Nurs 6600 walden university final portfolio nursing informatics

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Walden University – School of Nursing
Final Portfolio
NURS 6600 3 Capstone Synthesis Practicum – Nursing Informatics and Leadership &
Management
February 8, 2017
Michelle Muse
14413 Pinery Way
Midlothian, Virginia 23112
804-839-0908
michelle.muse@waldenu.edu
Registered Nurse
Virginia Commonwealth University Health System
Richmond, Virginia

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Table of Contents
Program of Study.............................................................................................................................3
Professional Development Plan (PDP) ……………………………………………………….5
CV or Résumé ………………………………………………………………………………..10
Portfolio Assignments from each of the following courses:
NURS 6001: …………………………………………………………………………………….. 5
NURS 6050: …………………………………………………………………………………….13
NURS 6051: ……………………………………………………………………………………..29
NURS 6052: ……………………………………………………………………………………..37
NURS 6053: ……………………………………………………………………………………..55
NURS 6401:...................................................................................................................................62
NURS 6411:...................................................................................................................................69
NURS 6421: ..................................................................................................................................93
NURS 6441: ................................................................................................................................125
NURS 6431:.................................................................................................................................148
NURS 6600 ………………………………………………………………………….181
End of Program Outcomes Evidence Chart .................................................................................205
Final Reflection………………………………………………………………………………..208

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Program of Study Form
Master of Science in Nursing, BSN Track
Based on the information that you provided, the following credits may be transferred into your program at Walden University.
This information is unofficial until all official transcript(s), international evaluation, and course description or syllabus is received.
Academic changes in the program you are considering may also influence the final review. For the most updated information
once you start your program, please refer to your degree audit located on your student portal.
Name: Michelle Muse Student ID Number: A00559450 Enrollment Date:12/01/2014
Program: Master of Science in Nursing Specialization: Nursing Informatics
Transfer of Credit Maximum: 25 Quarter Credits
Course
Number
Course Title Credi
t
Hour
s
Transfer Course /
Term to be Taken
CoreCourses
(21credits)
Core Courses: (All core courses must be completed before
starting the specialization courses.)
NURS 6001 Foundations of Graduate Study 1 Winter 2014
NURS 6050 Policy and Advocacy for Improving Population Health 5 Winter 2014
NURS 6051 Transforming Nursing and Healthcare Through Technology 5 Spring 2015
NURS 6052 Essentials of Evidence-Based Practice 5 Spring 2015
NURS 6053 Interprofessional Organizational and Systems Leadership 5 Summer 2015
SpecializationCourses
(30credits)
NURS 6401 Informatics in Nursing and Healthcare 5 Fall 2015
NURS 6411 Information and Knowledge Management 5 Winter 2015
NURS 6421 Supporting Workflow in Healthcare Systems 5 Spring 2016
NURS 6441 Project Management: Healthcare Information Technology 5 Summer 2016
NURS 6431 System Design, Planning and Evaluation 5 Fall 2016
NURS 6600C Capstone Synthesis Practicum 5 Winter 2016
Tentative focus for practicum experience: VCU Nursing
Informatics department.
Total Credits: 51
Transfer Courses
Course
Number Course Title Institution
Grad
e Credits

4
Official transcripts are required to award Transfer of Credit.

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Program of Study and the Professional Development Plan
Michelle Muse
Walden University
NURS 6001, Section 26490, Foundations of Graduate Study
January 8, 2015

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Program of Study and the Professional Development Plan
Continuing nursing education is essential to advance your career, even if it will still be at
the bedside. Finding a program of study, and making a plan to achieve those goals is the first step
the continuing education process. The purpose of this paper will introduce you to my personal
and professional goals, as well as my professional career and my plan of study while at Walden
University.
Education and Professional Background
My name is Michelle Muse, and I am going to give you a brief introduction to my
personal, educational, and career life. I am married to another nurse, and we have three children
together. I live in the suburbs of Richmond, VA, which is home to Virginia Commonwealth
University Health System (VCUHS). When I graduated from a diploma program at Southside
Regional Medical Center in 2003, I began working in this institution as a new graduate nurse in
their Surgery-Trauma ICU. I was fortunate to start working as a nurse in a large academic
medical center as this placed shaped my love for both formal and informal continuing education.
As a new graduate nurse I was thirsty for knowledge and soaked all that my preceptors gave me.
After attending numerous in-services, classes, and conferences during my first year as a nurse I
knew that I loved the continuing education and wanted to continue in a more formal manner to
obtain a Bachelor of Science in Nursing (BSN).
Virginia Commonwealth University (VCU) offered professional RN’s with a diploma
degree option of taking weekend classes once per month to achieve a BSN within 18 months.
When I started the program I was hesitant because I knew my writing skills were weak, as we
never had to write research papers in my diploma program. I had heard from other students that I

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worked with the papers were going to be difficult, and that I would be spending a fair amount of
the program writing. In fact the entire program was spent writing and doing research as opposed
to classroom didactics and tests. After sometime with a great deal of support from the VCU
writing center, my research and writing skills significantly improved. After finishing the
program, I decided to continue my focus on bedside career as I had moved to the Pediatric
Intensive Care Unit (PICU) at VCU. There was a large amount of information to learn in the new
environment as I felt like a new graduate nurse all over again. In the PICU is where I continued
to grow as a nurse, and found a love for pediatrics.
Professional Goals
The purpose of completing my Master’s degree is to give me an advanced education
degree that I can use to move forward in a career in nursing informatics. I feel that this is a
growing field, and will provide me with new challenges to learn. As I mentioned before I love
learning, and continuing my education at Walden is giving me a sense of satisfaction knowing
that I am expanding my knowledge base. My professional goals include becoming a stronger
writer using scholarly language, obtaining a graduate degree as an MSN, and advancing my
career working in the Nursing Informatics field. Earning my MSN will help me to achieve the
above goals by providing me an avenue to learn to become a better writer. I plan to utilize the
Walden writing center to help with the structure of my papers. Obtaining my MSN at the end of
the program will help me obtain my second goal, and for my last goal the education that I will be
provided in the program will prepare me to obtain a job in the nursing informatics field.
Course Outcomes

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Through this course I have been able to become accustomed to the online education
environment that Walden University offers. I have learned about how to format a paper in
American Psychological Association (APA) format, and learned that the writing center is there to
assist me with the APA structure and scholarly tone. I have also become familiar with the library,
and using the data bases to search for articles. The text that we used for this class has provided
me with information on how to make sure that I properly cite all of my sources in APA format
that I use to write my posts, and papers. Lastly, I have become familiar with the online learning
environment, and how to write my weekly posts for my classes.
Practicum
The practicum experience is one that will allow me to work with some in my desired field
of nursing informatics. This will give me some feel for putting into practice what I have learned
throughout the program. In the hospital where I currently work, we have a team of nursing
informaticists that work on our computer charting system. It is my hope when I get to the
practicum part of this program that I can work with someone in that department. I feel that this
will prepare me to work in my desired field when I am done with the program. This will give me
a sense of how nursing informatics is used to make the charting flow easier for the bedside nurse.
Summary
Working towards a Master’s of Science in Nursing will allow me to achieve my
professional goal of an advance degree. I plan to apply this degree in an academic setting to work
on charting systems, and to aid nurses with their daily work flow. Through this class I have
become more familiar with Walden University online program, blackboard, library, writing
center, and the use of APA format. I will expand on my experience as a student at Walden

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through the practicum experience. I am excited about the opportunity that is being provided to
me through Walden University.

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Michelle Hagen Muse, RN, BSN, CCRN
Clinical Nurse IV, Virginia Commonwealth University
14413 Pinery Way, Midlothian, VA 23112 Cell Phone: 804-839-0908
E-mail: michelle.muse@vcuhealth.org
ProfessionalSummary
Over 12 years of clinical nursing experience in the adult and pediatric population. Supplemental staff
nurse that floats to all pediatric units, and provides expert level nursing care.
ProfessionalExperience
Registered Nurse Supplemental Staffing for the Women’s and Children’s Division
September 2011-Present
Staff nurse that floats throughout the Women’s and Children’s Division at Virginia Commonwealth
University Able to provide nursing care to general floor, step-down, and intensive care patients. Patient
population includes 0-21, and postpartum females of all ages. Units include: Neonatal Intensive Care
Unit, Pediatric Intensive Care Unit, Pediatric Progressive Care Unit, Acute Care Pediatrics, Maternal
Postpartum/Newborn Nursery, Burn Care Center, Pediatric Hematology-Oncology Clinic, Pediatric
Emergency Department and Pediatric Dialysis.
Adjunct Clinical Instructor
Spring 2015-Present
J. Sargent Reynolds Community College School of Nursing
Responsible for a clinical group of eight nursing students while in their pediatric rotation. Provided clinical
guidance while working on the general care pediatric floor at Virginia Commonwealth University Health
System, and the students assumed care of 1-2 acute care pediatric patients each. I assisted the nursing
students in administering medications for pediatric patients, and completing nursing procedures such as
placing IV’s, Foley catheters, and nasogastric tubes. Provided education of the acutely ill pediatric patient.
Registered Nurse Endoscopy
August 2010-September 2011
Nursing care provided for adult and pediatric patients during procedural sedation for Endoscopy and
Colonoscopy procedures.
Nursing care included:
● Pre-Procedure assessments, and preparing patients for procedures.
● Monitoring patients during sedation, and administering sedation.
● Post procedure monitoring of patients during the recovery process from sedation and general
anesthesia.
Registered Nurse Pediatric Intensive Care Unit
January 2006-August 2010
● Nursing care for 1-2 critically ill pediatric patients birth-18.

