the Nursing Unit Manager (NUM) of a surgical ward. She has been made aware, through a number of recent audits, of an increasing incidence of...
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the Nursing Unit Manager (NUM) of a surgical ward. She has been made

aware, through a number of recent audits, of an increasing incidence of medication errors on the ward. She holds a meeting with the Clinical Nurse Educator (CNE) and Clinical Nurse Specialists (CNS) to address the issue of safe medication administration. She asks that they consider coaching some of the junior nurses who are underperforming in this area due to lack of knowledge or skills. 
Ellen is a CNS. She is asked by Sarah, an Enrolled Nurse, to witness her administering an intravenous (IV) medication. Ellen observes that Sarah fails to complete the necessary safety checks. She reprimands her loudly, saying that she is "unsafe" and that "this is the reason medication errors occur and patients die". She begins quizzing Sarah on the action of the drug, side effects, mode of administration and interactions. Sarah is embarrassed and flustered. The room is full of patients, relatives and staff, and she is conscious that everyone is now staring at her. She stutters a response. Ellen shows visible signs of irritation and impatience and interrupts her, taking over the procedure, telling her "this is how it is done". She instructs Sarah to come and find her the next time she has an IV medication to administer, and that she will supervise all her IV medication administration "from now on". She then leaves the room to answer her pager, leaving Sarah confused and embarrassed. Sarah's confidence is damaged by this encounter, and she subsequently feels nervous and afraid to perform any task without direct supervision by Ellen or another nurse. 
Christian is a CNS on the same ward. He witnesses the event. He observes that Sarah is lacking some skills and knowledge in the area of medication administration and offers to provide some coaching. Christian informs Sarah that he is trained as a coach, and explains that coaching can empower people by enabling them to develop their capabilities to meet new challenges. Sarah accepts his offer of coaching, and they arrange to meet the following day. 
During their meeting, it is agreed that Alice, the NUM, will be made aware of their coaching arrangement, and provided with updates on Sarah's progress. It is also agreed that any issues discussed in their coaching sessions will remain confidential, unless it is felt there is a risk to patient or staff safety. 
Christian begins by making some motivational assessments - asking questions to determine what issues they need to focus on in order to set goals that are realistic, desirable and motivating. 
"Can you tell me a bit about your situation, what you find particularly challenging, what you would like to learn? How do you like to learn?" He asks about Sarah's experience as an Endorsed Enrolled Nurse, and her previous experience with administering IV medication. Sarah states that she became an Endorsed Enrolled Nurse some years ago, but worked for an extended period in mental health, where IV medications were not frequently given. 


She states that she missed her annual clinical competence assessment last year as the CNE was on maternity leave. Sarah acknowledges that she needs a'refresher'. She says she prefers to learn by reading and watching demonstrations, before attempting to perform a task herself. Christian asks if she would like to talk about any barriers or pressures in her work or personal life that may affect her learning or clinical practice. Sarah states that she finds time management a challenge, and doesn't like to bother other nurses with questions and appear incompetent. She admits to feeling rushed when giving medications, and feels she does not have time to look up policies or protocols. Christian reinforces the importance of adherence to medication safety policy directives in order to ensure patient safety. He encourages Sarah to ask questions when unsure, regardless of time pressures, as providing education and support to ensure patient safety is the responsibility of all nurses on the ward. 
Christian and Sarah begin goal setting. They work collaboratively to set a number of realistic short term knowledge and performance-based goals. 
Sarah's learning goals: 

-Sarah will be able to list the five rights of safe medication administration. 
-She will be able to demonstrate safe administration of IV medication, in accordance with the ward's protocols. 
-She will be able to identify when to ask for help and where to access resources (online learning resources and unit policies). 
-She will be able to list the actions, contraindications and side effects of IV medications commonly given on the ward. Christian and Sarah work together to develop a systematic plan of action for achieving these goals, taking into consideration her learning style and previous experience. It is agreed that reading material will be provided and that Sarah will discuss any questions about the reading material with Christian. She will view online hospital training videos and attend an in-service demonstration with the CNE on the correct procedure for IV medication delivery. Sarah will then perform the task under supervision, providing a rationale for her actions. It is decided that Sarah's goals will be assessed and reevaluated at the end of the week. Christian agrees to be available to assist and assess Sarah on a daily basis, provided they are rostered on the same shift, and will ask the nurse in charge of Sarah's other shifts to be aware of her needs and to be available for coaching. 
Christian supervises Sarah's clinical practice throughout the week, providing feedback in close proximity to performance where appropriate. At the end of the week the goals are reviewed. Christian begins by giving Sarah the opportunity to self critique. He asks Sarah how she feels she has performed and what she feels are her strengths and weaknesses. Christian reinforces Sarah's positive steps and achievements. He identifies some ongoing gaps in her knowledge and skills and gives examples: 'I have observed you consulting 
the ward protocols and MIMs and seeking help from staff when appropriate this week, however you have still occasionally required prompting when doing your checks prior to administration - how can we work towards achieving that goal this week?' It is agreed that Sarah requires further coaching. New goals are established and a date and time is set for reevaluation


Question
1.     What is the problem statement that briefly describes the problem and outlines the important challenges that make the specific problem difficult to solve? 


2.     Imagine 3-4 possible solutions to the problem. Describe each of the possible solutions in enough detail as to be able to evaluate each possible solution's relative merits. 


3.     Make a list of the strengths and challenges of each possible solution and choose the one you think has the highest probability of solving the problem. 


4.     Design a scheme to implement your solution. Explain how the solution could be scaled up from a departmental to organizational (hospital) to a national scale. 


5.     Imagine your solution was implemented at a departmental level. Design and explain a method of determining whether your solution solved the problem at the department level. Explain what data would be needed to determine whether the solution worked. Outline how the data would be collected and analyzed and the timeline for evaluation. Estimate what the determination of success of your solution at the department level would cost by generating a resources request for determining success. 

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