Clinical Log: NGR 6723L

Student Name: Lisa Irvin

Preceptor Name: Francine Marabell

Clinical Location: Baptist Medical Center - South

This clinical log is a confidential personal journal and intended only to document participation and facilitate student/CON faculty
communication/evaluation. This lab requires a total of 135 clinical hours completed and the log submitted no later than the date for
FINAL LOG submission noted on the course schedule and under assignments. Both evaluation forms are due at the same time.

Review the course objectives and develop objectives specific to your learning environment in collaboration with your preceptor. This
activity is to be undertaken no later than the first week of the semester and individualized objectives must be approved by your course
instructor.

Course Objectives:

1. Evaluate the role of the nurse leader in ensuring that the philosophy and structure of nursing services provides for the delivery of effective nursing care.
2. Determine strategies used by the nurse leader to maintain proficiency, communicate and collaborate effectively, participate in policy and decision
making, and serve as an advocate for both staff and the recipients of nursing care.
3. Evaluate the role of the nurse leader in the administration of fiscal resources and the acquisition, allocation and utilization of fiscal resources.
4. Assess the use of the nursing process as the supporting framework for direction of patient care services including data acquisition, records and record-
keeping, planning, implementation, evaluation and provision of resources to optimize use of this process.
5. Help implement processes used to ensure that the practice climate enables nurses to practice in accordance with their professional education, promotes
professional growth and fosters a participative working environment.
6. Identify the components of the quality assurance/quality improvement program, the mechanisms to resolve problems and improve care, and evaluate
outcomes.
7. Participate in implementation of procedures and processes which guide nurse participation in ethical decision making.
8. Demonstrate understanding of the mechanisms used to promote evidence based administrative and nursing practice, including the use of research.
9. Analyze personnel and practice policies to determine their effectiveness in promoting equality and continuity of nursing services and cultural
competence in the provision of client care.

Individualized Objectives:
 1. Summarize how the hospital nurse leader juggles a variety of tasks such as patient satisfaction and staff retention without compromising

safety.

2. Outline steps the nurse leader uses to develop policies and procedures related to hospital-based patient care.

3. Describe steps required by nursing department leaders needed to maximize profits with regards to value-based purchasing.

4. Analyze the reporting tools used in conjunction with the electronic medical record to report data and determine validity of outputted

data.

5. Collaborate with nursing department unit councils to determine the effectiveness of the councils in allowing for nursing autonomy,

education and professional growth.

6. Describe the implementation of quality improvement programs designed to decrease catheter-associated urinary tract infections and

surgical site infections.

7. Analyze the role of nursing on the hospital ethics committee as it relates to end of life decisions.

8. Analyze the organizations evidence-based practices and evaluate their implementation into practice.

9. Working with the Human Resources department, describe steps taken to teach equality and inclusiveness of all staff members.