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● Patient population includes medical, trauma, oncology, surgical, nephrology, cardiac surgery, and
neurology.
● Responsible for the training of new nurses in the unit during orientation process,
● Shift charge nurse responsible for nursing assignments, assigning patient beds, and general
function of the unit.
Registered Nurse Surgical Trauma Intensive Care Unit
January 2004-January 2006
● Nursing care for 1-2 critically ill adults
● Recover patients directly from the OR
● Actively resuscitated at the bedside.
● Advanced wound care provided for trauma/surgical patients
● Care of liver and kidney transplant patients, and use of anti-rejection and chemo medications.
● Care of intubated and trached patients on ventilators and oscillators.
Education
Walden University-Masters of Science in Nursing
December 2014-present
Expected graduation February 2017
Virginia Commonwealth University-Bachelors Degree of Science in Nursing
January 2005-December 2007
Southside Regional Medical Center School of Nursing
Registered Nurse Diploma Program
January 2002-December 2003
Specialized Training
● Basic Life Support
● Pediatric Advance Life Support
● Neonatal Resuscitation Provider
ProfessionalOrganizations
American Association of Critical Care Nurses (AACN)
ProfessionalActivities
● Member of the Professional Advancement Program at Virginia Commonwealth University Health
System that supports nurse’s professional growth within the organization
● Developed a Poster providing information on the current research for Pediatric Venous
Thromboembolism (VTE)
● Poster Presentation on Pediatric VTE at Week of the Nurse 2013
● Poster Presentation on Pediatric VTE at the Pediatric and Neonatal Critical Care Conference at

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VCU Fall 2013
● Poster Presentation on Pediatric VTE at the Mini Magnet Poster Presentations February 2014
● May of 2013 Presentation given on Pediatric VTE to Nursing Leadership forum
● Pediatric VTE research submitted as Supplemental Staffing’s Evidence Based Practice project
● Summer 2013 and 2014-prepared an education blitz for Dialysis to do their annual update
requirements in pediatrics. Worked with fellow pediatric supplemental nurse to develop an
education day that included speakers from different pediatric specialties such as child life to
present on services available, pediatric nephrology attending to present on their expectations for
the pediatric patients, and the chaplain to provide education on end of life care. Developed
presentations to educate staff on normal pediatric vital signs and developmental levels.
Certifications
Pediatric Certified Critical Care Registered Nurse since 2008
Awards
● Finalist for the March of Dimes Nurse of the Year 2014 and 2015
● Finalist for the Virginia Nurses Association Top 40 under 40 2015
CurrentProjects
● Completed Evidence Based Practice Internship program at VCU on Venous Thrombosis
Embolism Prevention in pediatrics, and currently involved in the scholar program.
● Working with a task force to implement prevention methods for venous thrombosis embolism for
the pediatric units.
[Title Here, up to 12 Words, on One to Two Lines]

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A Health Advocacy Campaign for Pediatric Obesity Epidemic
Michelle Muse, RN, BSN
Walden University
NURS 6050, Section 19, Policy and Advocacy for Population Health
February 8, 2015

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A Health Advocacy Campaign for Pediatric Obesity Epidemic
Pediatric obesity has become an epidemic in our society, in the last two decades the
prevalence has more than doubled (Krishnamoorthy, Hart, & Jelalian, 2006). Children are
increasingly less active today, and their free time increasingly filled with activities that keep
them inactive such as video games, and watching television (Krebs & Jacobson, 2003). Obesity
in childhood has a high correlation with obesity in adulthood which will lead to increased
medical costs for our society (Groner et al., 2009). Working as a pediatric nurse or provider, we
have a responsibility to recognize these health problems as an epidemic, and work to develop a
health advocacy program that will provide a framework for prevention. The purpose of this paper
will introduce you the issue of childhood obesity as a population health concern, explore
successful prevention programs, provide a framework for prevention by developing a health
advocacy program, and discuss ethical concerns related to implementing such a program.
Pediatric Obesity
Obesity is defined as someone that is grossly over their ideal body weight, typically by
more than 20 percent (What is obesity, 2015). Pediatricians plot children’s height and weight
measurements on growth charts, and this will track the child’s body mass index (BMI). Using the
growth charts allows physicians to identify trends that could indicate an issue with a child’s
growth and development, and serve as an early warning sign if the child is becoming overweight
(Krebs & Jacobson, 2003). In pediatrics, when a child is between the 85th and 95th percentile for
their BMI, they are considered at high risk for obesity. Once a child has hit the 95th percentile
for their BMI, that child is now considered obese (Krebs & Jacobson, 2003). Identifying children
before they hit the 95th percentile is important because education and early intervention will

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increase the likelihood of preventing complications related to obesity. Currently 31 % of 6-19
year-olds in the United States are considered to be at risk of becoming overweight because of
their BMI being at 85% or greater (Krishnamoorthy, Hart, & Jelalian, 2006) At a young age these
children are developing type II diabetes, cardiovascular insufficiency, heart problems, and
hypertension that were once seen as adult health issues (Krebs & Jacobson, 2003). These
startling statistics show that our society is in need of a change in order make sure our future
population is healthier with a lower rate of obesity. There has been some research already
completed on programs that can provide a framework of prevention that will give a guideline for
policy change.
Energize: An Elementary School Program
Energize is a program that was developed to bring diet and exercise information to 3rd
and 4th graders as an addition to their physical education (Herbert et al., 2013). Schools provide
an opportunity to reach children at a young, impressionable age to teach them healthy habits.
Energize provides education on nutritional food choices, and well as encouraging different types
of physical activity (Herbert et al., 2013). A study completed in southern Indiana compared the
students that went through the Energize program to a control group that received no formal
education. Each group completed health questionnaires to assess their knowledge that was
repeated at the end of 12 weeks. In addition to the health questionnaire, each group completed
diet/activity logs over a 12 week period to compare trends (Herbert et al., 2013). The goal was to
evaluate the effectiveness of the Energize program to see if it made a difference in what the
students ate and if it increased their activity levels (Herbert et al., 2013). The results showed that
the Energize group consumed fewer potato chips and french fries and had a slight increase in

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vegetable consumption over the control group. This shows that the program was successful in
diet education as the students were making healthier food choices (Herbert et al., 2013). In
regards to activity levels, neither group showed any significant difference (Herbert et al., 2013).
One reason for this may be related to age, but also the limited time that the program was
evaluated. This shows that starting with kids at a young school age will help to prevent obesity
down the road.
MOMS Project
The dietary habits of parents have the most influence on their children as children tend to
mimic the lifestyle of their parents. The idea behind the Making our Mealtimes Special (MOMS)
project was to provide support to new mothers during the first year of their child’s life through
anticipatory guidance (AG) by the child’s pediatrician (Groner et al., 2009). AG is defined as the
direction given by an expert, such as a pediatrician, to anticipate upcoming concerns
(anticipatory guidance, 2011). Well child visits provide an opportunity for education and
behavior modification support. This study evaluated the effectiveness of two new AG programs,
Mom focused eating (MFE) and Ounce of Prevention (OP) with the standard practice according
to the Bright Futures (BF) (Groner et al., 2009). For the MFE program, moms were given
nutritional advice and guidance at their child’s well visit in hopes to influence the parents eating
behaviors. Parents were reminded that children mimic how their parents eat (French et al., 2012).
The idea was to provide a better role model for the child to prevent obesity. It has been shown
that if the mother is overweight than the child is 3x more likely be obese (Groner et al., 2009).
The OP program is a nutritional education program that provides information on the types of
meals and serving sizes young children need during the first year of life. The program

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encouraged parents to allow their children to determine when they were done eating and not to
use food as a reward (French et al., 2012). This program provides more guidance than the
standard care program BF, which provides more general information to the practitioner, but
nothing concrete on meal sizes. This program encourages breastfeeding, and the introduction of
table foods (French et al., 2012). Through the study comparing both anticipatory guidance
programs (MFE and OP) it was shown that by 12 months of age these children had better eating
habits (French et al., 2012). Starting education with mothers when they have new babies gives
them an opportunity to change their habits to hopefully prevent obesity in their children (French
et al., 2012).
Policy for Pediatric Obesity
Given the growing concern about increasing obesity rates among children, there is a need
to establish an advocacy program that will prevent the trend from continuing. Combining the
attributes of the Energize program and the Anticipatory Guidance programs, prevention can be
within our grasp. The AG program outlined success in reaching the new mothers as they are
bringing their children in for well visits. Changing the mothers eating habits, and also
influencing what the children eat through the OP, will offer better choices for children down the
road in their eating habits. If the AG program continued to provide guidance at the pediatrician’s
office until school age, than hopefully the habits would hold firm through adulthood. Once at the
school age level, programs like Energize can continue to encourage healthy eating habits along
with increased activity levels. Energize found success as they were targeting an impressionable
population, and finding a fun way to teach the kids.
For a Pediatric advocacy program to be developed, key stakeholders would need to be

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identified. For a successful program, nurses and pediatricians would be the most beneficial in
ensuring that implemented policies would be a success. As stated by Sandra Hassink, MD (n.d.),
“Pediatricians are in the best position to combat childhood obesity because they are dedicated to
children's health and well-being, and build long-term, trusting relationships with families. They
are also trusted leaders and advocates in the community.” Nurses have a key interest as well in
health promotion and disease prevention as they are guided by the American Nurses Association
Code of Ethics that states “The nurse promotes, advocates for, and strives to protect the health,
safety and rights of the patient” (2012). After providing the stakeholders with the facts about
childhood obesity previously mentioned in this paper, the next step would be to gain the support
of policy makers.
The policy makers would need to see the successful programs that are already in place
that have made improvements to show them that prevention is the key. Programs like Energize
(Herbet et al., 2013) would need to be taken to a national level through policy change to
encourage education in the public school system. Reaching children nationally would provide
more benefit than just localized areas. In addition to implementing programs like Energize,
schools need to offer healthy food choices that would include the removal of junk food from the
environment (Krishnamoorthy, Hart, & Jelalian, 2006). This could be addressed in a public
policy requiring schools to remove the foods that are low in nutritional value, and this would
supplement the education being provided (Krishnamoorthy, Hart, & Jelalian, 2006). Pediatricians
have the opportunity to screen patients at well visits and identify those that are at risk for
becoming obese. Education can be completed at well child visits by pediatricians about nutrition,
but families with low incomes typically buy the food that has less nutritional value because it is

