Running head: LEADERSHIP STRATEGY ANALYSIS 1

Leadership Strategy Analysis-Quality Improvement Process

Jessica DeRuiter, Kelli Koop, Jordan Lentz,
Mollie Morrissey, Elyse Sincler, & Katie VanderVelde
Ferris State University












LEADERSHIP STRATEGY ANALYSIS 2

Leadership Strategy Analysis-Quality Improvement Process
In order to provide evidence-based practice (EBP) and bed part of quality improvement,
Quality Improvement initiatives should be performed. Nursing leaders, managers, and followers
must be committed to a quality improvement culture. This assignment will give you the
opportunity to analyze a clinical activity from a Quality Improvement perspective (Bishop,
2014, p. 14). The leadership strategy performed is based on thorough assessment each shift per
registered nurse rather than every 96 hours.
Identify Clinical Need
Intravenous catheters (IVs) are continuously started in a wide-variety of patients, from
individuals who need chemotherapy to those who need a saline lock IV access. Approximately
200 million IVs are used in the United States each year and up to 70% of these patients needed
an IV in the acute care setting alone (Rickard et al., 2012). It is pertinent that nurses know how to
start an IV, thoroughly assess the sight often, use them properly, and know what the hospitals
policies are. Currently the policies require nurses to change the IVs every 72-96 hours to prevent
phlebitis, infiltration, and infection. This standard of practice is being challenged from routine to
clinically necessary replacement or removal (Ho & Cheung, 2012).
There have been several research studies on this subject that suggested clinically
indicated removal over routine replacement, because there was no clinical evidence that 72-96
hour replacement was more beneficial or needed. One study presented evidence supporting an as
needed replacement of intravenous catheters. The study showed that clinically indicated
replacement does not increase the risk of harm to the patient and the quality of care is not
hindered (Rickard et al., 2012). Another study found there was no significant increased risk of
phlebitis or bacteremia with IV indwelling times longer than 96 hours (Gallant & Schultz, 2006).
LEADERSHIP STRATEGY ANALYSIS 3

In pediatric units, nurses use an as needed replacement policy to decrease anxiety and increase
comfort in their patients (Rickard et al., 2012). If this is best practice for pediatric patients, it
should be considered whether it could be best practice for adults as well.
Interdisciplinary Team
In order to determine the need for having to change the IV catheters based on the patient
rather than using the 72-96 hour rule, an interdisciplinary team is essential to determine the best
quality of care for the patient. A team must work together to achieve cost-effective care while
achieving the highest quality of care in the health care setting (Yoder-Wise, 2013, p. 362).
Members of this team would include, nurses, physicians, case managers, and quality
improvement. Nurses, physicians, and case managers are involved, because of the direct care
they provide to the patient. Nurses are the most important because based on this change, they
will need to be using their best nursing judgment and knowledge to attain quality and safety for
the patient. Quality improvement is involved due to the involvement they have with the changes
that would be made in the policies and procedures. Team members need to trust each other and
work together to make the decisions based on the individual patient. As a result the team can
avoid any phlebitis, infiltration, and infection. Also the team is able to reduce any anxiety and
increase the patients comfort if the IV does not have to be changed within the 72-96 hours.
Data Collection Method
After the clinical need has been identified research is used to support and make change
on the clinical problem. As defined in Yoder-Wise (2013) Research utilization is used to
synthesize, disseminate, and use research-generated knowledge to influence or change existing
practices (p. 413). As a leadership strategy, the CINAHL database was used as a method of data
collection to retrieve nursing research articles in order to support research-generated knowledge
LEADERSHIP STRATEGY ANALYSIS 4