Week Hours Activity Analysis of Experience

(date of Completed (Insights, Lessons Learned, Leadership Techniques
participation) (Running Observed)
Total)
Week 1 2.5 hrs Emergency Dept Unit Council and Staff Helped to develop plan that will allow the departments
(1/16/17) meetings Unit Council to have a stronger presence and influence.
Began planning to assist with application for the
Emergency Nurses Association Lantern award.
Week 2 5 hrs (7.5 Clinical tracer and clean sweep of
(1/23/17) hrs) inpatient Med-Surg unit
Week 3 8 hrs (15.5 Design of surgical site infection (SSI)
(1/30/17) hrs) audit program
Week 4 10 hrs (25.5 Participated in performance
(2/6/17) hrs) improvement program to reduce
CAUTIs
Week 5 11 hrs (36.5 Met with ED Nurse Manager to design
(2/13/17) hrs) a Flex Staffing model. Additionally, I
met with members of the Lantern
application committee (mentioned in
Week 1) to discuss progress and
establish a timeline. I also completed a
clean sweep of the ED and educated
staff on accreditation compliance
opportunities
Week 6 10 hrs (46.5 I designed and created an improved
(2/20/17) hrs) Code Cart log book that includes
pictorial diagrams. I attended the code
blue meeting where the log book was
presented at and voted on to be
implemented hospital-wide.
Sepsis core measures were also
discussed with opportunities for
improvement. I worked with my ED
manager and preceptor to devise
improvement strategies
Attended interdisciplinary tracer rounds. Performed
clean sweep, patient tracer, unit education with new
nurse manager.
Together with my preceptor, we created a chart audit
tool to investigate potential SSIs and their relation to
surgeon, antibiotic choice, time of administration, etc.
The incidence of Foley catheter-associated urinary tract
infections (CAUTI) has been increasing in our hospital. I
assisted with this ongoing, hospital-wide effort by
performing visual assessments of catheters to ensure
guidelines were being followed. This was followed up
with chart audits for evidence of Foley care and any RN
counseling that was needed.
A Flex Staffing model would allow the number of staff
working to vary depending on patient volume. The
volume in the ED can vary on certain days and hours.
This model would allow the ED to put more funds back
into the budget without sacrificing staff.
When the committee noticed a need for improvement, I
assisted in designing a solution and worked to implement
it. The new book is designed to improve efficiency and
outcomes during a code. I will be tasked with creation of
the new log, hospital staff education and roll-out.
Regarding sepsis, historically there are many
opportunities for improvement. I took these
opportunities and individually coached ED staff members
on current guidelines.
Week 7 10 hrs (56.5 Examined recent cases of pressure
(2/27/17) hrs) ulcers caused by respiratory devices.
Conducted literature review and
consulted with respiratory department
to devise a plan that will have bedside
nurses collaborate with respiratory
therapists to enable a team approach to
monitoring potential pressure ulcer
risks.
Assisted my preceptor to prepare data
for upcoming meeting with executive
administration. Learned how data is
extracted and placed in a data base
where we can view our data on core
measures.
Week 8 11 hrs (67.5 I reviewed many of the organizations
(3/6/17) hrs) policies that pertained to ethical issues.
Met with members of the Ethics
Committee to discuss process of policy
revision and those involved. We also
discussed healthcare issues that arise
that may not be initially categorized as
ethical problems such as the acceptance
of gifts from patients.
I also had a meeting with a member of
our finance team to discuss how
patients are charged for supplies and
services. I am devising an education
plan that would demonstrate the areas
where the hospital loses money and
show staff what part they can play in
conservation.
Week 9
(3/13/17) SPRING BREAK
Conducting a literature review allowed me to use
evidence-based practice to help devise a teamwork
approach to the problem.
Preparing for a meeting with upper administration, I was
able to witness the pressure that is exerted on managers
to present metrics data that shows the hospital is meeting
its core measures. For measures that are in lower
percentiles, administration wants a concrete plan of what
management plans on doing to produce better scores. I
learned that
Learning about ethical issues was very interesting and
thought-provoking. There are issues that arise that I
would never have classified as ethical. I believe this will
allow me to devise solutions to problem based on
knowing what the root cause really could be.
Conservation of resources has been the topic of many
administrative meetings in the organization. I think it is
important to involve all levels of staff in the solutions to
these issues. I was grateful to learn about the charging
process that bedside nurses do not usually hear anything
about. By disseminating the information about ways the
nursing staff can conserve and be fiscally responsible will
help to keep the staff engaged and involved.
Week 10 14hrs (81.5 Attended interdisciplinary stroke
(3/20/17) hrs) meeting. Assisted stroke coordinator
with implementation of a new pre-
notification system for patients arriving
by rescue to the emergency
department. Over the course of a
couple days, we worked one-on-one
with all members of the staff regarding
this new process and what everyones
roles are
Week 11 14hrs (95.5 Met with members of Quality
(3/27/17) hrs) Improvement and Research
