible for control of pain through administering proper medication. Second, the nurse manages or prevents any complications that may arise in the treatment process. Third, the nurse maintains the quality of life of the patient. Lastly, the nurse ensures that final needs of the patient and family are fulfilled accordingly.

The family’s role is to provide support to the patient. The family plans the nature of care that they may provide to the patient. For instance, the healthcare facility may be unable to cater to some specific needs of the patient such as choice of foods, which the family can provide. The family also determines whether there is need for patient transfer to another facility of whether to provide home-based care. The religious leader will plan for meetings with the patient in order to cater towards the emotional needs of the patient. Frequent meetings can help address the emotional needs of the patient.

Role of the Case Management in the End-of-life Care

Case management is involved in meeting the patient’s diverse health needs. The process involves the careful monitoring, evaluation, planning, coordinating, and implementing the various options and services necessary for the patient’s health. Case management is concerned with caring for terminally ill individuals, rather than curing or seeking ways to extend their life. In hospice care, most of the services are offered in a home setting, and often using a multidisciplinary team approach. Case management includes palliative care, which entails implementing care and treatment approaches that fulfill the personal values of the patient. Case management thus emphasizes on individual values, comfort, comprehensive & compassionate care, and pain management approaches (Star, 2012). Case management also helps the patient to get the services and support they deserve to lead a quality life. Another role of case management is to counsel the family members of end-of-life care and preparing them to accept the inevitable.

Case management plays a critical role in helping the patient and family members make sound financial decisions. According to Star (2012), case management ensures that patients not only receive quality end-of-life care, but also minimize the financial burden to the patient and the healthcare facility. Case management also ensures that the patient maintains compliance and the family receives the appropriate reimbursement. Case management helps to ensure that the financial matters of the patient are put in order. For instance, case managers may ensure that the patient’s will is in order, process and ensure that all documents relating to beneficiaries are updated, and oversee the establishment of a funeral trust for the patient. Case management also offers grief counselling as part of personal healing.

How Case Management will be Evaluated in the End

It is important to evaluate the effectiveness of case management in helping the patient achieve quality services. In this case, case management can be evaluated based on how well it caters to the priorities of the 65 year-old dying from congestive heart failure. First, case management should ensure that the patient experiences minimal pain during the last days of his hospice care. Pain control should be tailored to suit the patient’s needs. Case management can also be evaluated based on how well it ensures that the patient’s wishes are honored, for instance, through processing and updating the beneficiaries’ records. Case managers must ensure that all the patient’s wishes are fulfilled.

Case management should be able to provide emotional support to the man as well as his family. In case of terminal illness, it is highly likely that the patient and family may experience emotional health issues such as stress or even depression. Case management should be able to address thoroughly such issues through counseling. Lastly, case management will be evaluated based on its ability to provide the patient with choice. The patient should be able to make a choice on the type of service to receive. For instance, the case management should allow patient to choose between home-based care and hospital based end-of-life care.

How the Team will Protect themselves from Litigation

Case managers are at times faced with legal litigation in the end-of-life care. The team will protect itself from litigation by carefully observing the Code of Medical Ethics with regard to the care of terminally ill patients. This code enumerates that physicians are obligated to ensure the patient experiences minimal pain and suffering, and that their autonomy and dignity are upheld throughout the period of care. Pain management is critical in the care of terminally ill patients. In the past, physicians have faced legal litigation due to lack of proper attention or actions to alleviate pain among the patient. The team will protect themselves from litigation by observing the state laws relating to the terminally ill.

Various states have enacted laws guiding the actions that physicians may take in case of terminally ill patients. Majority of states criminalize assisted suicide to terminally ill patients. However, some states such as Oregon have been able to pass laws allowing physician assisted death in terminally ill patients. Another way the team will protect itself from litigation is by observing the rules and regulations outline by the healthcare facility. Every healthcare institution has a set of rules of conduct that guide staff and patients alike. By observing these rules, one may be able abscond from litigation. The ethical code of conduct is an important tool in guiding the behavior of clinicians and other hospital staff alike. Observing the ethical code of conduct can help the team avoid any form of litigation.


Cohen, E. L., & Cesta, T. G. (2005). Nursing case management: From essentials to advanced      practice applications. St. Louis, Mo: Elsevier Mosby.

Woo, J. A., Maytal, G., & Stern, T. A. (2006). Clinical Challenges to the Delivery of End-of-Life             Care. Primary Care Companion to The Journal of Clinical Psychiatry8(6), 367–372.

Star, M. (2012). Care management role in end-of-life discussions. Care Management Journals,    13(4): 1-5.





The choice of Boolean terminology can markedly affect your search returns. Select a topic related to your area of practice, and select two scholarly databases to find information on the topic. Describe the search. What key words did you use? How many articles did your initial search yield? How did you narrow or expand the search? How many articles did you find once you narrowed or expanded the search? Summarize the results from the search.
Discussion on academic level for graduate nursing program. Emergency nurse practice.

Sample paper


The topic under consideration in this study is the nurses’ role with relation to informed consent. The scholarly databases selected include PubMed, an online collection of peer reviewed journal articles and other forms of publications, and the American Nursing Association database, containing books, journals, and other useful resources. The initial search in PubMed database yielded 57,777 articles. This search utilized the keywords “informed consent.” In order to narrow the research further, the second search utilized the keywords “nurses’ role in informed consent and journal.” This search was narrow and specifically requiring search results for journal articles only. The refined search yielded 72 articles only, all of which are journal articles relating to the topic area. Narrowing the search results is important since it enables one to identify the articles that best describe the topic of interest.

The second search utilized the keywords “informed consent or decision making or ethics”, which yielded 29 results. In order to expand the search results, the keywords “informed consent in health and social care and journal” were used. The search gave 58 search results. This indicates that Boolean searching is useful in enhance search results by either narrowing on search results or expanding the search results. Boolean searching can enable one to narrow down on specific resources such as journals, articles, or publications relating to the topic of interest (Notess, 2006). As such, it is a critical tool for researchers and learners alike.


Notess, G. R. (2006). Teaching Web search skills: Techniques and strategies of top trainers.        Medford, NJ: Information Today Inc.

Health Care Issue Analysis


Involvement in interdisciplinary professional coalitions/organizations allows the healthcare professional to stay current in one’s field or specialty, gain an understanding regarding navigating socio-

  1. Discuss the pros and cons of the health care scenario noted below.

In a highly unusual outbreak of measles in Springfield, Missouri, 18 children became ill, 10 of which of the children had not been inoculated against the virus because their parents objected. These parents do not perceive risk of the disease, but perceive risk of the vaccine.  They use information gained from mainstream media, connecting the vaccines with neurological disorders, asthma, autism, and immunology—and, decide not vaccinate their children.