on IVs. The database showed three articles that supported clinically indicated removal over
routine replacement: intravenous catheter removal, intravenous catheter guidelines, and
discontinuing intravenous catheters.
Nurse leaders may not necessarily be the ones actually conducting research, evaluating
research evidence, or developing evidence-based guidelines, but they will be facilitating the
application of research findings in practice (Yoder-Wise, 2013, p. 413). The chosen articles met
a certain criteria that are required to be considered nursing research. First, the articles that did not
come from nursing journals and/or contain nursing authors would be eliminated from the
selection. Articles that have nursing authors or come from nursing journals give a perspective
that generally relates to a nursing point-of-view. Next, the articles needed to involve an
experimental research study about the IV practices; literature reviews or articles presenting no
clinical data were excluded from the selection process. Finally, the selected articles were chosen
based on their good literature review, large population selection, and representation of their
studys methods and results. Without the development of evidence-based guidelines the method
of data collection, as using research findings to gather data, would have not been accomplished.
Establishes Outcomes
If nurses could provide thorough and detailed IV assessments habitually rather than
maintaining routine IV changes, clinically indicated IV replacement could be attainable. Overall,
this change has the possibility to prevent unnecessary IV changes, which would increase patient
comfort, decrease time-consuming interventions, and decrease hospital costs (Gallant & Schultz,
2006). Therefore, our goal is for hospitals to implement IV changes based on thorough
assessments by the year of 2015.
Implementation Strategies
LEADERSHIP STRATEGY ANALYSIS 5

In order to make changes within hospitals then nurses would need to be leaders in asking
for or supporting a change. The six phases of planned changes by Havelock would be an
appropriate way for a nurse to make a change to policy at a hospital. The first step of this phase
is building a relationship (Yoder-Wise, 2003, p. 328) the nurse would need to establish a
relationship with those who are in a position to make changes but should also reach out to others
who support the proposed change. The second phase diagnosing the problem and the third
phase acquiring relevant resources can be combined (Yoder-Wise, 2003, p. 328). This is
because the nurse or group of nurses who are proposing the change have already diagnosed the
problem and researched evidence based practice that is supporting the change. This is where a
presentation would be given to those in a position to make changes. Step four and five of the six
phases of planned change are completely out of the nurses hands because they are choosing the
solution and gaining acceptance (Yoder-Wise, 2003, p. 328). The nurse or nurses should
however continue to reach out to educate others and become a larger force asking for this change
to be made. If the decision is to change the policy, then education should be provided to the staff
at large informing them of the change and the EBP that supports it. The last phase of the six
phases of planned change is stabilizing the innovation and generating self-renewal (Yoder-Wise,
2003, p. 328).
If a hospital approves a change to policy of when an IV is changed then step 6 of the six
phases of planned change should include; the start date of the new policy should be established
along with an announcement to all effected staff. These staff include nurses, physicians, and lab
technicians that will be effected by the change in policy. The nursing staff should attend a
mandatory educational class that teaches proper start, assessment, and use of the IV. Nurses will
be on the front lines of this change and should be properly prepared.
LEADERSHIP STRATEGY ANALYSIS 6

Evaluation
As the plan is implemented, the team communicates to gather and evaluate data to
document that the new outcomes are being met (Yoder-Wise, 2014, p. 401). Having a reliable
evidence-based method for identifying when an IV needs to be removed is one crucial element to
solving the problem. Another critical part is making sure the nurses assessment skills are
adequate because they will have the responsibility of determining when the IV will be left in,
removed, or restarted. The purpose of the Roper-Logan-Tierney Model of Living is to assess
patients continually throughout their stay (Nursing Theory website, 2013). Roper believed that
each patient is unique and needs to be assessed and evaluated on an individualized basis before
and during care. Nurses are often asked and needed for different evaluations, so they have the
needed evaluation and assessment skills to determine if the IV is clinically necessary.
A standardized tool for assessing an IV is needed to help aid nurses in making a decision
to leave, restart, or remove the IV. Appendix A shows one example of a vascular access score
tool to help implement and evaluate each nurses assessment skills (King Edward Memorial
Hospital, 2013). The standardized assessment tool will help measure the improvement because if
one area of the assessment is not understood or addressed, there could adverse reactions for the
patient. The assessment tool should be reliable and incorporate evidence-based practice. Each
nurse needs to understand and comprehend the IV assessment tool because it can save a patient
from discomfort and costs associated with equipment and workload for staff.
The nurse manager of each floor should also do chart audits randomly to make sure the
nurses are doing thorough IV assessments. Chart audits help to gather information and will assist
the manger to determine if the IV assessment tool is safe and effective. The nurse manger needs
to assess that each nurse has knowledge about the correct use of the IV assessment tool. The
LEADERSHIP STRATEGY ANALYSIS 7