departments to discuss what programs
where underway, their progress and
what more needs to be done. Attended
weekly leadership rounds focusing on
staff knowledge of infection control
policies and practices. There was
focusing on hand hygiene before and
after patient contact. I also acted as a
secret shopper by observing hand
hygiene of all staff during patient
interactions.
Week 12 15.5hrs (111 Together with the stroke coordinator,
(4/3/17) hrs) chart tracers were conducted on staff
regarding stroke patients. Due to an
By attending the stroke meeting, led by the stroke
program coordinator, I witnessed how a meeting
comprised of those in leadership positions is conducted.
Decisions about certain changes needed to be discussed
and was occasionally met with opposition. In these cases,
due to the collaborative nature of the group. Alternatives
were considered and discussed.
Rounding through the departments that would be
affected by the new prenotification system was
interesting because I saw varying levels of reception and
interest. Unfortunately, there were (and probably always
will be) staff who do not agree with a change or are not
interested. I learned how to get through to these types of
staff members and make them engaged. I also learned
how difficult it can be to educate a small amount of
information to a large group while they are working and
may not give you their divided attention
Through these meetings, I learned about different types
of research programs and the complexity of them.
Infection control measures taken to reduce and prevent
infections is being highly emphasized due to the link to
financial reimbursement. There are daily manager
briefings on the number of recent infections and what is
doing to prevent and treat. Fortunately, staff are getting
used to the constant emphasis on hand washing and are
becoming more aware of its importance in infection
prevention. I saw how this hand hygiene program is
conducted weekly by managers and reports are sent to
senior management. Leadership techniques included
being good stewards of patient safety, enhancing staff
education and using research to guide decisions.
While continuing to provide stroke education, when staff
resistance was met, the department manager was notified
and together with the stroke coordinator, staff were
 upcoming Joint Commission
recertification survey, all staff need to
be educated on the hospitals stroke
policies and procedures. We also
continued to review the emergency
departments stroke pre-notification
procedures. During an unannounced
state inspection, prompted by a patient
complaint, I participated in data
collection and department rounding.
Week 13 14 hrs (125 I met with the manager of the language
(4/10/17) hrs) services department. I saw how they
coordinate with the many translators
used by the facility for patients who do
not speak English. Another part of this
role is ensuring pertinent signage and
documents are offered in other
languages. We also worked on a plan to
revise services provided to deaf people
due to a change in terminology
preference. I learned that deaf people
prefer the term deaf versus hearing
impaired.
Stroke tracers were continued to be
done on staff as well
Week 14 10 hrs (135 Part of this week was spent in the
(4/17/17) hrs) House Supervisors office. The role of
this position is to ensure that the
hospital is staffed and taking proper
steps to admit and discharge patients in
counseled on the importance of conducting continuing
education so that the hospital stays in a constant state or
preparedness and is providing good patient care. This
demonstrated the importance of a strong
interdisciplinary partnership.
An unannounced site visit by a state inspector was an
interesting experience. Needless to say, leadership was
very involved in this situation and apprised of the
seriousness. I saw the professionalism and coordination
required. This was an example of the need to ensure
compliance with all state regulations at all times.
Fortunately, leadership was able to demonstrate
continued staff education and training and the complaint
was unsubstantiated.
Being aware of and cognizant to the needs of other
cultures and communities of people is an important
leadership quality. Cultural sensitivity also brings with it
certain legal responsibilities. This is due in part to the
fact that if the organization does not provide equal and
fair communication avenues for all patients, this can be
considered discrimination.
I was able to witness how this leadership position
requires a lot of independent decision-making, critical
thinking, crisis management and assertiveness. Part of
the position involves dealing with physicians who may
inappropriately demand their patients be placed in
 a timely manner. They are also
responsible for service recovery when
needed. Responsibilities include
staffing, assigning inpatient beds,
responding to codes and coordinating
with the floors to facilitate discharges,
to name a few.
The remaining time was spent
reviewing what was learned during this
internship, completing the evaluations
and attending meetings for quality
initiatives and upcoming inspections
certain areas. These situations need to be dealt with in a
professional, collaborative way.
I did notice that leadership involves attending a lot of
meetings, devising plans and then taking these to staff for
implementation. In the area of quality, there is a strict
analysis of quality measures. The managers responsible
for those that need improvement need to present plans
for such.