  1. Discuss health care implications of school-age vaccinations at the macro system levels.
  2. Discuss your macro-level leadership stance of this controversial health care risk.
  3. Find a professional coalition/organization that supports your stance regarding use of vaccines for school-age children and your involvement with this professional coalition/organization.Description of the Assignment

The purpose of this project will be to address a health care controversy related to school-age vaccination. The project will entail researching the laws entailing the vaccination of school-age children at a state level, and taking a stance on this debatable issue.  Leadership skills at the macro-level will be applied.

Sample paper

Health Care Issue Analysis

Speaker notes

Controversy surrounds the vaccination of school-age children in the society. Some parents object to their children taking vaccines to gain immunity against preventable diseases such as measles, citing various health concerns. Among the major concerns, include the risk developing neurological disorders, asthma, and other complications. The media propagates these health concerns related to inoculation of school-age children against preventable diseases. This is despite overwhelming research showing low association between inoculation and the aforementioned health concerns.

Failure to provide vaccination among school-age children leads to increased risk of future recurrence of preventable and often fatal diseases such as measles, polio, mumps, rubella, and others. Despite the increased risks associated with failure to provide vaccination, moral and legal concerns emerge over whether authorities should force parents to give their children vaccination. The principle of autonomy in health care settings dictate that patients have the right to choose the various forms of treatment or procedures that can be done to their bodies.

Pros and Cons Related to Vaccination of School-Age Children

Children who receive vaccination may enjoy various benefits as relates to the case study. One of the benefits is reduced risk of contracting measles and other preventable diseases. From the case scenario, 10 of the children infected with the virus had not been inoculated against the disease, while 8 had received immunization. Another benefit of receiving vaccination is reduced risk of disease epidemic. Most outbreaks are likely to occur in areas where there are high number of individuals without vaccination. Vaccination reduces the risk of disease transmission. This is because those who are vaccinated are less likely to become ill and pass it to others. This also reduces death rate from preventable diseases such as measles.

Vaccinations may present certain complications among children. In most cases, vaccine-related adverse effects such as fever, mild rash, and temporary joint pain are reported. Information obtained from media indicates that vaccinations increase the risk of developing various illnesses such as neurological disorders, asthma, autism, and problems with the immune system. From the case scenario, 8 children had received vaccination against measles, yet they experience a recurrence of the virus. This indicates that vaccination may fail to prevent diseases.


Health care Implications

The medical stance of children greatly depends on the attitude of their parents or guardian towards vaccinations. When parents advocate for vaccination as the key to eliminating diseases, children are more likely to develop a positive attitude towards vaccination. Education also plays a critical role in ensuring that children develop a positive attitude towards vaccination. Teachers can play a critical role ensuring that children develop positive attitudes. By educating children on the benefits and the need for vaccination, children are able to recognize its importance and at the same time demystify the myths surrounding vaccination.

The parent’s stance of children receiving vaccinations depends on whether they perceive the risks or the disease or risk of vaccination. According to Browne, Thomson, Rockloff, & Pennycook (2015), about 40% of parents in the U.S. may delay vaccinations or refuse vaccinations of their children sighting various health concerns. The 40% of parents hold a negative attitude regarding vaccination. The major contributing factor towards the negative attitude among parents is lack of proper understanding of the role of public vaccination campaigns. Another factor contributing towards negative attitude on vaccination is lack of trust towards health authorities. Parents may lack confidence in public health authorities to deliver positive health outcomes to their children. This can lead to a negative attitude on vaccinations.

Another reason contributing to negative attitude is inaccurate personal biases that are shaped by one’s interactions with others in the community (Browne et al., 2015). For instance, the media can significantly influence one’s personal biases in favor of or against a particular situation. Another reason contributing towards the negative attitude is the idea of complementary and alternative medicine. Parents who believe in complimentary and alternative medicine hold contradicting medical beliefs to those held in the contemporary medical field. Certain sociocultural factors influence parent’s opinions regarding contemporary medical practices (Browne et al., 2015). For instance, some parents believe in adopting purely natural approaches to health.

There are various benefits to giving school-age vaccination against preventable diseases. First, vaccination helps in reducing pandemics such as measles outbreak among school-age children. Vaccination also prevents deaths that could result from the preventable diseases. According to Whitney et al. (2014), vaccination will prevent about 322 million cases of disease among individuals born between 1994 and 2013. Immunization will prevent a further 732,000 deaths. Receiving vaccination is cost effective among parents and the society. The cost of providing vaccination is lower comparing to that of treatment when affected by the preventable disease. In addition, there are societal costs associated with illnesses. Vaccination helps in elimination of preventable diseases thus making the diseases no longer a pandemic (Whitney et al., 2014). This helps in protecting future generations against consequences of such diseases. Lastly, vaccination helps in reducing incidences of disease transmission. Children who receive vaccination are less likely to develop preventable illnesses. This helps reduce disease transmission rate.

Various implications may emerge when children fail to receive vaccination. One of the implications is higher incidences of epidemics occurring  in the U.S. Vaccination helps prevent various diseases among the population. When a large segment of the population is not vaccinated, it is easy for a particular communicable disease to spread, becoming a pandemic. Another implication is higher death rate. Whitney et al. (2013) notes that death rate is higher in populations with low vaccination rates. Children who do not receive vaccination pose health risks to others. This is because they are likely to easily acquire diseases and infect others who are close to them.

Related: Health Policy Presentation-Long-term Care

Macro Leadership Stance

There is no risk in school-age receiving vaccinations against preventable diseases. An overwhelming body of evidence indicates that adverse health impacts of vaccinations are rare, and thus vaccinations are safe. According to data from the Centers for Disease Control and Prevention (CDC) (2013), only a small fraction of children who receive vaccination experience adverse effects of MMR vaccine. For instance, only 4 in 10,000 children develop febrile seizure. Febrile seizures are convulsions that may occur when a child experiences fever. Since the introduction of vaccines, deaths from preventable diseases such as measles has significantly reduced. In the past, preventable diseases such as measles were a leading cause of death. This shows the efficacy of vaccinations in preventing deaths from diseases such as measles, mumps, and other diseases. According to Whitney et al. (2015), immunization prevents about 322 million illnesses among those born between 1993 and 2013. Vaccinations has helped eliminate some diseases such as polio and measles. For instance in 2000, measles was recognized as less endemic to the population. There is no risk to the population since the vaccines are thoroughly tested before they are availed for countrywide use in inoculation.

