For this week’s post, I will use the plan, do, study, act model, also known as the PDSA model. THE PDSA model helps nurse leaders improve the quality of a system (Katowa-Mukwato et al., 2020). There are four steps to this model:
The DNP leader must plan the implementation of a change and hypothesize the outcome.
The change must be implemented as the leader collects data.
The leader must compare the data to what he or she initially hypothesized.
Based on what new conclusions the nurse leader has been confronted with, he or she must act on the recently learned information.
This could be changing something about the implementation, or maybe this is continuing to monitor or even implementing the change as permanent.  
The clinical issue I propose changing is poor staffing in the medical intensive care unit. Poor staffing can lead to poor outcomes related to nursing care quality (Bae, 2021). The medical intensive care unit where I work has been slowly losing staff, and recently there has been an increase in staff leaving, including me. My contract here is in four weeks, and I have not seen any senior leadership planning to replace this lost staff. The ratios are out of sorts now in the medical intensive care unit, which is unsafe. Not only that, but we cannot take admissions, so patients that need critical care are backed up in the emergency room, which causes other problems.  
We will start by planning our intervention. Implementing strict nurse-to-patient ratios is the intervention that will best address this problem. This should be a maximum of two patients per nurse in the medical intensive care unit. Suppose this causes a backlog of patients in the emergency room. In that case, the emergency room should be placed on divert, or the emergency room nurse leader should address the possibility of flexing the patient-to-nurse ratios. The expected response is that nursing care quality will increase, as well as staff satisfaction which will reduce burnout and help maintain full-time nurse staffing levels. We will implement this intervention immediately. As the new policy takes effect over three months, specific data trackers should be trended, including patient safety events, nurse terminations, and overall unit productivity. We will consider this new information when deciding to make the new policy permanent or restart the PDSA process to identify a new intervention.  

References
Bae, S. (2021). Intensive care nurse staffing and nurse outcomes: a systematic review. Nursing in Critical Care, 26(6). https://doi.org/10.1111/nicc.12588

Katowa-Mukwato, P., Mwiinga-Kalusopa, V., Kabwe, C., Kanyanta, M., Chanda, D., Mbewe Mwelwa, M., Wahila, R., Petronella, M., & Carrier, J. (2020). Implementing evidence based practice nursing using the PDSA model: Process, lessons and implications. International Journal of Africa Nursing Sciences, 14, 100261. https://doi.org/10.1016/j.ijans.2020.100261

Nursing simulations are beneficial to use in clinical practice; however, sometimes this may not always be the case. The purpose of this discussion post is to describe the potential limitations that may occur during nursing simulations. In addition, this clinical problem will be addressed using the application of the PDSA framework. According to Coury et al. (2017), the PDSA framework can serve as a standard quality-improvement process, ensuring patient safety.

             Simulations in nursing practice, whether a school or work environment, focuses on patient safety and the participant’s knowledge of how to keep the patient safe during a scenario. Koukourikos et al. (2021) share that the limitations of a simulation include inadequate training of the instructor, as well as a scenario that has not been well organized and thought out.

 Furthermore, in applying the PDSA framework, also known as the plan, do, study, and act framework, to this clinical problem, the first step focuses on planning. During the planning stage, I would ensure that all instructors are trained to use the simulator. In doing so, I would provide appropriate teaching by initiating mandatory training and assessing an understanding. I would also have the instructor show their knowledge by doing a return demonstration. In addition, I would also create a rubric, of which the instructors would need a satisfactory score. According to Koukourikos et al. (2021), educators must be familiarized with technology to ensure smooth operation during the simulation.

During the doing phase, I would work with the instructors to create each scenario related to the different body systems. For example, while designing a well-thought scenario of the patient who has congestive heart failure, I will write the script to reflect the scenario. in addition, I would also reach out to Laerdal to ensure the SIM mannequin can express all the clinical findings or complaints that a CHF patient may experience, furthermore, creating that lifelike experience for the student.