chart audits should be random and weekly unless there are a few nurses who have higher
incidence of IV associated complications. The manger should then re-educate about the proper
use of the IV assessment tool to ensure the patients are receiving safe, quality nursing care.
Conclusion
Practicing safe, quality nursing care and using evidence-based practice is the key to
improve patient outcomes. Quality improvement is always on the minds of nurses, as well as the
entire interdisciplinary team. Implementing a new IV policy could save patients from the
discomfort of another poke, along with costs associated with materials and increased workload
for the nurses. Nurses develop assessment skills to identify bad IV sites but if there is a
standardized assessment tool there would be a decreased risk of IV associated complications.
Nurses will be responsible for the assessment of the IV sites on every shift, whether it is less than
or greater than 96 hours. The nurse will be able to make independent evaluations and decisions
regarding re-insertion, removal or to leave it in before or after 96 hours. Completing a thorough
assessment and using a standardized IV assessment tool is essential to get hospitals to adopt a
new IV policy/procedure.








LEADERSHIP STRATEGY ANALYSIS 8

References
Ferris State University. (2014). NURS 440: leadership [Syllabus]. Retrieved from
https://fsulearn.ferris.edu/webapps/portal/frameset.jsp?tab_tab_group_id=_2_1&url=%2F
webapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_1105
2_1%26url%3D
Gallant, P., & Schultz, A. (2006). Evaluation of a visual infusion phlebitis scale for determining
appropriate discontinuation of peripheral intravenous catheters. Journal Of Infusion
Nursing, 29(6), 338-345. doi: http://0-ovidsp.tx.ovid.com.libcat.ferris.edu/sp-
3.11.0a/ovidweb
Ho, K., & Cheung, D. (2012). Guidelines on timing in replacing peripheral intravenous catheters.
Journal Of Clinical Nursing, 21(11/12), 1499-1506. doi:10.1111/j.1365-
2702.2011.03974.x
King Edward Memorial Hospital. (2013). Monitoring a peripheral intravenous site.
Retrieved from
www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectiona/4/a4.2.3.p
df.
Nursing Theory website (2013). Roper-logan-tierney model of living. Retrieved from
http://www.nursing-theory.org/theories-and-models/roper-model-for-nursing-based-on-a-
model-of-living.php
Rickard, C., Webster, J., Wallis, M., Marsh, N., McGrail, M., French, V., & ... Whitby, M.
(2012). Routine versus clinically indicated replacement of peripheral intravenous
catheters: a randomized controlled equivalence trial. Lancet, 380(9847), 1066-1074.
doi:10.1016/S0140-6736(12)61082-4
Yoder-Wise, P. (2011). Leading and Managing in Nursing (5
th
ed.). St. Louis, MO: Mosby Elsevier.
LEADERSHIP STRATEGY ANALYSIS 9

Appendix A
VASCULAR ACCESS SCORE TOOL
Clinical Signs and Symptoms VAS Clinical Interventions
IV site appears healthy 0 No signs of phlebitis Observe IV
site, Remove the cannula if no
longer required
One of the following is evident
Slight pain near the IV site
Or
Slight redness near the IV site
1 Possible first signs of phlebitis
Observe the IV site closely
Remove the cannula if no longer
required
Continue VAS for 96 hours
Two of the following are evident
at or near the IV site Pain
Redness
Swelling
2 Early phlebitis
Remove the cannula
Re-site the cannula if appropriate.
Continue VAS for 96 hours
Early phlebitis
Remove the cannula
Resite the cannula if
appropriate.
Continue VAS for 96 hours
3 Medium phlebitis
Complete a Clinical Incident
Form
Perform microbiology sampling
see procedure below
Remove the cannula Consider
treatment
Re-site the cannula if appropriate
Continue VAS for 96 hours
All of the following are evident
and extensive
Pain along the path of the
cannula
Redness
Hardness extending along the
vein
Palpable Venous Cord
4 Advanced phlebitis or start of
Thrombophlebitis
Complete a Clinical Incident
Form
Perform Microbiology sampling
Consider treatment
Remove the cannula
Re-site the cannula if appropriate
Continue VAS for 96 hours
All of the following are evident
and extensive
Pain along path of the cannula
Redness
Hardness with purulent
discharge
Palpable venous cord
New pyrexia not explained by
other causes
5 Advanced stage thrombophlebitis
Complete a Clinical Incident
Form
Perform Microbiology sampling
Remove the cannula
Re-site the cannula if appropriate
Initiate treatment
Continue VAS for 96 hours.