It is significant for children to receive vaccinations against preventable diseases. It is every parents’ wish that their children stay healthy. As such, vaccination can help eliminate a number of preventable diseases and thus ensure children remain healthy. Another factor to consider is low complications arising from preventable diseases. Common complications include hearing loss, convulsions, paralysis, and others all which are preventable (Hendriks & Blume, 2013). Vaccination gives children immunity against preventable diseases common in some parts of the world where vaccination has not been effective. Thus while traveling, children can remain safe from such preventable diseases. Lack of vaccination increases the risk of spreading diseases to other children, for example, those who are yet to receive vaccination owing to their young age. There is increased risk of disease outbreaks when parents fail to inoculate their children. Lastly, parents bear a public health commitment to protect others by ensuring vaccination of their children.

Professional Coalition/Organization at the State Level

There are various organizations that address the use of vaccines for school-age children. Every Child By Two (ECBT) is one such organization. Its major aim is to develop awareness among parents about the importance of immunizing their children by age of two. ECBT is a non-profit organization founded in 1991. ECBT is involved in raising awareness of vaccinating children at the appropriate age. The organization also raises critical issues such as the need to ensure vaccine schedule compliance. The organization also dedicates efforts to fighting negative attitude towards vaccination among parents. The organization achieves this by providing key information about vaccine safety drawing on peer reviewed literature (ECBT, 2016).

Every Child By Two organization fully supports my stance. Every Child By Two organization has been critical in voicing various issues regarding vaccination in school-age children. Notable developments include its campaign programs on vaccine benefits and safety. The program on vaccine benefits aims at proving parents with critical scientific information on the number of deaths and infections averted through vaccination. With regard to safety, ECBT emphasizes on the elaborate systems that are put in place ensuring that vaccines are safe for use. The organization also helps provide key information about immunization schedules to both professionals and parents. The organization also provides schedules for parents who have missed vaccination programs and have been left behind as a result (ECBT, 2016).

Another major thing covered involves countering the misinformation that exist among the public regarding vaccinations. The organization details various research countering misinformation that parents have concerning vaccinations. For instance, the organization asserts there is no evidence suggesting that vaccination leads to autism. The professional organization also addresses what it terms as the “questioning parent.” This comprises of parents who are interested in having their children vaccinated but have numerous concerns. One of the greatest concerns raised by parents involves the issue of having too many vaccinations within a relatively short period. The organization notes that children currently receive more vaccinations compared to the past. While this is true, the organization notes that vaccines used in the past contained about 3000 antigens to about 153 antigens today (ECBT, 2016). This means that modern vaccines have fewer bits of the respective vaccine and thus more effective.

Parents play a greater role in influencing children attitudes towards vaccinations. Parents who discuss about the positive benefits of receiving vaccination with their children instill a positive attitude among them with regard to receiving vaccinations. The research indicates that about 40% of parents may refuse or delay vaccination of their children owing to the misinformation that exists. Educational programs that focus on countering the misinformation that exists and on providing information about the benefit of vaccination can help parents in positively changing their attitude towards vaccinations. My macro leadership stance holds the view that vaccination is safe and is key in fighting preventable diseases. Vast literature indicates that vaccination has significantly reduced deaths and eliminated disease outbreaks or pandemics, in particular measles and polio. Every Child By Two (ECBT) is a professional organization that dedicates efforts towards enlightening parents on the importance of having their children receive vaccination.


  • Browne, M., Thomson, P., Rockloff, M. J., & Pennycook, G. (2015). Going against the Herd: Psychological and Cultural Factors Underlying the ‘Vaccination Confidence Gap’. PLoS ONE, 10(9).
  • Centers for Disease Control and Prevention (CDC). (2013). Measles, mumps and rubella (MMR) vaccine safety. Retrieved from
  • Every Child By Two (ECBT). (2016). About. Retrieved from
  • Hendriks, J., & Blume, S. (2013). Measles Vaccination Before the Measles-Mumps-Rubella Vaccine. American Journal of Public Health103(8), 1393–1401.
  • Whitney, C. G., M.D., Zhou, F., PhD., Singleton, J., PhD., & Schuchat, A., M.D. (2014).Benefits from immunization during the vaccines for children program era – united states, 1994-2013.(). Atlanta: U.S. Center for Disease Control.

Related: Collaborative Leadership



Reflecting on this course,”American Association of Colleges of Nursing. (2011). The essentials of master’s education in nursing. Washington, DC: Author.” consider and answer the following questions: How do you envision using the AACN essentials learned in this course in your future graduate course work? How do you envision using the concepts learned in this course in your future nursing practice  Master’s Prepared Role as Executive Leadership?

Sample paper


Nursing is one of the important pillars of a good and competent health care sector. Nursing professional is focused on the provision of care of individuals, families and the community at large in the attempt to attain optimal health and quality of life. As a matter of fact, nurses constitutes the highest percentage of the entire workforce in the health care industry. This essay will examine how essentials of nursing can be applied and used in real life situation.

I plan to use the background for practice from the sciences and humanities to build on the competence gained in nursing programs through the development of deeper understanding of nursing and related sciences (Goode, 2013). Moreover, through the knowledge gained on organization and system leadership, I can arrange all the necessary resources to promote high quality and safe patient care. Leadership skills are necessary for emphasizing the importance of ethical and critical decision making and thus, eliminate all health disparities and promote excellence in practice. On the same note, I would put effort to continually improve the quality and safety of the care providers as well as clients by integrating every level of the healthcare organization. I must articulate in the methods, tools, performance measures and culture of safety principle to maximally satisfy my clients (Hewitt, 2015).

Through my position as a nurse executive, I would serve as the role model in exemplifying the mission and the vision of the organization.  Leadership and sense of direction are very important and thus, displaying my leadership will be significant to all nurses.  Moreover, I would value diversity and promote cultural competencies considering that we all have different strengths and weaknesses which can complement each other (Jenkins, 2007). Besides, I would encourage creativity and innovation from all staffs and thus increase efficiency and effectiveness of the organization.


Goode, C. J. (2013). Lessons learned from 10 years of research on a post-baccalaureate nurse                   residency program. . Journal of Nursing Administration, 43(2), , 73-79.

Hewitt, C. &. (2015). Essential competencies in nursing education for prevention and care                        related to unintended pregnancy. Journal of Obstetric, Gynecologic, & Neonatal                           Nursing, 44(1), , 69-76.

Jenkins, J. &. (2007). Establishing the essential nursing competencies for genetics and genomics.             . Journal of Nursing Scholarship, 39(1), , 10-16.

