Definition of Problem and Substantiation of the Need to Change
Problem
Informed consent is a key principle and legal requirement in medical care since it directly relates to the safety of the patients and the level of satisfaction derived from the medical services. As Grebe (2007) outlines, the process of obtaining informed consent from patients is challenging, especially when dealing with cases of cognitive impairment. The main challenge becomes how to determine if a patient has the capacity to make a decision that influences their treatment plan, whether on medication of any recommended procedures meant to fasten their healing process. Cardaso (2013) notes that the process involves dialogue between the practitioners and the patients in relation to the proposed medical treatment. Informed consent is appropriate for all health care decisions including high-risk treatment such as chemotherapy, radiologic examinations, and surgery among other procedures. Even in such dire cases, a nursing practitioner (NP) cannot offer any treatment without consent from the patient (Grebe, 2007). Despite the advantages associated with the practice, a problem arises in the case where the patients suffer from cognitive dysfunctions. The procedure affects the outcomes of this category of patients since some of these patients lack the capacity to give informed consent.
The problem affects the nature of the treatment the patients receives since they are not able to tell whether the proposed methods are the most applicable to their conditions. While nursing practitioners are obligated to provide the necessary information regarding different medication and how they affect the recovery process in the best way patients can understand, Petrini (2011) argues that this is often not easy specially when dealing with patients with cognitive disorders. Additionally, the patients with cognitive disorders may not be able to understand their role during the decision-making process, a situation which leads to incomplete informed consent. “The American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements—Provision 1 states, “Each nurse has an obligation to be knowledgeable about the moral and legal rights of all patients to self-determination” (Gerbe, 2007, p.40). Therefore, nurses must not only act ethically, but follow the set out procedures when seeking consent from patients before giving any medication. As per a research conducted by Cordasco (2013), the informed consent procedures conducted among the people with cognitive issues are incomplete since they do not meet all the required conditions. Consequently, the practice does not achieve the targeted purpose. To curb the problem, it is important to find a surrogate decision maker in case the condition does not require urgent attention. In the case of an emergency, the medical practitioners can make the decision that a reasonable person is likely to make provided it is in the best interest of the patient. Moreover, the patient’s family can also stand in as surrogate or proxy decision makers to help patients who have been determined not to be in a position of making an informed consent (Appelbaum, 2007). The patient can then assent to the decision or prior to the treatment plan decide on who has the authority to do the same. As such, nursing practitioners will not waste precious time while waiting for patients to give their view on the treatment plan.
Concisely, informed consent is a challenge when dealing with patients with cognitive issues. Change in medical policies is essential to ensure that the guidelines provide exemptions to informed concepts when dealing with such situations. The change will have the effect of allowing the medical practitioners to make the most appropriate decisions in cases where the patients are not able to decide and when there is no close associate to represent the sick individuals. The proposed change will have the effect of making the work of streamlining the medical operations especially in the case of emergencies.
Desired Possible Outcome
Working in a unit that has a high number of geriatric patients means that cases of cognitive impairment are high. While medical practitioners work within their best professional knowledge, available theory, and experience to provide quality care, patients have the right to accept or refuse medications as well as medical treatment (Cordasco, 2013). Therefore, a patient’s health and safety are at risk when a he or she has cognitive issues, which render them to not fully understand their treatment, possibly refusing medications and or treatments to aide in their recovery. Additionally, patients can also agree to any treatment or medication not understanding the outcomes or side effects (Appelbaum, 2007). In turn, the patients may end up blaming the practitioners for any negative side effects or outcomes they experience based on the medical treatment. Therefore, the key focus for this change plan is to help ensure that patients only assent to what they are fully aware of and avoid any legal, ethical, or physical consequences of their actions.
The successful implementation of the plan suggested in this paper will help ensure that cases of cognitive impairment are discovered early enough, which will help practitioners determine patients whose consent may be questionable. In turn, the practitioners will monitor patients’ overtime and determine their ability to make decisions that directly affect their recovery. According to Appelbaum (2007), effective cognitive evaluation programs, especially for geriatric patients, requires proper monitoring and evaluation overtime by assessing how patients respond to previous consent they provided and their knowledge of common issues that affect them. As such, it is important to ensure that nursing practitioners are equipped with the skills necessary to guide patients in making any informed consent. Merely defining medications and their side effects to patients does not amount to providing a good round to help foster informed consent. Thus, the focus should be on educating both patients, their family, which includes the public, and most importantly the practitioners on guidelines for determining whether patients can make informed decision, which tantamount to informed consent, and when practitioners or surrogates chosen by the patient, who may include close family members or any trusted parties can make such decisions (Petrini, 2011).
