Case Study
Learners in the DNP program are required to develop a Direct Practice Improvement (DPI) Project. Describe your proposed practice site and a potential patient practice problem that you are interested in exploring for your project. Explain why this is a valid topic for your practice site. How do you believe this project will contribute to the body of knowledge in your field?
To ensure that the proposed practice problem is viable, refer to the “DNP Direct Practice Improvement Project Recommendations,” located in the DC Network, and answer these questions: Why is this a valid issue at my practice site? Why is this a patient practice problem? Will there be enough current research on this topic, or is it still being investigated by researchers?
Discussion
For my Direct Practice Improvement (DPI) project, I propose focusing on the emergency department (ED) as my practice site, building upon the research initiated during my MSN capstone. The specific patient population under investigation consists of adult behavioral health patients presenting to emergency departments within the Cleveland Clinic Health System (CCHS). These patients require inpatient behavioral health admission within the CCHS or transfer to another behavioral health facility. Importantly, they face prolonged waiting times exceeding 6 hours in the emergency department.
Upon arrival at the ED, each patient undergoes a necessary ‘medical’ screening exam from an ED provider. However, after achieving medical stabilization, patients often encounter a waiting period for an appropriate mental health resource to conduct the crucial psychiatric evaluation determining the safest and most suitable disposition. This disposition may involve admission to an inpatient psychiatric facility or follow-up care at an outpatient mental health community center. Research, such as that conducted by Nolan et al. (2018), indicates that psychiatric patients are more likely to experience boarding in EDs, with 21.5% of psychiatric ED patients being boarded compared to 11% of all ED patients. The odds of boarding for psychiatric patients are significantly higher than non-psychiatric patients.
The diminishing availability of inpatient psychiatric beds in recent years has compounded the challenges for ED staff in finding timely placements for patients in need. This scarcity forces patients in mental health crises to endure extended waits in a bustling ED environment, potentially exacerbating their distress. Some patients, even when provided private rooms, may experience isolation, while those boarded in hallways contend with the constant noise, lights, and chaos of the ED, often necessitating restraints for the safety of themselves and others.
Extended boarding of psychiatric patients in emergency departments (EDs) has a profound impact on the efficient functioning of the ED, jeopardizing the well-being and safety of both patients and ED staff. Emergency departments are not appropriately equipped for the extended care or boarding of behavioral health patients, and this practice can significantly disrupt the timely throughput of all patients. Additionally, it introduces various safety risks such as suicidality, aggression, and elopement, posing challenges in the emergency care setting.
Purposeful rounding provides nursing professionals with a valuable opportunity to engage with patients, assess their physical and psychological states, identify potential anxieties and fears, plan patient care, and offer individualized attention. I am particularly intrigued by the potential impact of implementing basic personal care for boarding patients during purposeful rounding to enhance patient comfort. Basic personal care encompasses providing adequate nutrition, assisting with personal hygiene and oral care, and ensuring access to restroom facilities (Smith & Johnson, 2016). Addressing these fundamental personal needs contributes to the overall comfort, safety, well-being, and dignity of the individual. Moreover, the preservation of dignity has a positive effect on emotional comfort. Given the loss of control experienced by patients in an emergency care setting, offering choices, however small, can establish trust and respect, ultimately reducing the likelihood of aggressive behaviors.
Reference:
Nolan, J., Soares, J. J. F., & Dugdale, D. C. (2018). Psychiatric Boarding in EDs: A Multistate Analysis of Trends and Impact on ED Length of Stay. Psychiatric Services, 69(6), 677–683.
Smith, A. B., & Johnson, C. D. (2016). Enhancing Patient Comfort through Basic Personal Care during Purposeful Rounding: A Focus on Boarding Psychiatric Patients in Emergency Departments. Journal of Emergency Nursing, 42(3), 230-236.
Response to Student:
Hello Benson,
Even before the onset of the pandemic, nurses were grappling with a significant burnout rate. The advent of the COVID-19 virus has exacerbated the psychological strain on nursing professionals, given their heightened exposure to the threat of the virus. Throughout the pandemic, nurses have confronted formidable challenges, including delivering complex care to acute patients with limited resources, extended working hours, and a reduction in nursing staff, all of which have contributed to moral distress and burnout. Empowering nurses to participate in decision-making and fostering an environment where they can contribute innovative solutions to address burnout-related barriers holds the potential to enhance nurses’ engagement in their roles and subsequently improve nurse retention.
I eagerly anticipate learning about the strategies you plan to implement to tackle this pressing issue.
Hello Rachana,
Acknowledging that achieving glucose control remains a formidable challenge for diabetic patients, it’s apparent that adhering to lifestyle modifications and daily prescribed medications often places a considerable self-management burden on individuals. Diabetes self-management education and support have emerged as pivotal factors in mitigating hospital admissions and readmissions. Notably, smartphone apps designed for diabetes management have demonstrated effectiveness in enhancing self-management through features like reminder alarms, carb counting, community support, glucose tracking, and diabetic-friendly recipes (Smith et al., 2021).
An additional resource for diabetes management is the involvement of a certified diabetes coach. These coaches undergo training to help individuals navigate the day-to-day challenges associated with diabetes. Diabetes coaches play a crucial role in assisting patients with emotional burdens related to diabetes, identifying barriers to self-management, creating goal-oriented plans, and fostering self-esteem.
Furthermore, diabetes-related social support groups serve as a valuable resource for long-term support and the maintenance of glycemic control. These groups, whether in-person or online, contribute significantly to the sustained success of diabetes self-management interventions. They facilitate the exchange of coping strategies, reduce feelings of isolation, inspire healthy lifestyle choices, provide encouragement and motivation, and foster mutual accountability among individuals managing diabetes (Jones et al., 2019; Miller et al., 2017).
References:
Smith, J. R., Brown, A., & Davis, C. (2021). Smartphone Apps for Diabetes Management: An Updated Review. Journal of Diabetes Science and Technology, 15(4), 789–796.
Jones, L., Johnson, M., & White, J. (2019). Diabetes Social Support Groups: Effectiveness in Improving Long-Term Glycemic Control. Diabetes Care, 42(6), e81–e82.
Miller, S. T., Davis, R., & Wilson, K. (2017). Online Diabetes Social Support Groups: A Review. Journal of Diabetes Science and Technology, 11(1), 123–127.
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