Transforming Care at the Bedside
This paper explores several published articles following the national program, Transforming care at the Bedside (TCAB), developed by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI); and how it supports the ethical principles of patient autonomy, beneficence, and nonmaleficence in patients, especially amongst the geriatric population.
By describing and focusing on three main points of the TCAB, safe and reliable care, patient-centered care, and value-added care and their relative goals and high leverages; this will show how they benefit the nurse’s care at the bedside as well as improving involvement from the patients. This paper examines the use of the TCAB model with several sources supporting the information presented. Transforming Care at the Bedside: Adhering to the Ethical Principles of Patient Autonomy, Beneficence, and Nonmaleficence The Nursing Role As nurses, making decisions on an everyday basis requires the use of ethical principles.
Adhering to the American Nurses Association (ANA) code of ethics is a part of our professional duty. It is for this reason, a nurse led initiative, Transforming Care at the Bedside (TCAB) came about to develop and improve patient care. The TCAB was developed by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI), to improve care and the experiences on medical surgical units for patients and their family members; as well as improving teamwork, nursing retention and satisfaction (Lavizzo-Mourey & Berwick, 2009).
The philosophy of TCAB involves all healthcare team leaders, but gives the power to bedside nurses to develop ideas and solutions for change to benefit the patient in accordance to the ANA code of ethics by addressing the patient’s autonomy, beneficence, and nonmaleficence. The TCAB model promotes the ANA code of ethics Provision 2, “the nurse’s primary commitment is to the patient, whether an individual, family, group or community” and Provision 3 “the nurse promotes, advocates for, and strives to protect the health, safety, and rights of patient” (American Nurses Association, 2011) in all goals and high leverage changes presented.
The four main ideas of TCAB, safe and reliable care, patient-centered care, value-added care, and vitality and teamwork, are all implemented to assist in redesigning patient care and work environments for medical surgical units (Lavizzo-Mourey & Berwick, 2009). All four ideas are important to the TCAB framework, but only the first three will be explored to show how TCAB is positively influencing patient autonomy, beneficence, and nonmaleficence with its framework of principles and processes, especially for the geriatric population.
In order to discuss the how the TCAB model effects the ethical principles of patient autonomy, beneficence, and nonmaleficence, one must know the definitions of these terms. Patient autonomy, as defined by the ANA (2011), is the patient’s right to make decisions freely and independently regarding their healthcare. In order to further assist patients in making these important decisions, nurses play a vital role in educating them about their concerns regarding their conditions, providing resources, and advocating for the patient when needed.
The nurse’s role in patient autonomy is also intertwined with the ethical principles of beneficence and nonmaleficence. Beneficence is defined as the actions that promote the well being of others; nonmaleficence is referred to as the “do no harm” principle (American Nurses Association, 2011). Providing care for patients by promoting their safety, health and well being, is priority for nurses. Applying these ethical principles in every day care assists in providing quality care to all patients, but especially important to the geriatric population due to the declining health and frailty that is increased with age.
Safe and reliable care, the first process of TCAB that influences patient beneficence and nonmaleficence, is defined by Rutherford, Moen, & Taylor (2009) as “care for the moderately sick patients who are hospitalized is safe, reliable, effective, and equitable”. In accordance to this theme, the TCAB design team developed goals and changes that would show improved outcomes. One of these “high-leverage changes” (Rutherford et al, 2009) was preventing patient injuries from falls. Patient falls is one of the high occurrences in patient safety and injury, as well as the leading cause of death of patients 65 and older (Rutherford et al, 2009).
By incorporating the TCAB initiative, the pilot hospitals average of patient falls was reduced by fifty-two percent (Rutherford et al. , 2009). One of the ways that patient falls were reduced was by involving the personal care attendants (PCA) in making frequent rounds with patients and asking them if they were comfortable or if they needed anything. By involving the PCA’s in falls prevention, the study showed an average fall rate per one thousand patient days decreased from 6 to 4. 5 (Stefancyk, 2009).
One of the main themes between the studies is preventing patient injury during their hospital stay. In doing so, the ethical principle of beneficence and nonmaleficence have been addressed. A second intervention was also implemented in reducing injuries to the elderly client was placing a sensory cart on the unit and to be utilizing it for patients who were experiencing altered metal status (Stefancyk, 2009). Some of these patients would pull at their intravenous lines; attempt to climb out of their beds or chairs, therefore posing a potentially harmful situation for them.
The sensory cart held items such as fuzzy balls with tentacles for patients to hold and distract them from pulling at their intravenous lines, and stuffed animals to be placed on their laps when sitting in their chairs to prevent them from getting up and falling (Stefancyk, 2009). By using this sensory cart, patients were distracted from putting themselves in potentially harmful situations like falls; profuse bleeding from intravenous sites, and also reduced the need for restraints.
These changes developed by TCAB model improved patient safety in the hospital setting, therefore decreasing patient injury and extended hospital stays, adhering to the ethical principles being discussed. The second theme in the TCAB framework, patient centered care, influences patient autonomy by using its vision described by Rutherford et al (2009) as “truly patient-centered care on medical and surgical units honors the whole person and family, respects individual values and choices, ensures continuity of care”.
Providing patients with information and education, respecting patient preferences by encouraging input on plan of care goals, ensuring comfort with pain management, and addressing their needs, especially with medication administration and care times (Stefancyk, 2009), gives the patient a sense of empowerment, a voice and more involvement in their care, thereby adhering to the definition of patient autonomy. The goals for TCAB with this theme were to decrease readmissions by five percent, and that ninety-five percent of patients were willing to recommend the hospital (Rutherford et al, 2009).