Factors that led to the Problem Identification and Need for Change
A research by Hirschman et al. (2011) highlights that the number of older adults visiting emergency departments is estimated to rise to more than 34 million by 2040 from 16 million in 2011, which amounts to 25% of patients in this unit. Further, their study notes that about 26% to 40% of geriatric patients visiting emergency departments have cognitive impairment. Their study comprised of patients with delirium and dementia (Hirschman et al., 2011). From these statistics, about 10 to 15 older adult patients expected to visit emergency departments by 2013 might have cognitive impairment. Therefore, nurse practitioners will have to deal with more cases of cognitive impairment in the future that they currently handle. Besides, as Taraghi et al. (2016) outline, for chronic diseases such as heart failure, which are often high among elderly patients, geriatric patients have two-fold risk of cognitive impairment, which complicates healthcare delivery. Apart from increased rates of re-hospitalization. Taraghi et al. (2016) note that patients with heart failure who are cognitively impaired complicate the ability of practitioners to offer quality care by impacting the ability to perform self-care procedures. Moreover, physicians may underestimate cognitive impairment among such patients. Therefore, results from these studies show that cognitive impairment, especially among geriatric patients is high and has a myriad of consequences.
Apart from the statistics on potential increase of cognitive impairment cases in future, regulations on seeking informed consent from patients are generally stringent on the practitioners’ ability to determine what is often considered as the best option for the patient. Research has indicated that the length of most consent forms and details of such documents are often not friendly to the patients in terms of ability to read and comprehend (Cordasco, 2013). While physicians are expected to explain every detail to the patient, in most cases, the emergency of the patient, language barrier, low educational background, cognitive impairment, and old age among other factors reduce the comprehension ability. Therefore, physicians have to decide based on the data they have on the best approach to take with a patient and ensure that their recovery and access to quality care is guaranteed (Petrini, 2011). I turn, this calls for the need to individualize such situations and allow physicians to act as surrogates, but still respect the rights of the patient and avoid medical errors. “If a patient does not have capacity and his or her cognitive dysfunction is not expected to improve (or a decision needs to be made prior to it improving), a surrogate decision maker must be established, except in an emergency situation where the physician can determine the choice a “reasonable person” would make” (Cordasco, 2013, p.106). Thus, such modalities should only be used when proper determination is made that the patient is incapable of providing a proper consent on their own.
Organizational Structure and its Effect on the Proposed Plan for Change
The successive implementation of this plan will not affect most departments in the organization. The ANA code of ethics still dictate that the presumption of capacity remains even when there is an obvious indication that the patient has a diminished capacity to consent (Gerbe, 2007). The patient will still have the power to rationally think through options provided and give a decision that is informed on personal choice rather than coercion. Thus, it is the responsibility of the management to ensure that they facilitate guidance and equip nursing practitioners with all necessary material needed to determine if patients have cognitive impairment and how to proceed with treatment within guidelines of regulatory bodies. “Patients have the moral and legal right to determine what will be done with their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed judgment” (Grebe, 2007, p.40).
Therefore, nursing leaders and other administrators in the facility will need to spearhead discussions on recommendations made in this plan given that it affects different units, not only among geriatric patients, but also other patients with cognitive impairment. The plan will need professional guidance from legal consultants and policy providers from ANA to determine whether the recommendations and plan are legal or not. Besides, since the plan affects many people, there is a need to foster education to nursing practitioners to help determine patients with help cognitive impairment early enough either during hospitalization or during their first visits. Such an intervention will need an increase in professional assistance from physicians specialized in identifying cognitive dysfunction among patients and other conditions, delirium and dementia, which have been associated with high risks of cognitive impairment.
Training nurses on how to implement the plan will also require funding. Since the most affected division will be the emergency department, it will be critical to ensure that nursing practitioners working in this department are the first to get knowledge on new policy recommendations. Finally, the intent is to start the plan in the geriatrics unit and assess its effectiveness before employing the same in other departments. Therefore, this unit will need more funding to facilitate research on the effectiveness of the new policies and how they lead to improved care and enhance patient safety and quality of care.