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cheaper. Policy makers would need to look at developing programs that could provide aid to
lower income families to supplement the cost of fresh fruits and vegetables (Krishnamoorthy,
Hart, & Jelalian, 2006).
Policy Proposal
Politics is the process by which a group of people come together to make decisions and
involves those who take the time to participate in the process (Milstead, 2013). As medical
professionals, nurses are known in the political world as the “ones that do not show up”.
(Milstead, 2013). In order to influence change in the area of pediatric obesity, nurses need to
make their presence known and to be involved. To influence a politician on making the required
changes, they need to be persuaded of the fact that obesity has become an epidemic amongst our
children. The persuasion process can be completed through lobbying, which is defined
individuals that represents a special interest group and are looked to as experts by lawmakers,
and providing that information to the lawmaker (Milstead, 2013).
For lobbying to be effective, it is important to understand the process that makes this
effective. According to Milstead (2013) there are three legs, or three successful parts of lobbying,
that will make the process of having an advocacy program implemented at the local, state and
national levels easier. The first leg, or the first part, to successful lobbying is to locate
professional lobbyists that have connections, represent special interest groups, and are viewed as
experts in the healthcare area to advocate for program initiation. Lawmakers depend on the
experts to identify an area that need to be changed, so without lobbying no laws would be made
(Milstead, 2013). The American Nurses Association (ANA) has funds they set aside to spend on
lobbying, so becoming a member of a professional organization is a great way to get involved as

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a nurse. Utilizing the ANA lobbyists to advocate the need for obesity educations programs in
schools to lawmakers would be a successful first step in implementing an advocacy program
(Milstead, 2013).
The second leg, or second part, to success would be to identify grassroots constituents
that can lobby by electing officials with their votes (Milstead, 2013). Constituents have
knowledge and/or expertise about particular issues. These constituents are highly influential as
lawmakers depend on them to by their eyes and ears in the public. Grassroots Lobbyist are
visible in the legislative area which is important to implementing new laws to make advocacy
programs work (Milstead, 2013). The ANA recognizes the importance of grassroots lobbying
efforts and utilizes them to make their connections at the local, state, and federal levels
(Milstead, 2013). To implement an advocacy program for pediatric obesity it is important to
locate grassroots lobbyist that are in support of programs being implemented in schools as they
will be the voice I need in the legislative area as their lawmaker contacts listen to them.
The final leg, or third part, to implementing a successful advocacy program is being able
to provide funds to support legislative candidates that are in support of obesity health advocacy
programs for pediatrics. The ANA and American Academy of Pediatrics (APA) would be a start
to gain a source of funds for support. Sadly, getting elected to office has become costly, so often
the officials that gain access to office have been supported by interest groups that are able
generate the large sums of money from their members (Milstead, 2013). Raising funds for
support would be one hurdle that I would need to overcome in order to have my program become
a success. With the ANA and APA support, this obstacle may be easier to overcome since there
has already been a significant amount of research completed in this area. Both professional

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organizations are already strong advocates to improve outcomes related to pediatric obesity.
Current Policy
The Child Nutrition and WIC Reauthorization Act of 2004 required all local educational
agencies to create a plan of wellness for the schools in their areas, this was further strengthened
by the Healthy, Hunger-Free Kids Act of 2010 (Local Schools, 2014). “A local school wellness
policy is a written document of official policies that guide a local educational agency (LEA) or
school district’s efforts to establish a school environment that promotes students’ health, well-
being, and ability to learn by supporting healthy eating and physical activity (School meals,
2014).” The contents of the wellness policy include nutrition promotion and education, physical
activity, and other activities that will promote student wellness (Local Schools, 2014). This
policy directly aligns with supporting what I would like to accomplish with my policy in the
schools. The hope would be in the years to come that the nutrition promotion would include the
marketing of healthy snacks in the schools, and that vending machines would only contain food
and snack that fit nutritional standards (Local Schools, 2014). Continual review of these policies
are required, and there is continual opportunity to improve them as more research is done on
what works with preventing pediatric obesity.
Screening for obesity in the schools is beneficial as well as screening at well-child visits
by physicians. Some states have taken action to screen children in the schools for BMI, and if
over 85th percentile the schools send home a private note to parents to inform them of their
child's health risks (Childhood Obesity Legislation, 2015). The letter also offers some
information on how to make healthy lifestyle changes to decrease the child's risk factors
(Childhood Obesity Legislation, 2015). This policy, along with continued screenings at well

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child visits will continue to bring more awareness to the issue.
Ethical Dilemmas
When creating new policy's to treat health issues, there is typically ethical dilemmas that
will come up that need to be addressed. An ethical dilemma is defined as a choice between two
options that would bring a negative result that would violate personal or societal guidelines
(Ethical dilemma, n.d.). Provision one of the ANA's nursing code of ethics states, "The nurse
practices with compassion and respect for inherent dignity, worth, and unique attributes of every
person (2015)." Part of this means to me respecting the child for who they are, but also have
compassion and respect for the parents that have made decisions for their child. We as nurses
should practice non-judgmental care, which means understanding that parents have a knowledge
deficit when it comes to nutrition. One major ethical dilemma in making policies regarding
childhood obesity is respecting the parents as the decision makers for their children, even if we
know what they are doing is causing harm (Perryman, 2011). Within certain limitations of the
law, parents are allowed to raise their children as they see fit, and this typically aligns with how
the adult lives their life (Perryman, 2011). Providing policies that give more education to the
parents would work around this ethical dilemma by allowing the parents to make choices based
on the education provided. The idea of the MOMS project targeted parent dietary habits, and
then gave anticipatory guidance to encourage those parents to raise their children with better
dietary choices (Groner et al., 2009). Using this method would avoid causing an ethical dilemma
by allowing the parents to continue making choices for their children, and these would now be
educated choices.
Another example of an ethical dilemma is expecting parents to be able to provide the

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nutritious foods on limited resources. Food is expensive, and when feeding a family fresh fruits,
veggies, and unprocessed meat the cost can be overbearing to a low-income family (Perryman,
2011). Even with education on how to make the right choices, these parents would be unable to
provide the right foods. Part of the process to combat this issue would be to expand state-run
programs to provide subsidies so families can afford healthier foods. This would include
expanding Women, Infants, and Children (WIC) programs at the state levels to provide monetary
supplementation to families in need. The WIC program provides nutrition supplementation to
women, infants and children during crucial stages of growth, and is supported by the Department
of Agriculture (WIC, 2014). Currently WIC limits their support up to the age five for children,
through my advocacy program that age could be expanded to 18 years (WIC, 2014). This would
provide nutrition supplementation throughout the entire growth process, and alleviate the ethical
issue of families not having the funds to provide those foods.
Ethics Laws
For my programs on the prevention of pediatric obesity, it is likely that I would start in
my home state of Virginia before expanding to the national level. Virginia is governed by several
ethics laws that help to prevent the external influences that fall outside the range bribery, but are
still questionable in nature (Rosenson, 2006). Ethics laws are created typically in response to a
public outcry related to an event that is seen as scandalous, and are used to appease the public
(Rosenson, 2006). Monetary gifts are one way a lobbyist try to persuade lawmakers to make
certain changes, even though this is considered unethical. All legislators in Virginia have to
report all donations or gifts that are $100 or more and give details about their expenditures so
that they can be tracked (Kidd & Baer, 2014). In order to hold elected officials accountable,

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Virginia has mandatory reporting laws on financial transactions, contributions received, and gifts
(Vozella, 2013). Currently, Virginia is known to have one of the most unrestricted gift laws in the
nation (Vozella, 2013). If gifts are given to immediate family members, those do not have to be
reported because they were not given directly to the politician (Vozella, 2013). Virginia does not
have a limit on gifts either, and their only requirement is that the gifts cannot be used to persuade
official action (Vozella, 2013). Keeping the gift law in mind while lobbying for my specific
issues on childhood obesity, I would have to be careful that any financial support given to the
politician is done legally and is used for its intended purpose.
Conclusion
This papers has brought awareness to the issues of pediatric obesity in our society as a
population health concern. Prevalence has doubled in the last two decades forcing us to take a
look at the contributing factors (Krebs & Jacobson, 2003). Effective advocacy programs have
shown they can reduce the incidence of this disease as evidence by the MOMs Project and the
school-based Energize program. Each of these programs reached children in different stages of
development to hopefully make a difference as the child grows up. In order to establish policy
change, nurses face challenges along the way. These challenges include making their voice heard
in the lawmaking arena as we are seen as “those that do not show up” (Milistead, 2013). In order
to get ourselves as nurses out there, we have to take a part in the political process, and this can
only be done once we understand that process. Along the way, there will be obstacles that we
will have to overcome, with some of those being ethical dilemmas. For a change to occur with
the issue of pediatric obesity, respect for the parents being able to make decisions for their child
will have to be preserved. The process of change will be a long road in regards to pediatric

25
obesity, but the results will be fruitful in the end.