MSN Specialty Executive Leadership

Issue of clinical significance vs statistical significance paper


Clinical Significance (graded)

Explore these issues on the Internet and through other resources. Share what you find out on these topics:

Confidence Intervals: Why are they useful in helping to determine clinical significance?

There are many controversies surrounding the issue of clinical significance vs. statistical significance. Identify one of them and summarize it. Finish with your opinion about the controversy.

Sample paper


Most of the clinical processes encompass tests and research that requires medical practitioners to, measures values and population and that is where confidence interval comes in. A confidence interval is a probability that a value will fall between upper and lower bound of a probability distribution. It helps to measure the probability of a population falling between two set of values (Giles, 2016). Confidence intervals can be useful in many ways to the organization, and they are particularly useful in helping avoid possibly erroneous conclusions that the two groups have similar results when non-significant findings are reported. On the same note, it allows a more flexible and nuanced approach to the analysis of research data. In addition, they allow and enable investigators to test a hypothesis about their data, and they are also more informative about such important parts of research as the sample size as well as helping a scholar to create a correlation between results obtained and the population used in the study (Bray, 2016).

Most of the experts believe that physicians are only interested in the statistical significance of their main objective and there are only interested in establishing whether the obtained p-value is below alpha. However, in clinical research, it is not only paramount to measures and access significance of the differences between the evaluated groups, but it is also recommended. Thus, one of the controversies that exist between the two is that clinical significance is superior and more important than statistical significances as it provides more information and insight on the values obtained (Pontin, 2016). Unfortunately, there is no agreed settlement to this controversy, and thus it depends on individual physicians to choose what to use depending on the research and study he is conducting.


Bray, I. K. (2016). Family presence during resuscitation: validation of the risk-benefit &              self-confidence scales for student nurses.

Giles, T. L.‐C. (2016). Factors influencing decision‐making around family presence during                      resuscitation: a grounded theory study. Journal of Advanced Nursing.

Pontin, D. K. (2016). Family-witnessed resuscitation: focus group inquiry into UK student           nurse experiences of simulated resuscitation scenarios. . BMJ Simulation and      Technology Enhanced Learning, 2(3), , 73-77.

Health Policy Presentation-Long-term Care

Health Policy Presentation-Long-term Care


The purpose of this assignment is for you to identify an issue of concern for your role as an advanced practice nurse and to formulate a potential policy change to address that issue. There are many potential issues which can influence your practice setting or other issue which may negatively affect the patients with whom you work.

All of the course reading will help you to identify a topic for this assignment. You can think about the issue as related to your health promotion project. The policy you consider may be in reaction to the health promotion issue or something larger that is still related to that issue. There are hundreds of possible issues, but here is a list of a few to consider:

Child and elder care

Civil rights

Domestic violence

Drug abuse/addiction



Native American and migrant workers’ health

Long-term care

Immigration/illegal aliens

Legislative issues affecting advanced practice nursing

Barriers to practice

Access to care

As you begin to work on the possible policy change: the following ideas and steps should be considered:

Definition and description of the issue

Exploration of the background of the issue


Issue statement or statement of clarity

Possible methods of addressing the issue

Goals and options for changes

Risks and benefits of the changes

Evaluation methodology

Recommendation or solution

Identify the type of legislation, such as state, federal, scope of practice, reimbursement, loan repayment, or others.               

Review of the literature consists of a minimum of 3–4 peer-reviewed articles and 6–7 other outside sources.       

Describe the current policy or health policy issue and specify how it would impact nursing or healthcare.

Describe the specific aspects of the proposed policy or policy change.     

Identify the individuals who would benefit from the policy change and explain where support for the change would be

Describe the impact of the policy change on nursing practice and health care.     

Provide an analysis of the policy from your point of view and how this will influence your practice.

Sample paper

Health Policy Presentation-Long-term Care

Speaker notes

Definition and Description of the Issue

Long-term care refers to the continuum of social and medical services provided to those living with chronic health issues. Long-term care services are a combination of medical services, housing, and social services. Long-term care is considerably different from acute medical care – the latter aims at returning an individual to the state he or she was before the appearance of the medical condition. On the other hand, long-term care aims at helping individuals adjust to their new situation. Long-term care is much broader in terms of the services provided to individuals. While acute medical care focuses on medical services, long-term care also involves social services. The provision of long-term care involves a wide range of specialists or care providers. These include physicians, community caregivers, nursing home care providers, home care agencies, friends, and family members.

Exploration of the Background of the issue

According to Frank (2012), the lifespan of most Americans has tremendously improved owing to better nutrition and improved medical care. In addition, the Baby Boomers (born between 1946 and 1964) have increasingly aged, causing a rise in demand for acute care. Over the next 10 years, the demand for support and long-term care services will significantly increase due to the aging of this generation. In 2010, approximately 10 million Americans were in need of long-term care and support. Surprisingly, only about 20 percent of those in need of long-term care services receive professional care, the rest depending on family and friends. Projections indicate that the number of those seeking long-term care services will reach 15 million by 2020 (CDC, 2013). With the high number of those requiring long-term care and support, it becomes obvious that the cost of providing such services will likely increase in the future – a cost that is already extremely high for most American families.


There are a number of stakeholders directly affected by the issue. The baby boomers, or those born between 1946 and 1964, are currently entering old age (Bowser, 2013). As they advance in age, majority are increasingly requiring long-term care services due to various conditions such as Alzheimer’s condition associated with aging. These are the main stakeholders. Others stakeholders involved are the caregivers. These range from hospitals to physicians that provide medical services to those in long-term care facilities. Home care agencies are directly involved in providing care to those requiring long-term care. Assisted living facilities and nursing homes are also major stakeholders in long-term care. Family members, friends, and hospice caregivers are also important stakeholders.

Related: Nursing Sensitive Indicators

Issue Statement

The current long-term care system is in a crisis owing to capacity issues. With the current projected increase in the number of individuals requiring long-term care, the future situation may be dire. About 77 million Baby Boomers will retire over the next 10 years. Only a few have enough savings to pay for long-term care (Calmus, 2013). Long-term care is currently expensive and out of reach for majority of Americans. The average annual cost for a typical room in a nursing home will average $90,000. To make it worse, majority of Americans do not have adequate cover or funds for long-term care. According to Butler (2016), the cost of long-term care will rise in the next few years, which will average $138,000 per individual. It has become difficult to acquire private insurance to cover these costs since most private insurance firms either have increased their premiums or have withdrawn their services due to high costs. Currently, government programs have underserved the needs of most Americans, with Medicaid program covering only 40 percent of the total costs and Medicare covering only 23 percent of the total costs. This leaves most individuals with huge financial burden.