Effects of the Problem on the Quality and Safety of Health Care Services to Patients
As Dasgupta (2016) asserts, cognitive dysfunctions have been known to be highlight prevalent among geriatrics, and mainly affect hospitalized patients. Since cognitive disorders have adverse side effects on patient recovery outcomes, it is critical to reduce effects that hospitalization may have on cognitive effects. Therefore, ensuring high quality care for these patients is a necessity in facilitating their recovery and preventing worsening of their situations as previous research has evidenced that hospitalization increases the rate of cognitive decline (Dasgupta, 2016). As Dasgupta (2016) illustrates, “Cognitive impairment may affect the recognition of symptoms and management of chronic medical illnesses.” (p.8). Therefore, earlier detection of cognitive dysfunction, either through active training of caregivers or increasing the time patients are educated is necessary to increase the effectiveness of managing the disease after patients are discharged.
Moreover, since patients with cognitive impairment may provide judgement that can adversely affect their health and chances of recovery, it is vital that medical practitioners carefully guide them through modalities of care and their possible effects. Besides, in cases where a medical practitioner feels that patients have taken an alternative that jeopardizes their care, it is their duty to seek further professional assistance to enable informed decision-making by the patient (Fields & Calvert, 2015). Therefore, the focus should move to a patient-care approach from a diseased-focused treatment. Such care should then transcend to proper advice to the patient’s family on how best to handle the patient. In turn, the expectation is that there will be reduced mortality for patients with cognitive dysfunction as a result of refusing to take medication that would otherwise help them recover or assent to medication they would not have provided any consent if they were not cognitively impaired.
The Planned Change/Assessment
Literature Review
Cordasco (2013, p.100) defines informed consent as the process whereby the patient and the health care practitioner engage in a dialogue about a proposed medical treatment’s nature, consequences, harms, benefits, risks, and alternatives.” Cordasco (2013) notes that different court cases have ruled that any procedure performed on a patient without their consent tantamount to battery, which jeopardizes the latter’s safety. Besides, the process of seeking an informed consent also helps prevent any medical errors. The patient-physician interaction when seeking informed consent is the vital input, which is linked to reduced number of medical malpractice claims, increased patient satisfaction, and more realistic satisfaction from the patient (Appelbaum, 2007).
Nevertheless, Cordasco (2013) records that in most cases, procedures to seek informed consent are incomplete, with physicians failing to elicit patient preferences for treatment, explain clinical condition, clarify how patient influence decisions they make, and discuss basic elements of the consent. Therefore, Cordasco (2013) highlights that most physicians fail to assess whether patients have understood everything in the consent form before signing it. In fact, this research indicates that most patients could not recall most of the details in the consent form. Cordasco (2013) notes that previous research has attributed this to old age, low level of education, cognitive dysfunction, low intelligence levels, and low health literacy levels. Like Campbell et al. (2004), Cordasco (2013) also highlighted that patients from the minority race were found as less likely to recall contents of the consent forms that whites, which could be explained by low literacy levels. While Cordasco (2013) accepts that patients with cognitive impairment are vulnerable when making an informed consent, the researcher emphasizes on the need for a detailed research to ascertain whether a patient is competent enough to make an informed decision.
Another research by Fields and Calvert (2015) evaluates the ethical underpinnings of informed consent procedures among patients with cognitive dysfunction. Like other previous studies have indicated, Fields and Calvert (2015) note that a patient’s cognitive dysfunction can adversely affect their ability to understand different treatment alternatives. While explaining the importance of determining a patient’s capacity to make an informed consent, Fields and Calvert (2015, p.464) define capacity as “…the ability to understand and reason through the decision-making process so that a rational choice can be made about whether or not to consent to treatment.” Therefore, the author insist on the importance of ensuring that best practices guide the evaluation of the patient’s ability to understand options of treatment before signing any informed consent form.
One such best practice is informing patients the benefits and risks associated with different treatment option. In doing so, a physician should also gauge if the patient is in a position of understanding what they face with the treatment option and ask questions to clarify any issues they may feel are not adequately addressed. Like Cordasco (2013), Fields and Calvert (2015) insist that informed consent forms should not be mere formalities but an opportunity for the physician to interact with the patient and their family on critical issues affecting the patient’s health. Therefore, as Fint et al. (2010) suggest, one a physician has determined that the patient has a cognitive capacity to consent, caregivers must establish whether they are in a position of making an informed decision by assessing their competency level. Thus, all decisions must be made for the patient’s best interest (Fields & Calvert, 2015).
Taraghi et al. (2016) provided a comparison of key factors associated with cognitive impairment among patients with chronic heart failure. Research has indicated a higher prevalence of cognitive dysfunction among geriatrics who were female, lived alone or with their children, or had lower educational levels (Villarreal et al., 2014; Taraghi et al., 2016). Taraghi et al. (2016), thus, suggest that provision of patient-centered care was influential in improving a patient’s cognitive ability and reducing stress, which was associated with cognitive dysfunction. The research further outlines that there was a significant relationship between cognitive dysfunction with anemia, hypertension, and depression, which are common among the elderly. Besides, while relating cognitive impairment and heart failure, Taraghi et al. (2016) opine that the latter may have significant changes on neuro-imaging. Therefore, the authors suggest that in such cases, it is critical that caregivers work with the patient’s family to help reduce depression, which adversely affects a patient’s cognitive status. Consequently, the patient can then make informed decisions on their medication and provide consent to suggestions made by the physician.