26
References
American Nurses Association. (2012). Code of Ethics for Nurses. Retrieved from
http://nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses
Anticipatory guidance. (n.d.) Segen's Medical Dictionary. (2011). Retrieved February 3 2015
from http://medical-dictionary.thefreedictionary.com/anticipatory+guidance
Childhood Obesity Legislation - 2013 Update of Policy Options. (2015, January 1 Retrieved
February 6, 2015, from http://www.ncsl.org/research/health/childhood-obesity-legislation-
2013.aspx
Ethical dilemma. YourDictionary, n.d. Web. 6 February 2015.
<http://www.yourdictionary.com/ethical-dilemma>.
French, G. M., Nicholson, L., Skybo, T., Klein, E. G., Schwirian, P. M., Murray-Johnson, L., &
Groner, J. A. (2012). An evaluation of mother-centered anticipatory guidance to reduce
obesogenic infant feeding behaviors. Pediatrics, 130(3), e507-e517.
Groner, J. A., Skybo, T., Murray-Johnson, L., Schwirian, P., Eneli, I., Sternstein, A., & French,
G. (2009). Anticipatory guidance for prevention of childhood obesity: design of the
MOMS project. Clinical pediatrics.
Hassink, S. (n.d.). Institue for Healthy Childhood Weight. Retrieved February 5, 2015, from
http://ihcw.aap.org/Pages/default.a
Herbert, P. C., Lohrmann, D. K., Seo, D. C., Stright, A. D., & Kolbe, L. J. (2013). Effectiveness
of the Energize elementary school program to improve diet and exercise. Journal of
School Health, 83(11), 780-786.

27
Kidd, Q., & Baer, M. (2014, January 1). Virginia's Ethics Rules for Public Officals: The Need for
Reform. The Virginia News Letter, 1-7.
Krishnamoorthy, J. S., Hart, C., & Jelalian, E. (2006). The Epidemic of Childhood Obesity:
Review of Research and Implications for Public Policy. Social Policy Report. Volume 20,
Number 2. Society for Research in Child Development.
Krebs, N. F., & Jacobson, M. S. (2003). Prevention of pediatric overweight and obesity.
Pediatrics, 112(2), 424-430.
Local School Wellness Policy Implementation Under the Healthy, Hunger-Free Kids Act of
2010: Summary of the Proposed Rule. (2014, March 1). Retrieved February 5, 2015,
from http://healthymeals.nal.usda.gov/school-wellness-resources
Milstead, J. A. (2013). Health policy and politics: A nurse's guide (Laureate Education, Inc.,
custom ed.). Sudbury, MA: Jones and Bartlett Publishers.
Perryman, M. L. (2011). Peer Reviewed: Ethical Family Interventions for Childhood Obesity.
Preventing chronic disease, 8(5).
Rosenson, B. (2006). The Impact of Ethics Laws on Legislative Recruitment and the
Occupational Composition of State Legislatures. Political Research Quarterly, 619-627.
School Meals. (2014). Retrieved February 5, 2015, from http://www.fns.usda.gov/school-
meals/local-school-wellness-policy
What is Obesity? (2015, January 1). Retrieved February 8, 2015, from
http://www.utmbhealth.com/oth/Page.asp?PageID=OTH000778
Women, Infants, and Children (WIC). (2014, November 25). Retrieved February 8, 2015, from
http://www.vdh.virginia.gov/LHD/vabeach/clinic/wic.htm

28
Vozzella, L. (2013, April 28). Virginia Has One of Nation's Most Lax Ethics Laws for
Politicians. The Washington Post. Retrieved February 7, 2015, from
http://www.highbeam.com/doc/1P2-34580139.html?

29
Creating A Workflow Chart
Michelle Muse
Walden University
NURS 6051 Section 9
April 23, 2015

30
Workflow Chart
In order to evaluate practice to make necessary changes, a workflow analysis needs to be
completed. Workflow is defined as the execution of a series of tasks that take place in a
prescribed sequence (McGonigle & Mastrian, 2012). Through an analysis, the steps can be
optimized to ensure they are efficient and effective (McGonigle & Mastrian, 2012). Technology
has assisted in making workflows easier for nurses and doctors by making them more efficient.
The purpose of this paper will be to describe the workflow at Virginia Commonwealth
University Health System (VCUHS) of transferring a patient to the intensive care unit (ICU), and
then to explain the importance of being aware of workflow activity.
Moving a Patient to the Intensive Care Unit Workflow
Nurses at VCUHS are required by policy to round on their patients every hour to do what
is called purposeful rounding. This is when we make sure to address the 4 P’s which are pain,
potty, position, and possession. It is during this hourly check that we can assess if our patients
are stable. During this first step of our workflow, if it is assessed that the patient is stable our task
ends there until the next hour. If the patient does not appear stable, we can then pull the call bell
out of the wall to alert other staff though their Ascom phones that assistance in the patient’s
room is needed. The care partners will bring the Dinamap into the room so that a set of vitals can
be obtained. This information can be documented into our charting system by utilizing the
workstation on wheels (WOW’s). The computer charting system is able to calculate a Modified
Early Warning System (MEWS) score which is used to calculate a patient’s risk of becoming
critically ill based on physiological parameters (So et al., 2015). Once these tasks have been
completed, the nurse caring for the patient would notify the physician on if there is a concern that

31
a higher level of care may be required. To complete this step, the nurse can page from any WOW
by pulling up the hospital telepage website. Through the website, the nurse can look up the
physician’s pager number by typing in the physicians name and searching the contact. If the
patients seems to be unstable and needs assistance immediately, the nurse can call the Rapid
Response Team (RRT) by dialing *50 from any phone. The RRT would be the next step in the
workflow, as they are paged when the patient needs further assessment from critical care trained
personnel. The RRT members consists of a respiratory therapist, and a critical care nurse. Once
the RRT members arrive at the bedside, the nurse that is assigned to the patient gives them a
report of the current situation. Using the computerized medical record the nurse is able to give a
report of vitals and MEWS over the last 24 hours. The RRT members can offer suggestions to
the nurse or medical team to help stabilize the patient or call for additional resources such as an
intensive care unit (ICU) physician. The next step in the process starts when the ICU physician
arrives at the bedside to assess the situation. If the ICU physician determines that the patient
needs further assistance to be stabilized, he/she can decide to increase the patient’s level of care.
Typically, for a patient to be moved to the ICU, the order has to be placed into the computerized
medical record by the physician that is caring for the patient. This notifies the bed management
team that an ICU bed is needed for an unstable patient. The bed management team will use the
electronic bed board to determine which of the ten ICU’s at VCUHS has a bed for the patient.
There is typically one ICU that will keep a bed empty, this is known as the code bed. This allows
for a speedy bed assignment, and the transfer of an unstable patient. Once the patient has been
assigned an ICU bed, the nurse that is assigned to the patient on the current floor will call report
to the receiving nurse to hand off care. The report includes all the pertinent medical information,

32
recent vitals, events leading to hospitalization, and events leading to the transfer. While the nurse
calls report, the patient is placed on a transport monitor, and the necessary emergency equipment
is gathered to transport the patient to the ICU. The process ends when the nurse in the ICU
assumes care of the patient.
Metrics for Soundness of Workflow
To assess the use of calling an RRT when a patient becomes unstable, the RRT members
have a survey that is filled out by the staff that were caring for the patient. This helps the team to
identify if they were of assistance to the nurse, and if there was anything that the team could
have done better. In addition to the surveys, the RRT team has to collect chart data on the patient
to review the vitals and assessment info to see if they could have picked up the patient’s illness
any sooner. The MEWS scores are helpful, but it is not a perfect science. Lastly, the amount of
time it takes to transfer the patient is recorded through the bed management system from the time
the order is placed, until the patient is in the ICU.
Workflow Improvement
The workflow of transferring a patient to the ICU when it has been determined that the
patient has become unstable could improve some steps to make the process more efficient. The
process of evaluating the workflow is called optimization which occurs routinely in some
organizations or in response to clinician concerns (McGonigle & Mastrian, 2012). One of the first
issues with the workflow is calling the RRT, although this process is simplified by dialing *50
from any phone, the time it takes for the team to arrive needs to be streamlined. Typically the team
will arrive in 10 minutes which can seem like an eternity to a floor nurse that is not comfortable
with caring for an acutely or critically ill patient. It would be better if the response time was reduced

33
to about five minutes. In order to optimize this process, the RRT could be notified by pushing a
button on the wall similar to calling a code. In addition to this processes improvement, when the
alert goes out to the RRT, the patient’s physician should get a page as well. Currently it is the
nurse’s responsibility to notify the patient’s physician of the RRT call which is an extra phone call
that has to be made. The next recommendation to the process, is to improve the speed of the
transfer. If the patient’s nurse forgets to notify the physician that the patient is acutely ill, then this
will cause a delay in the order being placed to move the patient. To improve the flow, the bed
board could have an open bed that the patient could be transferred to without the physicians order.
This would be reserved for emergency situations only, and when the patient is unable to wait for
the orders to be placed.
Importance of Knowing the Flow
In order to successfully implement the steps in a process, it is important to know the
appropriate flow. There are two types of workflows, sequential and parallel (McGonigle &
Mastrian, 2012). In the sequential workflow each step is dependent on the previous step being
completed successfully. In the parallel workflow two or more steps can occur at the same time.
In order to understand what steps are involved to achieve the appropriate and most efficient
sequence, a process map is developed to give a visual display. This allows the steps to be listed
one by one, and then optimized when deficiencies are observed (McGonigle & Mastrian, 2012).
Without this process of knowing the individual steps, no improvements would be made and the
system would remain inefficient.
Conclusion

34
The workflow of moving an acutely ill patient to the ICU has multiple steps involved.
Once all the steps to assess the patient, and identify the increased level of care need by the RRT,
then the patient can be moved. To streamline this process placing a button at the head of the bed
would make it easier for the patients nurse to call for the team to come when they are needed.
Optimizing this process will make it safer for patients in the hospital, and make the process
easier for the nurse.

35
References
McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge
(Laureate Education, Inc., custom ed.). Burlington, MA: Jones and Bartlett Learning.
So, S. N., Ong, C. W., Wong, L. Y., Chung, J. Y., & Graham, C. A. (2015). Is the Modified
Early Warning Score able to enhance clinical observation to detect deteriorating patients
earlier in an Accident & Emergency Department?. Australasian Emergency Nursing
Journal.