Possible Methods of Addressing the Issue

There are a number of possible ways to improve on this issue. First there is need to develop private insurance to increase their contribution to coverage of individuals requiring long-term care. Private insurers have the potential to cover more Americans compared to the state and federal governments. Plans should involve ensuring that those in employment receive automatic enrolment with an insurer of their choice. The second method of addressing the issue is through revamping the Medicaid program. Currently, the program covers 40 percent of the costs. The federal government should develop ways of increasing coverage of the program to about 60 percent of the total costs. This can greatly help individuals requiring long-term care. The next way to address the issue is by developing personal and community initiatives. There is need to educate the public on issues relating to health and financial planning. This can enable them prepare for the future. Lastly, home and community based services can help reduce costs in the sector.

Goals and Options for Changes

The major goals of the changes should be to reduce the current costs of long-term care services. The high cost of long-term care delivery is currently leaving families with huge financial burdens. The changes should aim at lessening the financial burden incurred by families in long-term care. Another goal is to create awareness among individuals about the need to invest in long-term care. According to Freundlich (2014), majority of individuals harbour misconceptions about coverage of long-term care costs. Individuals lack adequate knowledge on what costs are covered by Medicaid and Medicare programs. The next goal is to create awareness among individuals on the need to lead healthier lifestyles. There is need to create awareness on the need to adopt healthier lifestyles even at an advanced age.

Risks and Benefits of the Changes

There are certain inherent risks in the proposed changes. For instance, there is risk of increased taxes associated with increasing the coverage of Medicaid program to 60%. This might be counterproductive to growth. Engaging the private insurance firms may also lead to reduced savings among workers (Freundlich, 2014). Private insurance firms may charge high and unaffordable premiums. The cost of private insurance may be high discouraging majority of workers. There is also risk of failure by the legislature to pass the amendments required to effect the changes. The process may take long worsening the current crisis further. Lastly, there is risk of inadequate information to back up the proposals (Bray, Ren, Masuyer, & Ferlay, 2013). For instance, the actual costs of the proposed changes are not yet known. The major benefit from these changes will be reduced costs of long-term care among individuals.

Evaluation Methodology

The evaluation methodology will lay emphasis on cost. It is important that an appropriate strategy should keep costs down (Nicolle, 2014). An appropriate strategy should aim at reducing costs of long-term care and ensuring that individuals are able to access long-term care without overburdening their loved ones. The appropriate strategy should be able to reduce private spending from personal savings or bond and instead utilize insurance services.

Recommendation or Solution

This research recommends involving the private sector in reducing the high burden of long-term support care cost among families. Long-term insurance plans can help individuals reduce their dependence on the government sponsored Medicaid and Medicare programs. Individuals should start buying insurance premiums while young, which can enable them purchase cheaper premiums or receive discounts (Donald et al., 2013). The government should also work with private insurance firms to ensure that they reduce premium costs to those taking cover for long-term care support. Currently, private insurers are wary of providing comprehensive coverage to the poor. Payroll tax can be used to finance a catastrophic plan or even a short-term plan that can pay benefits up front.


  • Bowser, B. A. (2013). Why long-term care for U.S. seniors in headed for crisis. PBS News Hour. Retrieved from
  • Bray, F., Ren, J. S., Masuyer, E., & Ferlay, J. (2013). Global estimates of cancer prevalence for 27 sites in the adult population in 2008. International Journal of Cancer132(5), 1133- 1145.
  • Butler, S. M. (2016). Consensus plans emerge to tackle long-term care costs. The Journal of the American Medical Association, 315(14): 1-9.
  • Calmus, D. (2013). The long-term care financing crisis. Center for Policy Innovation Discussion Paper 7 on Health Care. Retrieved from
  • Centers for Disease Control and Prevention (CDC). (2013). Long-term care services in the United States: 2013 overview. Retrieved from
  • Donald, F., Martin‐Misener, R., Carter, N., Donald, E. E., Kaasalainen, S., Wickson‐Griffiths, A., ..& DiCenso, A. (2013). A systematic review of the effectiveness of advanced practice nurses in long‐term care. Journal of Advanced Nursing69(10), 2148-2161.
  • Frank, R. G. (2012). Long-term Care Financing in the United States: Sources and Institutions. Applied Economic Perspectives and Policy, 34(2), 333-345. doi:10.1093/aepp/pps016
  • Freundlich, N. (2014). Long-term care: What are the issues? Robert Wood Johnson Foundation.–what-are-the-issues-.html
  • Nicolle, L. E. (2014). Antimicrobial stewardship in long term care facilities: what is effective?. Antimicrobial resistance and infection control3(1), 1.


Standards and regulations on CPAP and BIPAP

Standards and regulations on CPAP and BIPAP


Reviewed and research evidence of relevant regulations and Standards regarding the use of CPAP and BIPAP. Should also include a chart with the summary.

Sample paper

Standards and regulations on CPAP and BIPAP

Most of the governments around the world are striving to ensure that they fight poverty, disease and ignorance. Providing good medical care for all the citizens has been hectic for a very long time. However, it is the duty of these governments to ensure that there is the availability of crucial machines in all public hospitals to ensure they can reduce the mortality rate of both infants and adults. One of those important machines includes the CPAP and BIPAP.  Continuous positive airway pressure machine is a machine that helps to administer a treatment that uses mild air pressure to keep the airways open (Jensen, 2008). CPAP is used to people who have breathing complications and infants whose lungs have not fully developed. On the other hand, Bilevel positive airways pressure that performs a similar function as that of CPAP. However, the BIPAP treatment is a non-invasive form of therapy and includes breath timing feature that measures the amount of breaths per minute. The only difference between the two machines is that the CPAP has one pressure setting while the BIPAP has two pressure settings making it easy for patients to breath.

There are several rules and regulation and standards that come with the use of CPAP and BIPAP machines and should be observed by both medical practitioners and all patients.

  • The Medicare should cover 3-month trial – a patient who has been diagnosed with obstructive sleep apnea should go for a three month trial with the therapy unless stated otherwise by the concerned doctor.
  • The eligibility of this therapy widely goes for all people with medical insurance and has been diagnosed with this disease. Since the medication and the therapy may be costly to low-income citizens, they are widely advised to have a medical insurance before engaging in this therapy.
  • An oral appliance is not enough- most people tend to think that one or two oral appliance is enough and think that they are fully treated, but this is not the case. Patients who already have gone through oral appliance need to be followed and diagnosed to ensure that the medication worked effectively(Kopelovich, 2012).
  • Positioning- the positioning of the patient should be in slant position to enable him to have a good and spontaneous breathing room. The air should be delivered to the patient at a constant pressure during inspiration and expiration.
  • CPAP proceeds BIPAP – in most cases, patients who are suffering from obstructive sleep apnea are usually subjected to CPAP. If the patient does not respond to the treatment, he is then subjected to BIPAP, which has two levels of pressure to completely eliminate the apneas.