During the study phase, with the collaboration of instructors, and participants, I would evaluate the effectiveness of the scenario by engaging in a prebriefing to explain the scenario and functions of the simulator to the instructors, as well as informing the students where needed supplies are located, and logistics, such as syringes, how to operate the touchscreen, as well as operation of other technology.

Lastly, during the act phase, I would work with instructors as they ran the scenario and evaluated the effectiveness. In addition, I would also evaluate whether the learner can understand the stimulation, that is, are they able to make connections in relation to the presented diagnosis, as well as develop adequate interventions that are safe for the patient.  In closing, implementing the PDSA framework within simulations in nursing practice aims to ensure that all staff are trained and feel confident using the simulator. In addition, the learners can engage fully in taking care of the patient in simulation and feel confident while providing care, making SIM nursing an educational and pleasant experience for all. 

                                References

Coury, J., Schneider, J. L., Rivelli, J. S., Petrik, A. F., Seibel, E., D’Agostini, B., Taplin, S. H., Green, B. B., & Coronado, G. D. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC health services research, 17(1), 411. https://doi.org/10.1186/s12913-017-2364-3

Koukourikos, K., Tsaloglidou, A., Kourkouta, L., Papathanasiou, I. V., Iliadis, C., Fratzana, A., & Panagiotou, A. (2021). Simulation in clinical nursing education. Acta Informatica Medica, 29(1), 15-20. https://doi.org/10.5455/aim.2021.29.15-20

ssue: The number of patients in the emergency department restrained increased during the fourth quarter of 2022.
Why is this an issue: Since the increase in restraint use, the number of injuries for medical staff and patients has increased by 27%.
Improvement Aim: By April 1, 2023, restraint use in the ED will decrease by 50%.
Measurement strategy: The number of injuries to medical staff and patients associated with using restraints will decrease during the second quarter by 50%.
Change idea for preventing injuries when restraining patients.	Questions/Predictions
All ED medical staff will undergo a ten-hour training on the proper procedures for restraining patients. This training will include avoiding injury for both medical staff and patients. It will also include using other strategies besides coercive means to calm agitated patients, including seeing the situation from the patient’s perspective (Wong et al., 2017). Medical staff will also learn to reflect on their biases to prevent disparities in restrained patients (Mubarak et al., 2022)	The training will need to occur every six months to maintain restrained patients at a low number.     Training will not prevent all injuries to medical staff and patients from occurring during the restraining process (Wong et al., 2020).   Medical staff will complain that because of the number of homeless and patients suffering from substance abuse/mental illness that comes to the ED, training will not reduce the number of patients that need restraining.
Plan, Do, Study & Act (PDSA)   Plan: ED medical staff will undergo five training sessions at two hours each concerning restraining a patient properly to avoid injuring both patient and staff. The training will also include how to use other strategies for agitated patients other than using restraint, how to identify a patient that needs restraining, how to use cultural competence to see a situation from the perspective of the patient, and how to reflect on their own bias to prevent disparities in restrained patients.   Do: Before restraining a patient, medical staff will apply their training until they have exhausted all viable solutions, making using restraints on the patient the last resort.   Study: Second quarter findings will be reviewed and discussed at a staff meeting. Discussion about changes in injury rates for patients and medical staff will ensue. Suggestions for improvement and follow-up recommendations will also be made.   Act: How will this project continue to be monitored? Are there other changes needed to reduce injuries caused by restraining patients?

References

Mubarak, E., Turner, V., Shuman, A. G., Firn, J., & Price, D. (2022). Promoting antiracist mental health crisis responses. AMA Journal of Ethics, 24(8), E788-794.

Wong, A. H., Ray, J. M., Rosenberg, A., Rosenberg, A., Crispino, L., Parker, J., McVaney, C., Lennaco, J. D., Bernstein, S. L., & Pavlo, A. J. (2020). Experiences of individuals who were physically restrained in the emergency department. JAMA Network Open, 3(1), e1919381. doi:10.1001/jamanetworkopen.2019.19381