36
Running head: CREATING A WORKFLOW CHART 1
Appendix
Br Hourly Rounding-Is
the patient stable?
Process is complete
Y
e
s
No
Call the Rapid
Response Team by
dialing *50
RRT arrives to the
bedside, Nurse
provides report
Additional backup
needed?
Y
e
s
No
RRT assist
nurse with
stabilizing the
patient
Call ICU
physician
ICU doctor determines
if patient needs to be
transferred to ICU
ICU Physician
assists RRT
with stabilizing
the patient
Y
e
s
No
Order placed to transfer
patient to ICU
Bed management
assigns patient a bed
Report is called
to nurse in ICU,
and patient is
transferred,
process is
complete

37
To Float or Not to Float: A Literature Review
Michelle Muse
Walden University
NURS 6052, Section 15, Essentials of Evidence-Based Practice
May 8, 2015

38
To Float or Not to Float?
Float pool nurses, also known as supplemental nurses at Virginia Commonwealth
University Health System (VCUHS), can be moved from unit to unit as often as every four
hours. In general this is a practice that just always been what VCUHS does, and not based on any
literature reviews. Spending four hours with a group of patients is not a long enough time period
to assess, implement, and document interventions that are required for quality patient care. It
becomes exhausting to move to three different units during a twelve hour shift, and attempting to
provide quality nursing care. This led me to wonder what the literature would say about how
long a nurse’s shift should be, and how often should a float pool nurse be moved? The literature
defines a float pool nurse as someone that is used to staff in response to the variability of patient
care demands (Dziuba-Ellis, 2006). By definition a float pool nurse is a body to fill a staffing
hole, but in reality the float pool nurse has to function at the same level as the nurses who work
on that floor every day. Stepping into an unfamiliar environment is stressful for a nurse, as
he/she is unfamiliar with the work flow, organization of the unit, and location of necessary
supplies. The purpose of this paper will be to take a look at what the literature states regarding
float pool nursing, effect on quality of patient care, and what is the ideal amount of time a nurse
should be spending on a particular unit, and to provide a recommendation for a practice change.
Developing a Research Question
In order to determine a research topic, ideas need to be generated on areas of interest. In
the early stages, ideas can be generated by asking questions about areas of interest to narrow the
topic (Ploit & Beck, 2012). To arrive at my topic, I started by polling nurses that I worked with

39
for various “questions” that they desired an answer to. A few of the ideas that I was given was to
look at was if ventriculostomy sites should be covered with a dressing or left open to air. A
second idea given was to address concerns about when to change IV fluids, as the current
practice is to change bags 24 hours and lines every 96 hours. A third question offered was to
look at nursing satisfaction when floating to different units, and this question led me to my
research project. As I reflected on this problem, I realized that it was more than just nursing
satisfaction, but also patient satisfaction. As a patient I would want the same face throughout the
day/night so that they could get to know me. Switching a nurse out after four hours can lead to
errors in patient care, and possible missed orders. The quality of care would diminish as the
nurse has to rush through assessing his/her patients, chart, and give report to head to the next
unit.
To take a closer look at nursing satisfaction and patient quality when floating, I
brainstormed questions related to this idea. The following five questions helped me to identify a
research question that is significant, researchable, and feasible (Ploit & Beck, 2012).
1. What are the consequences of moving a nurse from her patients after 4 hours?
2. What factors would increase patient satisfaction with their nursing care?
3. What is the nurse’s satisfaction with her job with moving units every 4 hours?
4. Is there increase in errors with a nurse working shorter shifts?
5. When handoff is rushed, what is missed when passing off the patient?
In order to research a question, there are several considerations to take into account to determine
if it is a feasible project. These include the amount of time required for the study, availability of

40
study participants, cooperation of prospective participants, available facilities and equipment,
cost, researcher experience, and any ethical considerations (Ploit & Beck, 2012). Researching the
satisfaction of nurses floating would be a relatively easy project. As a research study this could
be done by doing a literature search to compare the information already researched on this topic.
The cost for this type of project would be low, and would not require a huge participation from
others. As a researcher this could be done from home making the facilities free. There is minimal
ethical considerations as this would not place unethical demands on participation (Ploit & Beck,
2012).
Development of a PICOT Question
In order to develop a well worded question, it is important to identify all the components
of the acronym PICOT which stands for population (P), intervention or issue (I), comparison of
interest (C), outcome (O), and time (T) (Ploit & Beck, 2012). For the purpose of this project I
have identified the population as the patients as their care is directly affected by how often their
nurse changes throughout the day. The intervention to improve quality patient care would be
allowing the float nurse to remain on the unit they started their shift on instead of moving them
to a new area every four hours. The comparison would be continuing current practice and
moving the nurse every four hours to the units that have holes in their staffing. The outcome
would be the quality of patient care as identified by the literature and later research. For the
purpose of my question the time would not be a factor as there is no defined time period for the
intervention to be completed (Ploit & Beck, 2012). My PICOT question when formulated is: For
patients what is the effect of having their nurse remain on one unit for the duration of their shift

41
in comparison to reassigning that nurse in four hour increments on the quality of patient care?
With the PICOT question is identified, a literature search through scholarly articles can be
commenced.
Literature Search
In order to conduct an effective literature search, keywords need to be identified that can be
used to search the databases. To identify keywords that can be used in the search I reviewed my
PICOT question and my background questions. Key words identified were: reassignment, float
nurses, supplemental nurses, supplemental pool, float pool, shift work, continuity of care, handoff,
quality of care, staffing patterns, work shift duration, and patient satisfaction.
Literature Summary
Kaisch, Begeny, and Anderson (2012) completed a study on the effects of having nurses
on different shift schedules on the quality of patient care, and sense of teamwork within a unit.
As a longitundinal study, a focus group was utilized to interview the nurses pre-intervention, and
post intervention. The nurses and assistive staff identified that having some nurses work 8 hours
shifts vs 12 hour shifts made it difficult to give patients consitient, quality care. The result of
schedules that were not the same left the unit in utter confusion during change over, and the
patients with multipe different nurses during the day. To intervene, the nurses were changed so
that everyone was working a 12 hour shift. This was a challenge at first because several of the
nurses were resistant to the change, but once they were given the results of the focus group they
seemed more willing to make knowing it would benefit patients. After 4 months of everyone
working the 12 hour shifts, the focus group revealed a better sense of teamwork and continutity

42
of care. One nurse is quoted saying “‘We keep the same patients now. I report off to the same
nurse who comes back in 12 hours and I receive report from that same nurse.’’
Larson et al. (2012) completed a comparative study of the work load of a float pool nurse
versus a staff nurse on a unit. To conduct the research, shifts with float nurses working were
randomly chosen, and the researchers rounded on the units that the nurses were working on for
that shift. Data was collected about the float pool nurses assignments and the unit staff nurses
assignments. The assignment difficulty of the float nurse and unit nurse was gaged by three
variables that inlcuded patient volume (how many patients the nurse was caring for), patient flow
(admissions, transfers, and discharges) for the nurse, and acuity of patient condition (determined
by the hospital acuity tool). The statistical analysis of the data revealed that the float nurse’s
patient difficulty load was slightly higher than unit nurses.
In the Pediatric Intensive Care Unit (PICU) at Boston Children’s Hospital completed a
study on continuity in nursing care (CINC) as a patient-centered model of care and the effect on
patient outcomes. CINC is defined as the number of different nurses that are assigned to care for
a patient (Siow, Wypij, & Berry, 2013). A secondary analysis of data that was obtained from the
institutions databases to review patient outcomes that included length of stay (LOS), duration of
mechanical intervention, adverse events, and ICU acquired infections. These outcomes were
compared to the Continuity of Care Index (CCI) that ranged from 0 (different nurses care for a
single patient every shift) to 1(the same nurse care for the patient) to calculate the CINC for the
patients identified in the study. The study by Siow et al. (2013) concluded that CINC was not
significantly associated with preventing adverse events which contraindicates that a better CINC
would lead to better patient outcomes. The study may have been limited by reviewing the

43
databases as they were not created to review the relationship of CINC and patient outcomes.
Scott et al. (2006) studied the hours nurses spent at work and its effect on patient safety
through a random sample of critical care nurses in the United States. Nurses in the study
completed a logbook over a 14 day period that was used to record the number of hours worked,
time of day worked, over time hours, days off, and sleep-wake patterns. On work days the nurses
completed a questionnaire about their shift and ability to stay awake while on duty. There was
space in the logbooks to identify any patient errors or near errors that may have occurred during
the work hours. The study identified that approximately 65% of the nurses reported they
struggled to stay awake at some point during their shift. Approximately 27% of the nurses
identified they made at least 1 error, and about 38% reported making at least 1 near error. The
longer the shift the nurse worked, the more likely he/she was to make an error or a near error.
Estabrooks et al. (2009) completed a systematic review on the shift length on the quality
of patient care. The review identified that the longer the shift, the more potential there is for a
negative impact on quality patient care and safety. Errors were made towards the end of the day
when the nurse become tired. On the other hand, the review also found that the 12 hours shift is
beneficial to patients, as nurses provide better patient care due to the fact they were with the
patient the entire day. The review concluded that additional research would need to be
conducted in order to determine which correlation is more accurate.
Literature Synthesis
The literature search revealed there is a correlation on the length of a nurse’s shift,
continuity of patient care, and the effect that it has on the quality of patient care. In the study by
Kaisch, Begeny, and Anderson (2012) it was identified by the staff that having nurses on