Relevant Change Theory to Proposed Change
While popular theorists such as Lewin (1951) and Lippitt et al. (1958) have suggested different change models or theories, which are applicable in different fields, including the nursing one, this paper will focus on Lippitt et al.’s (1958). Although Lewin’s change phases (unfreezing, moving, and refreezing) can be categorized as easily implementable, Lippitt et al. (1958) provides phases which can easily be assimilated into nursing core process elements, that is, assessment, planning, implementation, and evaluation (Mitchell, 2013).
Table 1: Lippitt et al. (1958) change Theory.
(Source: Mitchell, 2013)
For this project, the first phase is the assessment of the problem, which as already highlighted, is the need to properly identify patients with cognitive issues early on in treatment by having cognitive impairment evaluations in place, determining cognitive capacity and competence, as well as having alternative consent procedures. The next phase will involve presentation of the need for change to nursing leaders, nurses, medical practitioners, other caregivers, and patients in the facility. This stage will be crucial in influencing the need to motivate people to support the suggested change process. While Lippitt et al. (1958) note that external motivators can help assess agent’s motivation and resources, it will be critical to ensure that professionals from ANA and other regulatory bodies act on the best interest of the organization.
In the fourth phase, it is expected that the researcher will help define the change process and note the timescale for the implementation. Refinement of the plan will take place after consultation with different stakeholders in the organization. While I have worked on providing this proposal, my belief is that the organization should decide on an appropriate change agent in the fifth step. If given a chance, I will first focus on implementation of the plan based on its success in the geriatrics unit before fostering the same to other departments. Once the pilot programs have succeeded and proper evaluation made on the success of the change plan, the sixth change will require that I mobilize all practitioners to help implement the planned change. My key focus will be on the intrinsic motivations of the employees in the facility to encourage them into trying a new policy. Increased quality care and patient satisfaction will be their main goal and reward.
Finally, I look forward to helping evaluate the success of the project but only doing so as a consultant. This will provide room for other medical practitioners to evaluate if the project is a success, give suggestions or improvement, and possible see its implementation in other areas. In turn, my hope is that my team will feel motivated and help address contentious issues that arose from the project.
Figure 1: Force Field Analysis Diagram
The Planned Change/Planning and Implementation
Plan for Utilization of Resistant and Enabling Forces in Affecting Change
The main forces for change is that patients expect better treatment and effective service delivery in the case of emergencies. The need for better treatment is what necessitates policies to ensure customer satisfaction, which explain patient expectations. This factor is, however, challenged by a lack of capacity to embrace change among physicians and patients. Similarly, since patients with cognitive impairment may not be in a position of providing informed cases during emergencies, this plan is necessary improve service delivery. Nevertheless, the lack of impairment may make the change process slow. Moreover, as explained by Cordasco (2013), there is a need to educate patients on informed consent, including their rights, benefits of consent forms, and need for surrogates when they are unable to give consent. Physicians will have to deal with any negative attitudes among patients and try to convince them on how the change plan will help them.
In turn, this also explains the result of informed consent, making appropriate decisions, which is also a key factor for change. To achieve this, there is a need of goodwill from patients, whose support is the primary input in the success of the plan. Proper decision making influences the effectiveness of recovery by avoiding cases where patients reject care that could have helped them recover. Additionally, as seen in the literature review, hospitalization and re-hospitalization also lead to a cognitive decline, which impairs the patient’s ability to make an informed consent. Thus, this creates a need to reduce hospital revisit as a factor for change although lack of enough specialists may be a major challenge. Thus, the management will play a critical role in helping ensure that more specialists are employed to reduce the patient load per physician.
While patients benefit from better care, specialists would get higher salaries. The added responsibility of determining whether patients can make an informed decision and deciding the necessary interventions is critical. Therefore, specialists will have to receive training on informed consent procedures. However, some specialists may find the added salaries as an excuse not to work overtime, which may end up reducing efficacy of care. In addition, training may not resonate well with all physicians as some may resist it given the time the training may take. However, ensuring that the training does not interfere with their schedules and off-times coupled with a salary increase may encourage more specialists to take the training. Nevertheless, the focus should be more on the intrinsic motivators than extrinsic ones.