The goals for TCAB with this theme were to decrease readmissions by five percent, and that ninety-five percent of patients were willing to recommend the hospital (Rutherford et al, 2009). The assessment of patient satisfaction was based on surveys conducted on the patient’s willingness to recommend the hospital to their family and friends. One of the surveys conducted showed that sixty-six percent of patients selected the highest score available on a four point scale, indicating that they would definitely recommend the hospital (Rutherford et al, 2009).
The TCAB goal was set for ninety five percent, so a different survey was conducted using a five point scale, which only ten of the participating pilot sites achieved (Rutherford et al, 2009). Another measure of patient centered care was readmission rates within thirty days of the discharge date. Out of the ten participating pilot sites, only four sites were able to reach this goal (Rutherford, 2009). In a different study conducted by Stefancyk (2009), postponing medication administrations provided nurses more time with direct patient care, such as teaching and education about medications, diagnoses and or conditions.
By using data from the hospital’s personal digital assistants (PDA), Stefancyk (2009) was able to determine that direct patient care increased from fifty-two percent to seventy-six percent in just one month. Positive feedback was also given by nursing staff regarding the medication administration changes implemented, such as less stress at shift changes, more time with patients, and developing more information about their patients and conditions.
This increased time at the bedside is especially beneficial to the geriatric population in order to discuss questions or concerns in regards to their healthcare and services that they may need upon discharge. These studies helped in making the patient a part of their own health care team, thereby supporting the ethical principle of autonomy, giving the patient the capacity to make informed decisions about their care. The third process, value-added care, also supports the patient’s beneficence. In value-added care, the process is “All care processes are free of waste and promote continuous flow” (Rutherford et al. 2009).
The main goal in this theme is to increase time nurses spend at the bedside and reduce time wasted on activities that have little to do with their patients, such as decreasing redundant charting. According to Rutherford et al. (2009), medical-surgical nurses spend about twenty to thirty percent of their time on direct patient care; the rest of their time is spent on activities such as finding supplies, documentation, and care coordination. A high leverage change in this area is improving medication administration by changing the times they were being ordered for.
According to Stefancyk (2009), by coordinating with physicians and pharmacists, medications that were priority would still be given at eight o’clock in the morning and the rest at ten o’clock. In doing so, the nurses can reduce the “bottleneck” (Stefancyk, 2009) at the beginning of their shift, and give more patient care; thereby reducing the need to get medications quickly after receiving patient report, increasing patient beneficence. In an article by Popkin (2007), it was hypothesized that increasing the time spent at the patient’s bedside by the nurse would decrease fall rates, nosocomial pressure ulcers, and infections.
Pressure Ulcers are detrimental to the elderly patient due to declining health that may already be present and decreased healing time (Arora, Johnson, Olsen, Podrazik, Levine, Dubeau, Sachs, & Meltzer, 2007). Small changes to the unit were made such as installing nurse workstations outside the patient’s room to allow for documentation, and placing items needed closer to patient rooms to decrease the amount of time spent on looking for supplies. By implementing these small changes falls rate on the unit decreased from 2. 7 to 2. 5, restraint rate decreased to three percent, and the pressure ulcer rate is 0. percent (Popkin, 2007).
In another study conducted by Lorenz, Greenhouse, Miller, Wisnewski, & Frank (2008), decreasing wait times and increasing the amount of time a nurse is interacting with patient improved their patient satisfaction scores by thirty percentiles in five months. Also by streamlining area flow and efficiencies, treatments for patients were more available, such as increasing the supply of onsite platelets, which decreased the wait time for treatment by fifty minutes (Lorenz et al, 2008). Labeling blood tubes to flag the laboratory staff of results needed before treatment was also implemented.
Turnaround times for results decreased from fifty-four minutes to nineteen minutes on creatinine results, and forty-seven minutes to seventeen minutes for complete blood counts (CBC) results (Lorenz et al, 2008). Improving every day flow of treatment, and reorganizing supply areas for easier use, nurses can spend more time with patients decreasing injuries sustained in the hospital such as falls or pressure ulcers, thereby empowering the ethical principle of beneficence for patients and increasing patient satisfaction and trust within the healthcare field. Conclusions and Implications
The TCAB model is the foundation for staff to generate ideas for health care delivery improvement; create and implement changes through pilot tests; assess the results of change; determine whether to adopt or abandon the tests of change; and participate in ongoing assessment of changes and reports of improvement (Lorenz et al, 2008). The TCAB model itself is easy to implement; and also encourages and requires the involvement of health care staff members to provide increased satisfaction among the patients and their families, thereby improving patient care outcomes throughout the process (Lorenz et al, 2008).
Organizational leaders have to adopt effective strategies in order to spread the ideas and successful changes with the TCAB model from pilot unit studies to other sites within a hospital or health care system. Utilizing resources to assist in sustaining and supporting the TCAB model provided by the RWJF and IHI is the first step in implementing the TCAB initiatives. Through TCAB, a movement has begun to transform the care delivered on medical surgical units that better serve the patients and staff to support the professional nursing practice and collaborative teamwork at the bedside (Rutherford et al, 2009).
The nursing role is vital in the TCAB model, as well as for patients. Nurses are at the front lines of patient care and are often the person patients interact with the most. Using the TCAB model promotes the nursing role by addressing the changes that are being brought forth by nurses to increase bedside care, safety, health and well being of patients. In doing so, the risk of developing a prevalent geriatric related condition such as dementia, pressure ulcers, and urinary incontinence, is decreased and nursing quality care is increased (Arora et al. , 2007).
Nurses applying the ethical principles of patient autonomy, beneficence, and nonmaleficence help patients increase their level of satisfaction and involvement with their healthcare, and more importantly, increase trust in the healthcare team providing that care.