44
different schedules disrupted the flow of the unit and the quality of patient care. Larson et al.
(2012) identified that float nurse tend to have more difficult assignements. Scott et al. (2006)
found the longer the nurse’s shift, the more likely there are errors that could be made as nurses
get tired. My literature search revealed a few inconsistencies which made this PICOT question
difficult to answer. One article by Kaisch, Begeny, and Anderson (2012) found that having the
same nurse for a 12 hour shift made the teamwork and the work flow of the unit easier. However,
Estabrooks et al. (2009) identified through the sytemeatic review that the 12 hour shift is a
problem area, and a potential negative impact on patient care. The reason for the inconsistencies
could be contributed to the lack of research in the area of what the effect of the shift duration is
on the quality of patient care. The lack of research was identified as in issue in the systematic
review by Estabrooks et al. (2009), as well through my own literature search.
PICOT Question
The purpose of my project was to review the literature to identify what the literature
states is the best practice in concerning the moving of a float pool nurse every four hours. My
PICOT question is: For patients what is the effect of having their nurse remain on one unit for
the duration of their shift in comparison to reassigning that nurse in four hour increments on the
quality of patient care? To answer this question I conducted a literature review by searching
several databases such as the Cumulative Index to Nursing and Allied Health Literature
(CINAHL), Cochrane Library, Pub Med, and Joanna Briggs. I utilized several keywords to help
me narrow my search, and identified five articles that were relevant to my question. From the
five articles described in my literature review, two provided evidence that nurses working 12
hour shifts tended to make more errors, and feel sleepy at least one time during their shift. This

45
would lead the researcher to believe that moving a nurse, especially every four hours, would lead
to increased errors the longer the nurse shift is.
Nursing Practice Change Supported By Evidence
Estabrooks et al. (2009) completed a systematic review of the literature to determine the
length of a nurse’s shift and its effect on quality patient care. Shift work was defined in the
article as work patterns that extend beyond the conventional 8 hour work day. For most nursing
units this means dividing the 24 hour day in two 12 hour shifts or three 8 hour shifts. In the
healthcare world there is the responsibility of human life where the decisions made can impact
the patient’s future. It is important for the nurse that is participating in the assessments and
decision making to be alert, and making sound decisions. Numerous studies have reviewed the
effect of shiftwork on the quality of patient care. According to Estabrooks et al. (2009) review
there were 12 studies that were included, with two of the studies identifying the relationship
between shift length and the number of errors made. One article identified that the nurse was 3.5
times more likely to make errors when working a 12.5 hour shift or longer. Similarly, a second
article identified that the nurse was 2 times more likely to make an error when working a 12.5
hour shift. According to this review, the best practice for nurse may be working shifts that are
shorter in length to avoid the burnout at the end of the day. For the float pool nurse, this literature
review finds evidence that it may not be best to move the nurse every four hours, especially the
last 4 hours of their day when the nurse is most tired.
Scott et al. (2006) completed a research study to determine the effects of long work hours
on the performance of healthcare providers. The research study completed a random sample of
critical care nurses to complete logbooks that collected information about the hours worked, time

46
of day worked, overtime hours, days off, and sleep-wake patterns for a 28 day period. Through
the data analysis, the outcomes were analyzed as errors made during the work shift vs no errors
made during the work shift. The majority of the nurses included in the study worked 12 hours
shifts, and all of the respondents worked full time hours. Interestingly, 86% of the shifts reported
in the study were longer than what the nurse was scheduled for as some of the nurses were
identified they were coerced into voluntary overtime. Two-thirds of the nurses identified they
struggled to stay awake during some point of their work shift, and 20% admitted to falling asleep
at least once during their work shift. Making at least one error during the shift occurred for at
least 27% of the nurses, with 38% identifying that they almost made an error. Most of the errors,
or near errors that were identified many of the involved medication administration. The longer
the shift, the error or near error rate increased. The risk for making an error nearly doubled when
the nurses worked 12.5 consecutive hours. The data also noted nurse’s risk of falling asleep at
work doubled when they worked shifts that exceeded 8 hours. Overall the results of this study
reinforced that nurses should not work long hours. When moving a nurse during their shift, their
ability to avoid errors is compounded with the fact that they are unable to form a relationship
with the patients they are assigned to. When moving a nurse every four hours, their interactions
with the patients become limited.
Using the Evidence
After reviewing the literature and the evidence presented, the literature supports that
nurses tend to make more mistakes when working longer hours. At VCUHS, float pool nurses
typically work 12 hour shifts per the guidelines given them when they sign on to work for the
supplemental pool. During the typical 12 hour day, the nurse can be moved up to three different

47
times. According to the evidence working long hours is not necessarily safe. One could assume
based on the literature that during the last four hours of the shift, the nurse is at her most
vulnerable to make errors. VCUHS has identified that one of their goals is to obtain zero events
of preventable harm. Safety first is a strong culture throughout the health system and encouraged
by leadership. During the course of a supplemental nurse’s shift there is a possibility of 15-20
different patient contacts within a 12 hour period if that nurse is moved every four hours. In
order to prevent the possibility of errors, leaving a nurse on one unit for the duration of their shift
would provide the best conditions to allow that nurse to prevent errors. Typically when staying
on the same unit the nurse will have the same group of patients for the entire 12 hours. This
allows the nurse to form relationships, and decreases the possibility of confusing the assignment
with a previous assignment.
Dissemination of the Evidence
In order to communicate the information found in the literature review, a meeting with
the supplemental leaders would be where I would start. Consolidating all the findings into an
evidence based practice poster will put the information into an easy read format that the leaders
would be able to read. This poster can also be presented at various poster presentations, such as
conferences, to get the information out to other nurses throughout the hospital and the
community. Writing a journal article based on my literature search would broaden the audience,
and get the information out to a more global so that hopefully other hospitals could benefit from
the research. In order to change practice at VCUHS, I would have to get buy in from my
leadership team and have a champion to aid me on the journey that has more experience in
practice change. Currently the supplemental pool’s nurse manager is on board with nurses only

48
being moved twice in one 12 our shift as opposed to every four hours. With the supplemental
leadership support, the information could be presented to the nursing director and chief nursing
officer. With executive leadership teams support, the practice of having the supplemental nurse
only moved twice could be trialed to see if it improved safety in our institution.
With any practice change there tends to be pushback from those that do not want change
to occur. In my case the pushback would come from the units that the supplemental nurses work
on as they benefit from the float pool nurses moving every four hours. When the units do their
schedule, there are holes left that are undesirable shifts for the unit’s nurses to work. Often these
small blocks of times are what cause the frequent shifting of the supplemental nurse. In order for
the change to work, the units have to be willing to keep the nurse for more than a four hour
period which may affect budgeting and staffing. In order to address the pushback, the units
would need to be provided education on the need for the practice change through in-services.
The nurse managers for each unit would need to have a presentation on what the literature
provides as the best evidence to prevent medical errors. With education, I believe pushback
would be reduced to acceptance of the practice change.
Summary
Research questions need to be feasible for a study, and narrowed down by identifying
topics that are relevant to the question. To conduct a literature search it is important to identify
the key words that will locate the information in the journal databases that will be relevant to the
question. In order to develop a research question, it needs to meet all parts of the PICOT
acronym. After all the parts are identified, and the PICOT question is stated, a literature search
can commence. Nurses that work in a float pool are moved as often as every 4 hours, and this

49
makes it difficult for them to provide quality patient care or develop patient relationships. The
literature revealed that the longer a nurse works, the less observant he/she is and has the potential
to make errors. Therefore, moving the nurse during the last part of their shift could potentially
have detremential effects on patient care as the nurse is at the most tired point of their day. The
study in the Boston PICU determined that patients that had more continuity in care did not show
any decrease in adverse events (Siow, Wypij, & Berry, 2013). From the literature search no
direct conclusion was found as to what is the best practice in how often a float pool nurse should
be moved. Minimal research has been done on the length of a nurses shift and its effect on
patient care as concluded as an issue in the systematic review by Estabrooks et al. (2009).
Overall, the best practice for a supplemental nurse to contribute to patient safety would include
reducing the number of time the nurse is required to move from unit to unit. Recognizing that the
literature provides evidence to state that the longer a nurse works the more likely he/she is to
make errors. In order to enhance patient safety, and foster an enviroment of patient safety it is
necessary to support that supplemental nurses should not move every four hours. By working
with leadership on the unit level to gain support, the practice change can begin to occur.
Developing a poster would provide the leadership with the ability to review what the evidence
recommends, and then support the change. The process of change will take awhile as the hospital
has been utilizing the ability to move nurses every 4 hours to help accommodate staffing.
Overcoming the pushback with be easier once all the units are educated on the importances of
allowing the supplemental nurse to remain one unit for the duration of their shift.

50
Reference
Dziuba-Ellis, J. (2006). Float pools and resource teams: a review of the literature. Journal Of
Nursing Care Quality, 21(4), 352-359.
Estabrooks, C. A., Cummings, G. G., Olivo, S. A., Squires, J. E., Giblin, C., & Simpson, N.
(2009). Effects of shift length on quality of patient care and health provider outcomes:
systematic review. Quality and Safety in Health Care, 18(3), 181-188.
Kalisch, B. J., Begeny, S., & Anderson, C. (2008). The effect of consistent nursing shifts on
teamwork and continuity of care. Journal of Nursing Administration, 38(3), 132-137.
Larson, N., Sendelbach, S., Missal, B., Fliss, J., & Gaillard, P. (2012). Staffing patterns of
scheduled unit staff nurses vs. float pool nurses: A pilot study. Medsurg Nursing, 21(1),
27-32.
Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for
nursing practice (Laureate Education, Inc., custom ed.). Philadelphia, PA: Lippincott
Williams & Wilkins.
Scott, L. D., Rogers, A. E., Hwang, W. T., & Zhang, Y. (2006). Effects of critical care nurses’
work hours on vigilance and patients’ safety. American Journal of Critical Care, 15(1),
30-37.