Provide a brief strategic assessment of the outcomes achieved related to each of the identified personal objectives noted above and
your plan to integrate the learning into your academic development and professional practice:

Objective 1: Observed training and education of new nurse manager regarding unit compliance to Joint Commission standards. Topics
included environmental concerns, cleanliness, and patient privacy. It was accompanied by a tracer of a current patients chart. I was able to
witness how this nurse manager responds to patient and family complaints, retains staff and maintains a safe and pleasant working
environment. This will allow me to use some of these methods and techniques in my own practice as future manager.

Objective 2: The stroke meeting and subsequent staff education allowed me to witness decision making and collaboration. Getting a group
together from different areas allows for different perspectives of the issue. Also, during a patients hospital stay, they encounter many
different departments participating in their care. It is essential that departments be willing to collaborate on issues that have an impact on
patient care.

Objective 3: The role of the nurse leader in budgeting is becoming a larger one. Observing the complexity of scheduling and budgeting for
an entire department has given me insight into what a large part of the management job it is. Additionally, staffing and budgeting is a
constant, ongoing process throughout each fiscal year. This includes hiring new staff, training, and annual performance reviews with
associated merit increases. An indirect budget issue is that of value-based purchasing and ensuring that core measures are being met.
Performance plans that address any deficiencies must be in place.
Objective 4: Core measure data is reviewed by performing various reports built into the EMR. This data is reviewed for accuracy and
validity and then applied to the provision of patient care services. Data that demonstrates lower than anticipated results is further scrutinized
to determine any causes and possible solutions. Performance improvement projects are created based on these data. Depending on the
projects planned, interdisciplinary teams may be formed to accomplish objectives.

Objective 5: Application for ENAs Lantern Award will require year-long planning and promotes professional growth. This award
recognizes emergency departments that are exemplars in their field. We will gather data on staff and patient satisfaction, wait and through-
put times as well as education and certifications of the staff. I plan to co-chair the ED Lantern Committee. This will allow me to utilize my
leadership skills by assisting with such a large project.

Objective 6: This week focused on taking a step towards decreasing the hospitals rate of surgical site infections. These are on the list of
conditions that will not be reimbursed by CMS. The hospital wants to receive as much reimbursement as possible to pay for expenses while
also providing excellent patient care. To accomplish this, I audited all colorectal surgery cases performed during a period of two weeks. My
task was to determine how much time had elapsed between surgical cut time and antibiotic administration time, antibiotic choice, patient
temperature and blood glucose, along with other data points. These are all factors that, when coupled together, greatly increase the patients
chance of developing an SSI. These data will be used to create a standardized process of care given to this population of patients.

Week 4 also focused on performance-improvement projects. Like SSIs, costs associated with hospital-acquired CAUTIs will not be
reimbursed. There is currently a big push to eradicate these unnecessary infections. A program is in place to use best practices, in the form
of a Foley bundle of catheter dos and donts, designed to change the way we care for Foley catheters. I assisted with this initiative by
rounding on nursing units, reviewing Foley care with the nurses and looking at individual cases to ensure compliance with the bundle.
During rounding, a few problems were uncovered and I am working with our performance improvement team to devise solutions. This week
allowed me to see the complexity of designing, implementing, and monitoring a PI program.

Objective 7: Working with members of the ethics committee, policies that needed revision were identified. It is important to ensure ethics
policies are current to organization standards as well as best practice standards. The Ethics Committee is a multidisciplinary team comprised
of members of both the nursing and medical departments, social work, and risk management. There seems to be a heavy emphasis on the
role of nursing in the ethical decision-making process. Learning how policies are devised and written will allow me to identify situations
that fall under the category of ethics without it being explicitly stated.

Objective 8: Research has been demonstrated to play a large role in the creation of policies, procedural changes and staff education. As a
Magnet-designated facility, the hospital must demonstrate the use of evidence-based research to guide nursing practice. I frequently
encountered the question what does the literature say? being asked when trying to solve a problem. When the problem of pressure ulcers
being caused by respiratory devices was discovered, we did literature reviews to see if this was a problem in other facilities and what were
some potential solutions.

Objective 9: Inclusiveness and cultural sensitivity are essential qualities any organization should possess. During this internship, I saw this
demonstrated frequently. During new staff orientation, part of the program is dedicated to information on care for members of the LGBTQ
community. This is a new topic that has not had to be addressed until now. As more and more people are forthcoming with their sexual
orientation or gender identity, informing both current and new staff what they need to know regarding all aspects of this culture group is
important. This is an example of how nurse leaders need to be informed and abreast of aspects of having to possibly modify the cultural
teaching of staff so that all patients are treated respectfully. This applies to the varying cultures found among staff as well.

I certify that I have completed the individualized objectives and clinical lab hours noted above under the supervision of
_____Francine Marabell____________________________________________________________________________________

Student Signature: _________________________________________________________________________________________

Date: ___4/21/17________________ ____________________________________________________________________________