A summary chart of regulation and standards for use CPAP and BIPAP

Rules and standards case
Oral appliances All medical experts should follow their patients to ensure that they are fully treated, and they should not make any assumption if the patient is taking oral appliances.
Positioning The patient should be positioned in an appropriate position to allow him or to breathe spontaneously
Eligibility All patients are eligible to the treatment, but it works best for those with medical insurance because it becomes easy to cater for expenses.
Trial period  It is mandatory for all patients to undergo trial therapy for a minimum of three months and await further instructions from their doctors.
CPAP proceeds BIPAP BIPAP is the last resort that doctors seek after the failure of CPAP, which may not work in some patients.



Jensen, C. T. (2008). Postoperative CPAP and BiPAP use can be safely omitted after laparoscopic Roux-en-Y gastric bypass. urgery for Obesity and Related Diseases, 4(4), , 512-514.

Kopelovich, J. C. (2012). Pneumocephalus with BiPAP use after transsphenoidal surgery. Journal of clinical anesthesia, 24(5),, 415-418.

Nursing Sensitive Indicators

Nursing Sensitive Indicators



National initiatives driven by the American Nurses Association have determined nursing-sensitive outcome indicators that are intended to focus plans and programs to increase quality and safety in patient care. The following outcomes are commonly used nursing-sensitive indicators:

•  Complications such as urinary tract infections, pressure ulcers, hospital acquired pneumonia, and DVT

•  Patient falls

•  Surgical patient complications, including infection, pulmonary failure, and metabolic derangement

•  Length of patient hospital stay

•  Restraint prevalence

•  Incidence of failure to rescue, which could potentially result in increased morbidity or mortality

•  Patient satisfaction

•  Nurse satisfaction and staffing


Mr. J is a 72-year-old retired rabbi with a diagnosis of mild dementia. He was admitted for treatment of a fractured right hip after falling in his home. He has received pain medication and is drowsy, but he answers simple questions appropriately.

A week after Mr. J was admitted to the hospital, his daughter, who lives eight hours away, came to visit. She found him restrained in bed. While Mr. J was slightly sleepy, he recognized his daughter and was able to ask her to remove the restraints so he could be helped to the bathroom. His daughter went to get a certified nursing assistant (CNA) to remove the restraints and help her father to the bathroom. When the CNA was in the process of helping Mr. J sit up in bed, his daughter noticed a red, depressed area over Mr. J’s lower spine, similar to a severe sunburn. She reported the incident to the CNA who replied, “Oh, that is not anything to worry about. It will go away as soon as he gets up.” The CNA helped Mr. J to the bathroom and then returned him to bed where she had him lie on his back so she could reapply the restraints.

The diet order for Mr. J was “regular, kosher, chopped meat.” The day after his daughter arrived, Mr. J was alone in his room when his meal tray was delivered. The nurse entered the room 30 minutes later and observed that Mr. J had eaten approximately 75% of the meal. The meal served was labeled, “regular, chopped meat.” The tray contained the remains of a chopped pork cutlet.

The nurse notified the supervisor, who said, “Just keep it quiet. It will be okay.” The nursing supervisor then notified the kitchen supervisor of the error. The kitchen supervisor told the staff on duty what had happened.

When the patient’s daughter visited later that night, she was not told of the incident.

The next night, the daughter was present at suppertime when the tray was delivered by a dietary worker. The worker said to the patient’s daughter, “I’m so sorry about the pork cutlet last night.” The daughter asked what had happened and was told that there had been “a mix up in the order.” The daughter then asked the nurse about the incident. The nurse, while confirming the incident, told the daughter, “Half a pork cutlet never killed anyone.”
The daughter then called the physician, who called the hospital administrator. The physician, who is also Jewish, told the administrator that he has had several complaints over the past six months from his hospitalized Jewish patients who felt that their dietary requests were not taken seriously by the hospital employees.

The hospital is a 65-bed rural hospital in a town of few Jewish residents. The town’s few Jewish members usually receive care from a Jewish hospital 20 miles away in a larger city.


Analyze the scenario (suggested length of 2–3 pages) by doing the following:

A.  Discuss how an understanding of nursing-sensitive indicators could assist the nurses in this case in identifying issues that may interfere with patient care.

B.  Analyze how hospital data on specific nursing-sensitive indicators (such as incidence of pressure ulcers and prevalence of restraints) could advance quality patient care throughout the hospital.

C.  Analyze the specific system resources, referrals, or colleagues that you, as the nursing shift supervisor, could use to resolve the ethical issue in this scenario.

D.  When you use sources to support ideas and elements in a paper or project, provide acknowledgement of source information for any content that is quoted, paraphrased or summarized. Acknowledgement of source information includes in-text citation noting specifically where in the submission the source is used and a corresponding reference, which includes:

•   Author

•   Date

•   Title

•   Location of information (e.g., publisher, journal, or website URL)

Sample paper

Nursing Sensitive Indicators


One of the major roles of a nursing professional is to ensure that patients receive comprehensive care. Nurses have a role of ensuring that they provide quality health care to their patients as per the hospital guidelines. Similarly, nurses must observe the ethical guidelines while making critical decision and when administering care. From the case study, it is evident that the management was unable to identify the importance of patient satisfaction in administration of various services. Lack of provision of quality services in the patient management system is an indicator of failure and incompetence on the part of management.

According to Montalvo (2007), a crucial role of the nursing sensitive indicators is to ensure that patients receive quality care and that the nursing outcomes are positive. In line with this, they ensure that patients give a higher satisfaction rating for the services provided and spend less time in the hospital. If the nurses had adhered to all the nursing sensitive indicators while examining Mr. J, the situation would have been better – as it is clear that the professionals did not take into consideration the varied needs of Mr. J. From the case study, the nurses employed restraints to put Mr. J under control owing to his dementia. Worse still, the nurses failed to provide Mr. J. the required attention. For instance, Mr. J. had to await his daughter in order to communicate to the nurses that he wished to visit the washroom. Mr. J was able to give verbal instructions to his daughter, meaning that he could be able to communicate to the nurses and express his wish had they been giving him close attention.