51
Siow, E., Wypij, D., Berry, P., Hickey, P., & Curley, M. A. (2013). The effect of continuity in
nursing care on patient outcomes in the pediatric intensive care unit. Journal of Nursing
Administration, 43(7/8), 394-402.
Walden University Library. (2012). Levels of evidence. Retrieved from
http://libraryguides.waldenu.edu/evidencepyramid

52
Appendix
Literature Review
Citation Type of
Study
Design Type
Framework/
Theory
Setting Key Concepts/
Variables
Findings Hierarchy
of Evidence
Level
Estabrooks, C. A., Cummings,
G. G., Olivo, S. A.,
Squires, J. E., Giblin,
C., & Simpson, N.
(2009). Effects of shift
length on quality of
patient care and health
provider outcomes:
systematic review.
Quality and Safety in
Health Care, 18(3),
181-188.
Type of
Study:
Systematic
Review
Design Type:
Framework/
Theory:
Hospital
Units
Concepts:
Shift length
Quality of
Patient Care
Healthcare
provider
outcomes
Independent
Variable:
Shift Length
Dependent
Variable:
Quality of
patient
care/healthcare
provider
outcomes
Controlled
Variable:
Long hours have the
potential to have a negative
impact on quality patient
care and safety. Errors
during med administration
and procedures have been
documented in relation to
the 12 hour shift.
Findings from the review
also determined that the 12
hours provided better
patient care.
There is insufficient
evidence to conclude shift
length has an impact on
patient care outcomes.
Level 1
Systematic
review of
RCT’s,
nonrandomize
d trial,
clinical trials,
and
observational
studies
Kalisch, B. J., Begeny, S., &
Anderson, C. (2008).
The effect of
consistent nursing
shifts on teamwork
and continuity of care.
Journal of Nursing
Administration, 38(3),
132-137.
Type of
Study:
Quantitative
Survey Focus
Group
Design Type:
Before and
After
Framework/
Theory:
210 Bed
Communit
y Hospital
Concepts:
Teamwork
Continuity of
patient care
Independent
Variable:
Duration of
Nursing Shift
Dependent
Variable:
After implementation of 12
hour shifts, a focus groups
found that continuity of
patient care and teamwork
was better. There was less
confusion during the shift.
Level IV
Observational
Study

53
Nursing Job
satisfaction,
Team work,
quality of
patient care
Controlled
Variable:
Changing all
staff members
to 12 hour shifts
Larson, N., Sendelbach, S.,
Missal, B., Fliss, J., &
Gaillard, P. (2012).
Staffing patterns of
scheduled unit staff
nurses vs. float pool
nurses: A pilot study.
Medsurg Nursing,
21(1), 27-32.
Type of
Study:
Quantitative
Design Type:
Observationa
l
Framework/
Theory:
Medical-
Surgical,
Cardio-
vascular,
neurology,
and
orthopedic
inpatient
unit’s
communit
y hospital.
Concepts:
Staffing
Patterns
Difficulty of
Patient
assignments
Independent
Variable:
Float Nursing
Dependent
Variable:
Difficulty of
patient
assignments
Controlled
Variable:
Through statistical analysis
of the data it was found that
float nurses tended to get
slightly more difficulty
assignments.
Level 4
Observational
Studies
Scott, L. D., Rogers, A. E.,
Hwang, W. T., &
Zhang, Y. (2006).
Effects of critical care
nurses’ work hours on
vigilance and patients’
safety. American
Journal of Critical
Care, 15(1), 30-37.
Type of
Study:
Quantitative
Design Type:
Survey
Framework/
Theory:
Critical
Care
Nurses
Concepts:
Shift length
Quality of
Patient Care
Independent
Variable:
Shift length
Dependent
Variable:
Occurrence of
Extended work shifts are
associated with significantly
decreased levels of
alertness.
Level 4
Observational
study

54
errors, adverse
effects on nurse
alertness
Controlled
Variable:
Siow, E., Wypij, D., Berry, P.,
Hickey, P., & Curley,
M. A. (2013). The
effect of continuity in
nursing care on patient
outcomes in the
pediatric intensive
care unit. Journal of
Nursing
Administration,
43(7/8), 394-402.
Type of
Study:
Quantitative
Case
Controlled
Design Type:
Retrospectiv
e
Framework/
Theory:
Pediatric
Intensive
Care Unit
Concepts:
Continuity in
Nursing care
Patient
outcomes
Quality of
patient care
Independent
Variable:
Age
Gender
Mortality risk
Diagnosis on
admission
Type of
admission
Type of patient
Dependent
Variable:
Intensive Care
Unit length of
stay
Duration of
mechanical
ventilation
Controlled
Variable:
CINC was not significantly
associated with preventing
adverse events which
contraindicates that a better
CINC would lead to better
patient outcomes. The study
may have been limited by
reviewing the databases as
they were not created to
review the relationship of
CINC and patient outcomes.
Level 4

55
Planned Change for a Workflow
Michelle Muse
NURS 6053 Section 13
Walden University
July 3, 2015

56
Planned Change for a Pediatric Hematology/Oncology Clinic
As a supplemental nurse at Virginia Commonwealth University Health System (VCUHS)
I work all over the hospital, filling in where there are nursing holes in staffing. The benefit of my
job is that I get to see how different units run, which gives me insight to inefficacies in the unit
workflow. Workflows is the process of going from point A, to point B, and then to point C to
complete a task (Laureate Education, 2012c). One of the units that I work on is the pediatric
hematology/oncology (heme/onc) clinic. The unit is located in an older part of the hospital that
was created before we had tube systems. The tube systems allows nurses to send and receive
medications from pharmacy, send and receive items from other units, and send blood samples to
the lab. This allows the nurse to save time on running around, giving them more time to focus on
the patient which improves workflow. In the pediatric heme/onc clinic, nurses have to walk to
pharmacy to get medications, walk to other units to pick up needed items, and walk to send
blood work to the lab since there is no tube system. This creates time away from the patients, and
an increased workload for the nurse. The purpose of this paper is to review the pediatric
heme/onc workflow, and to make a recommendation for change to improve this process using a
change theory model.
Workflow Problem
In the pediatric heme/onc clinic patients have to get their labs drawn prior to
chemotherapy treatment to determine if their bodies can handle treatment. Patients have to meet
certain blood count levels, which makes treatment dependent obtaining the patient’s blood work,
and results in a timely manner. During a busy clinic day, there could be 8-10 kids that come in
for morning labs prior to treatment. For each lab draw, the nurse has to walk down two flights of

57
steps to send it in the tube station located in a different part of the hospital. This process takes
10-15 minutes of time away from the patients. The time out of the clinic over the course of the
day results in patients waiting for longer periods. Once we have the lab results and know the
patient can receive their chemotherapy we fax the orders to the pharmacy. The pharmacy will
call the clinic to let us know when the medication is ready. The nurse has to leave the clinic and
take a 5-10 minute walk to the other side of the hospital to pick up the chemotherapy. This
process is timely, and again causes a disruption in the workflow for the nurse which increases the
patient wait time.
Proposed Change
To improve the process a planned change needs to occur as it will be well thought out,
and utilizes knowledge to make the process easier for the nurses in the pediatric heme/onc clinic
(Marquis & Huston, 2012). Ideally, it would be easiest if the clinic could be moved to a newer
part of the hospital where a tube system was already in place. The best location for the clinic
would be close to the chemotherapy pharmacy to shorten the distance the nurse would have to
walk to pick up medications. However, this change would be costly, and difficult to obtain.
Therefore, a simpler solution to this issue would be to hire an unlicensed assistant personal
(UAP) that would work in the clinic full time. UAP’s presence in the hospital and clinic’s to
perform tasks that are delegated to them by the professional nurse has been increasing due to the
nursing shortage (Marshall, 2006). This labor is cheaper, and it provides the nurse another pair of
hand to complete daily tasks (Marshall, 2006). For the pediatric heme/onc clinic the UAP’s only
job would be to run the labs down to the tube station, and to pick up the chemotherapy
medications. With one person having this as their job this would free the nurses from having to

58
make those runs. The nurses would be available in the clinic to make flow of the day run better,
and the work flow process would be improved. This change would align with VCUHS’s mission
and vision statement that the hospital is committed to providing excellence in patient care and
fostering the contributions of all members of the team in the care of patients
(Mission/Vision/Values, 2015). The values of VCUHS include providing exceptional service by
putting the needs of the patient first. Often families are frustrated with the lengthy waiting times
in the clinic. Satisfied patients and families make for a better overall healthcare experience.
A Model for Change
The five step Stages of Change Model (SCM) model provides a guideline on how to
incorporate this new position in the pediatric heme/onc clinic, and justify the hiring of this new
employee. SCM’s five stages include precontemplation, contemplation, preparation, action, and
maintenance (Marquis & Huston, 2012). Since this model breaks it down into individual steps, it
makes the appearance of the change easier to obtain. During the first stage, precontemplation, the
clinic would continue to practice as usual because there is no intention to make a change
(Marquis & Huston, 2012). In the second a stage, contemplation, an individual in the unit would
identify the need for change and establish themselves as the change agent (Marquis & Huston,
2012). To complete this stage, the nurse could complete a literature review of how other clinics
run and the benefits of using a UAP. This information could be presented to the unit manager
along with the current work system and how it is inefficient. In the third stage, preparation, the
individual would start making plans to implement the change (Marquis & Huston, 2012). This
would include posting the job on the human resources website. Then the manager would conduct
interviews of potential candidates, selecting an individual. Once the person is hired, then he/she

59
will need to be trained and the unit will need to figure out how to best utilize the individual to
optimize their work flow. In the fourth stage, action, the new employee has learned their position
and the staff has modified their behavior to adapt to this change (Marquis & Huston, 2012). This
is a great time to reflect on how this new employee is fitting in, and if the position has improved
the workload for the nurses. With feedback, roles changes can be made so that the job give the
maximum benefit to the workflows. Lastly, in the fifth stage, maintenance, the new employee
has acclimated to the job and has become a functional part of the unit. The nurses in the unit see
this individual as asset to making the day run smoother. The job role for the UAP has been well
defined, and everyone has accumulated to the change.
The Change Process
“An impassioned champion is an essential ingredient in all models of change”
(Schifalacqua, Costello, & Denman, 2009). The champion for change, also known as the change
agent, would have to be one of the staff nurses. After the nurse has carefully identified the need
for the UAP, then the manager would need to be convinced that the new position should be
created. The manager is the one that works with the unit’s budget, and can determine if this
would fiscally possible. The nurse manager is the middleman between the senior leadership and
the nursing staff, and they are responsible for communicating the needs of the staff (Witges &
Scanlan, 2014). It would be the nurse manager’s job to communicate with senior leadership
about how creating this new position will alleviate the strain on staff, and improve care for the
patients. In addition to communication with senior leadership, the nurse manager ensures that the
unit meets the institutions mission and values. Once the position is open for applications, the
nurse manager and staff on the unit would need to form a committee to interview the candidates