Implementation Steps of the Proposed Plan
Given the focus of this change plan, the following steps will be taken to ensure its successful implementation:
- The first step will involve notifying the organization’s management on the problem, proposed changes, outcomes, and implementation plan.
- After the presentation, I will discuss the plan with the management to identify areas of improvement and rectify on them before presenting another draft.
- The second draft will be discussed with caregivers who will through a survey provide their survey on whether the project will impact change, areas of improvement, whether they want to be part of the change process, and how the change can be implemented.
- The proposed changes will then be compiled and a final draft prepared with consultations from different internal and external specialists to determine its legality.
- The plan will then be presented to the public, who mainly constitute patients and their families to present their views on the plan. The education will include the benefits of informed consent forms, need to have surrogate patients, increasing comprehension of consent forms, and understanding the need for earlier detection of cognitive impairment.
- Once the plan is approved, the implementation process will commence.
- Available funding from the organization’s management will help in training, salary increases, getting necessary equipment, and patient education on the need for the program.
- Finally, the implementation will start in the geriatrics unit, which will be closely monitored by specialists for three months.
- The effectiveness of the planned change will then be evaluated to determine areas that need change and whether it can be adopted on a largescale basis. If ineffective, further research will be made to determine new policies. However, its success in this department will help implement the same in other departments.
Since capacity assessment is crucial in determining whether patients benefit from this plan, the researcher will use capacity assessment tools adopted from Fields and Calvert (2015) (Table 2). Additionally, this research will train physician on determining criteria for decision-making capacity (Table 3).
Table 2: Capacity assessment tools.
Table 3: Criteria for decision making capacity.
Planned Change/Evaluation
Evaluation Criteria
The plan for this proposed change is expected to first use a three-month pilot study in the geriatrics unit as a base for decision-making on whether to implement the project in the whole organization. Therefore, to evaluate its success, the researchers who will mostly comprise caregivers in the unit and specialists employed by the organization will analyze data on cases of patients with cognitive impairment and how they responded to the guidelines in Table 3 with the help of the capacity assessment tools in Table 2. Moreover, the time taken to detect cases of cognitive impairment among patients will also be used in the evaluation process. While the study plans to use a series of surveys among patients and physicians, reports from specialists employed by the organization will act as the main guide in determining whether the project succeeded or not.
Data Collection Plan
Most data will be collected daily by nurse practitioners and other specialists working in in the geriatric unit as they assess patients. However, all patients will have to give their consent to participate in the survey, which will be carried out with the aid of the tools identified in Table 2 and Table 3. The rates of improved ease in seeking consent from patients, rates of the use of surrogates, or modified consent forms suggested by Cordasco (2013) will also be analyzed. This change plan hopes to identify new revised consent forms that summarize information in a way patients with cognitive impairment can easily understand. Surveys and feedbacks from caregivers in the facility in the facility will also be taken by a team selected by the management. Finally, with the specialists involved in training and education will assess how caregivers use the new assessment tools and how responsive patients are.
Student Self-Identified Strengths and Weaknesses as Change Agent
The expectation that this project will help see a reduction in cases of delays in decision making especially during emergencies for patients with cognitive impairment is a major change agent. Besides, the project is expected to increase alternatives in decision making and make it easier for patients to understand and recall details in consent forms. Finally, the project will also focus on a patient-care based approach to treatment through interaction between patients and caregivers, which will improve delivery.
Nevertheless, with possible negative attitudes from patients, it will be challenging to convince them that the change plan is meant to provide better care. Besides, lack of resources to employ more specialists and conduct the training process may make evaluating the success of the project challenging.
Strategies for Inter-Professional Communication and Collaboration
The success of this project depends on whether everyone affected by it comes on board. Proper communication remains a major requirement to help see the project completed successfully. However, devising a good change plan has not been easy. I still need more consultations with my organization on how to implement the project. My decision to try out the project in one unit may mean that if it fails, then the management may not try it in other areas, which would have shown different results. However, I believe that more research will help improve the plan.
Moreover, this project’s success needs frequent meetings aimed at addressing new developments in the implementation of the project. Since many stakeholders are involved, departmental meetings will be a good place to address key issues that arise after the implementation of the project. Suggestions from such meetings can then be combined and further directions provided by the management. Finally, help from professionals from bodies such as ANA and the organization’s legal team will also ensure that specialists and caregivers act within stipulated codes of ethics. In turn, this will ensure that caregivers do not engage in practices that may be termed as illegal or went outside the set nursing conduct.
References
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