The red depression on the patient’s lower side of the side could also have acted as a sensitive indicator. This depression was a clear indication that Mr. J had developed a pressure ulcer due to maintain the same posture over a protracted period. Worse still, after helping him access the washrooms, the nurse lay the patient on the same posture as before. She was keener on reapplying the restraints instead of making sure that Mr. J felt comfortable. In addition, the nurse should have removed the restraints and allowed the patient some movement, albeit with close supervision. The patient’s food tray comprised of pork cutlet among other items. This is despite Mr. J being Jewish; whose members avoid consuming pork as a religious belief. The nurse included a cutlet of pork in his tray, which shows some degree of irresponsibility on her part. The nurse also ignored Mr. J’s daughter when she inquired about the food, which indicates arrogance and insensitivity towards other people’s feelings.

A number of resources, referrals, or colleagues can be used to resolve the ethical issue in this scenario. Cooperation of the different practitioners within the health facility can be important in resolving the ethical issue (Ulrich et al., 2010). For instance, the nursing in charge could cooperate better with the kitchen supervisor to ensure that there were no diet errors. With regard to the certified nursing assistant, it is important to ensure that she performs crucial functions such as ensuring that all patient needs are addressed. There is need to inculcate professionalism among all nurses when performing their duties to ensure that patient outcomes are achieved. There is need for the kitchen supervisor to ensure that he/she counterchecks the patient’s dietary requirements with that provided. This can reduce cases of a mix-up of the patient orders.


Montalvo, I. (2007). The National Database of Nursing Quality Indicators® (NDNQI®). Retrieved June 10, 2016, from

Ulrich, C. M., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010). Everyday Ethics: Ethical Issues and Stress in Nursing Practice. Retrieved June 10, 2016, from




Healthcare organizations accredited by the Joint Commission are required to conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause is identified and a plan of action established, it is useful to conduct a failure mode and effects analysis (FMEA) to reduce the likelihood that a process would fail. As a member of the healthcare team in the hospital described in this scenario, you have been selected as a member of the team investigating the incident.


It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog.

Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further evaluated and discharged from triage to the emergency department (ED) patient room. He is admitted by Nurse J. The admitting nurse finds that Mr. B has a history of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain. After the nurse completes Mr. B’s assessment, Nurse J informs the ED physician of admission findings and the ED physician proceeds to examine Mr. B.

Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency department physician. Respiratory therapy is in-house and available as needed. At the time of Mr. B’s arrival, the ED staff is caring for two other patients. One patient is a 43-year-old female complaining of a throbbing headache. The patient rates current pain at four out of ten on numerical verbal pain scale. The patient states that she has a history of migraines. She received treatment, remains stable, and discharge is pending. The second patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results are pending for this patient. Both of these patients were examined, evaluated, and cared for by the ED physician and are awaiting further treatment or orders.

After evaluation of Mr. B, Dr. T, the ED physician, writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears to have had no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication (hydromorphone) is administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle relaxation from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patient’s medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be making it more difficult to sedate Mr. B.

Finally at 4:25, the patient appears to be sedated and the successful reduction of his (L) hip takes place. The patient appears to have tolerated the procedure and remains sedated. He is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m. and Mr. B is resting without indications of discomfort and distress. At this time, the ED receives an emergency dispatch call alerting the emergency department that the emergency rescue unit paramedics are en route with a 75-year-old patient in acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure machine programmed to monitor his B/P every five minutes and a pulse oximeter. At this time Nurse J leaves his room. The nurse allows Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35, Mr. B’s B/P is 110/62 and his O2 sat is 92%. He remains without supplemental oxygen and his ECG and respirations are not monitored.

Nurse J and the LPN on duty have received the emergency transport patient. They are also in the process of discharging the other two patients. Meanwhile, the ED lobby has become congested with new incoming patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showing a sat of 85%). The LPN enters Mr. B’s room briefly and resets the alarm and repeats the B/P reading.

Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which includes assessments, evaluation, and the ordering respiratory treatments, CXR, labs, etc.

At 4:43, Mr. B’s son comes out of the room and informs the nurse that the “monitor is alarming.” When Nurse J enters the room, the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2 sat is 79%. The patient is not breathing and no palpable pulse can be detected.

A STAT CODE is called and the son is escorted to the waiting room. The code team arrives and begins resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular fibrillation. CPR begins immediately by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are administered. After 30 minutes of interventions, the ECG returns to a normal sinus rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called and, upon the family’s wishes, the patient is transferred to a tertiary facility for advanced care.

Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in Mr. B. The family had requested life-support be removed, and Mr. B subsequently died.

Additional information: The hospital where Mr. B. was originally seen and treated had a moderate sedation/analgesia (“conscious sedation”) policy that requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation training module. The training module includes drug selection as well as acceptable dose ranges. Additional (backup) staff was available on the day of the incident. Nurse J had completed the moderate sedation module. Nurse J had current ACLS certification and was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by the manager demonstrated that the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was available and in working order in the ED on this day.


  1. Complete a root cause analysis (RCA) that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome).


  1. Discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario.
  2. Discuss a change theory that could be used to implement the process improvement plan developed in B.


  1. Use a failure mode and effects analysis (FMEA) to project the likelihood that the process improvement plan you suggest would not fail.
  2. Identify the members of the interdisciplinary team who will be included in the FMEA.
  3. Discuss steps for preparing for the FMEA.
  4. Apply the three steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B.
  5. Explain how you would test the interventions from the process improvement plan from part B to improve care in a similar situation.


     Note:You are not expected to carry out the full FMEA, but you should explain each step, and how you would apply it to your process improvement plan.


  1. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities.


  1. When you use sources to support ideas and elements in a paper or project, provide acknowledgement of source information for any content that is quoted, paraphrased or summarized. Acknowledgement of source information includes in-text citation noting specifically where in the submission the source is used and a corresponding reference, which includes:
  •   Author

  •   Date

  •   Title

  •   Location of information (e.g., publisher, journal, or website URL)



In more than one occasion in our lives, we find things and events going contrary to our expectations and health care sector is no exception. Sentinel events occur in the course of duties of many doctors and nurses as some unanticipated events in the healthcare settings may occur leading to death or serious physical and psychological injuries to victims. When such events occur in the workplace, a root cause analysis should be conducted to determine whether the event occurred out of negligence or it was purely accidental. A root cause analysis (RCA) is a method of problem-solving employed to aid in identifying the root cause of faults or problems at the individual or organizational levels. A root cause analysis is useful in describing the depth or extent of the causal chain where an intervention could be easily employed to improve the performance of an individual or the organization and to prevent further damage and to protect future outcome (McFarland, 2013). This paper attempts to conduct a root cause analysis of in a hospital where a patient, Mr. B medical condition got worse which eventually lead to his death despite being airlifted for more medical attention.