60
to determine who would be the best fit for the unit. Once the UAP was hired, the nurse manager
would continue to assume the responsibility of managing the positions duties and it how it will
best fit the clinic.
In order to ensure a successful change, the change agent needs to have great
communication skills. Maintaining communication with everyone affected by the change will be
essential as all changes disrupt the homeostasis or balance of the group (Marquis & Huston,
2012). A smooth transition can be made by communicating to the members of the clinic when to
expect the new employee, and educating what the UAP’s role will be. The leader needs to ensure
communication with the management team to give feedback on how the change is affecting the
workflow process. In addition to effective communication skills, the leader needs to be able have
solid decision making skills. Decision making is defined as the process that a group or individual
takes to arrive at a conclusion using specific criteria to judge each option (Gilley et al.,2010).
When determining which candidate to hire, it will be important to choose one that will be benefit
the team, and justify the reason for their decision.
Conclusion
Identifying areas in a workflow that can be improved will result in better care for the
patients. For the pediatric heme/onc clinic, the addition of a UAP would streamline the process
of sending labs, obtaining supplies, and obtaining chemotherapy for treatment in a timelier
manner. Nurses would be able to focus their care on the patients instead of running around the
hospital will lead increased patient satisfaction.

61
References
Gilley, J. W., Morris, M. L., Waite, A. M., Coates, T., & Veliquette, A. (2010). Integrated
theoretical model for building effective teams. Advances in Developing Human
Resources, 12(1), 7–28.
Laureate Education, Inc. (Executive Producer). (2012c). Organizational dynamics: Planned
change and project planning. Baltimore, MD: Author.
Marquis, B. L., & Huston, C. J. (2012). Leadership roles and management functions in nursing:
Theory and application (Laureate Education, Inc., custom ed.). Philadelphia, PA:
Lippincott, Williams & Wilkins.
Marshall, M. (2006). The use of unlicensed personnel: their impact upon professional nurses,
patients and the management of nursing services. Nursing Monograph, 4-8.
Mission/ Vision/ Values. (2015). Retrieved June 4, 2015, from
http://www.vcuhealth.org/careers/mission-vision-values
Schifalacqua, M., Costello, C., & Denman, W. (2009). Roadmap for planned change, part 1:
Change leadership and project management. Nurse Leader, 7(2), 26–29.
Witges, K. A., & Scanlan, J. M. (2014). Understanding the Role of the Nurse Manager: The Full-
Range Leadership Theory Perspective. Nurse Leader, 12(6), 67-70.

62
Design Considerations and Workarounds
Michelle Muse
NURS 6401 Section 2
Walden University
October 9, 2015

63
Design Considerations and Workarounds
Over the last several decades the popularity of computers has increased in many facets of
our daily lives as it has improved our ability to capture, store, and retrieve data. The advent of
the World Wide Web increased our ability to access knowledge such as medical information. In
the healthcare setting, technology integration of computers has allowed us to improve patient
outcomes by providing a safety net such as the bar code medication administration (BCMA)
system that allows the nurse to verify the right patient, the right dose, at the right time before
administering the medication. When implementing new technologies it is important to keep the
end user in mind when designing the products such as the BCMA. The purpose of this paper will
be to review design considerations in reference to the hardware, software and human-computer
interaction, as well as reviewing potential workarounds that could result in adverse patient
outcomes when implementing new technologies.
Hardware Considerations
Hardware is defined as the physical components of a computer, and peripherals (Saba &
McCormick, 2015). In the case of creating a BCMA within an institution it is important to
consider how the structure of the computer and barcode scanner will work within the flow of the
nurse’s daily activity. The hospital room has limited space for the patient and equipment that is
necessary to provide quality care. In order to use a BCMA system you need to have computer,
and a scanner that communicates with the computer. The question becomes how to design a
system so that the nurse can have access to the computer system when administering
medications. For example, the computer can be rolled into the patients room on wheels or have a
built in computer at each bedside that the nurse access. If the nurse is unable to have easy access

64
to the computer then she will not be able to use it to verify the patient or their medications. In
addition, the scanner needs to be designed so that it reaches the patient. If the scanner is tethered
to the computer this may limit the ability of the nurse to scan the patient’s armband if they are
unable to get it close enough to the patient. A second consideration for a BCMA is designing the
computer to have components that are up to date so that they function at the highest level. A
nurse is going to be less likely to use a computer if it is extremely slow in accessing the needed
program to perform the BCMA procedure.
Software Considerations
Software is defined as the instructions given to the computer’s hardware to perform the
work needed (Saba & McCormick, 2015). Writing software requires a person or team that is
skilled in the ability to translate the human language in to the machine language by coding the
information into a programming language (Saba & McCormick, 2015). In order to design
software it is important to consider including someone that is highly skilled in the ability to code
the information desired so that you have a program that is usable (Saba & McCormick, 2015).
This means the designer of the software needs to have an understanding of how the end user
(healthcare team) will be using the system and for what purpose (Su & Liu, 2010). A nursing
informatics specialist should be included in the design team to be the liaison in communicating
what the healthcare staff will need. In addition, when designing the software it will be essential
to consider having the program tested by the end user to ensure that it will be able to be
incorporated into the workflow by someone familiar with the medical field (Middleton et al.,
2013). This means testing in real world simulations to ensure the program will be safe to use,

65
and will not hinder practice. Dr. Patricia Button states that when she was implementing an
electronic health record in her institution, she held a fair that allowed all the nurses to come and
test all of the options in one room (Laureate Education, Inc, 2012h). By allowing the nurses to
test each system, she was able to determine which system would be accepted easily adopted by
the team members.
Human Factor Considerations
The human factor or the human-computer interaction (HCI) is an attempt to understand
the relationships between, tools they use, living and work environments, and tasks they perform
(Saba & McCormick, 2015). When designing technology tools that will be used in the healthcare
field it is important to consider how the user will interact with the system in the environment and
how the system will look to the user. Presentation is the first impression the end user will have,
and when they will make their initial judgment on the technology (Rojas & Seckman, 2014). One
example of this is the aesthetics, or how pleasing the appearance is to the user. How a person
interacts with the equipment or computers system is influenced by the emotional or cognitive
process it produces (Saba & McCormick, 2015). When implementing technology it is always
important to keep the end user in mind, and to understand how they will interact and feel about
the system. In addition to aesthetics, the technology needs to feel natural to the user and not
difficult to learn (Rojas & Seckman, 2014). One example of this is the EHR, when implementing
a system the user needs to feel like they can retrieve the data easily and the format is readable.
Navigating the chart should be an intuitive process, and one that makes sense to the user (Rojas

66
& Seckman). If a system feels awkward, and the information is difficult to retrieve the end user
will not incorporate the technology into their daily workflow.
Workarounds
Workarounds are defined as when a professional cuts corners or deviates from the
accepted and expected practice protocols (McGonigle & Mastrian, 2012). In the healthcare
setting the deviations are not intended to put the patient at risk, but rather improve work flow in
an already busy and fast paced environment (McGonigle & Mastrian, 2012). When new
technology is implemented it typically meant to improve patient safety, when the end user feels
as if the new work flow impedes on their ability to accomplish tasks in a timely manner they will
create a workaround (Halbesleben, Savage, Wakefield, & Wakefield, 2010). The benefits to the
workaround is that it makes the tasks sometimes easier to accomplish. In the case of BCMA an
example of the workaround could be not scanning the armband because the patient lost it when
transporting back from a test. In order to scan the armband the nurse would have to order a new
one from the admission department, wait for the armband to arrive, and then apply the armband
to the patient. If the nurse is already in the room ready to administer the medication this could
add time to the task that the nurse in his/her busy day may not have to give. The consequence of
not scanning the armband may lead to the nurse administering the medication to the wrong
patient because she is unable to verify that patient’s identity per hospital procedure. The
consequences associated with bypassing a safety practice could lead to an adverse event, and if
the error was severe enough the loss of being able to practice bedside nursing. When purchasing
a new informatics system I would purchase one that allows workarounds but in a limited manner.

67
In the case of the BCMA, if there is a hard stop in place to administering medications without an
armband this could delay care in an emergent or urgent situation. The best example of this is a
patient admitted to a new unit, and has an armband on from the emergency room. In the
emergency department their bands scan differently to allow medication administration in urgent
situations. On the floor the nurse is unable to scan the ER’s armband, but the patient is writhing
in pain. As opposed to waiting for a new inpatient armband to arrive, the nurse can administer
pain medication after verifying the right does, and the right patient by using the existing
armband. This will allow the nurse to chart the medication in real time, and increase patient
satisfaction by having the medication administered immediately. This is just one example of how
a workaround would be useful.
Conclusion
When designing and implementing new informatic technologies it is important to keep in
mind the end user so that the technology will be adopted for use. Technology is implemented to
improve patient safety, and increase positive outcomes. When designing these systems it
important to keep several considerations in mind when designing the hardware, software, and
how the end user will interact with the technology. As long as each consideration is given
thought, then the technology will be incorporated in to the healthcare workflow with ease, and
increase positive patient outcomes. In addition, it is important to design systems that allow
minimal workarounds, but have an understanding of when those workarounds will be necessary.

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