Question 1

Nurse J can neither be held responsible for the worsening of the medical condition of Mr. B nor can she be termed negligent.  The nurse followed the instructions from the doctor T to administer the diazepam and hydromorphone for sedation purposes. Some of the causative factors of this sentinel event include understaffing and the current patient’s conditions in terms of weight and use of oxycodone which may have altered the effects of sedation process.  Due to lack of enough personnel, nurse J and LPN on duty were forced to attend and receive the emergency transport patient rather than attending to Mr. B to ensure that his medical condition was stable, and he was fully awake before leaving his side. Nurse J shows her responsible nature by placing Mr. B on an automatic blood oximeter to monitor his blood pressure and oxygen saturation levels.

Question 2

After the discovery of the root cause of the errors in the hospital, the joint commission investigating this event should propose an additional of hospital staffs, especially in the emergency department to attend to new arrivals and discharging others. This action would ensure that nurses attending to other patients are not called to attend to new arrivals before they are through with the patients at hand. Overworking and overstretching the nurses and medical personnel ability will always result in errors and thus the hospital needs to add more staffs to guarantee high-quality medical services.

Question 3

The sole function of the hospital is to save lives and to administer medication to various individuals. The failure or the error that occurred lead to the death of a patient who was admitted to the facility with the aim of saving his life can be attributed to lack of enough staffs. To prevent the occurrence of such an event, the facility needs to have the more qualified medical personnel.  The members who qualify to participate in this Failure Mode and Effect Analysis include hospital administrators, all supervisors, and medical practitioners (Ben-Daya, 2009).  Some of the basic steps to be followed include identification of the medical administration process, assigning the members identified and selected, team leader and team facilitator and finally designating the steps in the FMEA process that constitute of functions.  In addition, there is the need to identify the severity of the occurrence of a failure if it leads to death or worsening of the patient’s condition, the frequency of occurrence of the failure. Finally, before the implementation of the new process, there is the need to determine how easily can a failure or error be detected and handled.

Question 4

Intervention may be necessary for healthcare considering that they include activities and actions for which nurses and medical practitioners are responsible that are intended to improve the medical condition of a patient. Most of the intervention conducted by all practitioners should be intended to benefit the client. In the case of any emergency, the medical personnel should conduct independent, dependent and interdependent interventions to save the life of the patient. At times, the nurse may be forced to initiate interventions independently to save the patient’s life, at times they may require waiting for authorization or on other occasions they may be required to work together to save lives.

Question 5

A professional nurse should ensure that there is an equal distribution of hospital facilities and resources across all departments and levels of the facility to ensure that they offer quality medical services (Tannenbaum, 2013). Moreover, the nurse should adopt flat organization structure and accept opinion and views from the junior staff on how to improve the services offered by respective facilities. In other occasions, attending leadership classes and training may prove vital to the nurse to help him or her to exercise control and deal with pressure from all sectors considering that healthcare sector is paramount to a country and at times, it is forced to work under pressure.


Ben-Daya, M. (2009). Failure mode and effect analysis. In Handbook of maintenance management and engineering , 75-90.

McFarland, D. (2013). Root Cause Analysis. Root Cause Analysis (November 29, 2013).

Tannenbaum, R. W. (2013). Leadership and organization. Routledge.


Identify a specialty need seen in your Microsystem–Smoking Paper


  1. Identify a specialty need seen in your Microsystem–Smoking. Review the relevant health policies (local, state, and national) that exist or that could be developed to address this specialty need.
  2. 2. Describe the policy, the relevance to your Microsystem, and strategies that can be implemented by the CNL to improve health promotion efforts in the Microsystem.

Topic –Smoking Microsystem — The VA.  Please include a reference page


Smoking Microsystem

One of the specialty needs seen in the microsystem is smoking. There is need to offer counseling to patients on life-style modification with regard to smoking. Currently, there are a number of local, state, and national health policies that address the specialty need. The VA healthcare facility has adopted a smoke-free policy at the local level that applies to all VA healthcare facilities. All VA healthcare facilities have adopted a smoke-free policy. This policy was initially adopted in 1991. This policy is conversant with the federal policy of establishing smoke-free zones to all employees as well as members of the public using these facilities. Smoking areas have been established for all employees and members of the public in places detached from the healthcare facility.

The above policy is of great importance to the microsystem. Numerous researches provide details of the health impacts of secondhand smoke to individuals. There is strong evidence linking various health problems including lung cancer to exposure from secondhand smoke. According to a CDC Report (2014), secondhand smoke is associated with a host of health problems in children and adults. In children, it is associated with severe asthma attacks, sudden infant death syndrome, ear infections and respiratory system infections. According to CDC (2014), secondhand smoke increases the risk of developing stroke and cardiovascular disease in adults by about 25 percent. It also increases the risk of developing lung cancer by about 20 to 30 percent. The local policy helps prevent exposure of secondhand smoke to patients at the hospital hence keeping them safe from the health risks involved.

There are also state and local policies that address the specialty need. Various states as well as the federal government have outlined policies that regulate smoking in public places. Currently, more than 16 of the U.S. states have already adopted smoke-free laws. These laws regulate the use of tobacco in places such as restaurants, bars and private workplaces. In 2009, the Family Smoking Prevention and Tobacco Act was signed into law, given the U.S. Food and Drug Administration the powers to regulate the manufacture and distribution of tobacco products (“FDA,” 2015). These policies are meant to protect members of the public from exposure to secondhand smoke. The policies are also meant to prevent young people from engaging in smoking. The young are particularly vulnerable to influence hence the need to protect them. It is also important to regulate tobacco use in public in order to help recovering tobacco users drop the habit.

There are a number of strategies that Clinical Nurse Leaders (CNLs) can implement to improve health promotion efforts in the microsystem. First, there is need to offer support to all tobacco users with an aim to help them quit the habit. Clinical Nurse Leaders should be at the forefront in helping individuals with tobacco dependency to quit the habit. They can also do this by referring them to reputable rehabilitation centers. Clinical Nurse Leaders should be role models in in the fight against tobacco use by fully embracing the Health Professional Code that regulate tobacco use. They should show leadership in the fight against tobacco use. Clinical Nurse Leaders should be at the forefront of advocating for appropriate health policies regarding tobacco use both at the healthcare facilities and at the national levels. For instance, they can advocate for educational campaigns to be included in media on the harmful impacts of tobacco use.


Centers for Disease Control and Prevention (CDC). (2014). Health Effects of Secondhand            Smoke. Retrieved from:   

U.S. Food and Drug Administration (FDA). (2015). Tobacco Products. Retrieved from:    46129.htm


Data Management-Fishbone diagrams