NUR 684 Module 2 Microsystem Assessment Paper Example

A 5P Microsystem Assessment of an Orthopedic and Surgical Unit

[Student Name]

Southern New Hampshire University

NUR 684: Clinical Nurse Leader Capstone

Module Two Microsystem Assessment Paper

[Instructor Name]

[Date]

A 5P Microsystem Assessment of an Orthopedic and Surgical Unit

A clinical nurse leader's first task on any unit is to see it clearly. An assessment built from impressions tends to confirm what the assessor already believes; one built from data can surprise. The microsystem assessed here is Clearwater General's 32-bed orthopedic and surgical floor, a composite unit, examined using a structured framework and the unit's own numbers. It describes each dimension of the framework, reports what the data show and explains how the findings point to an improvement focus for the scholarly project.

The Framework

Nelson et al. (2002) studied twenty front-line clinical units recognized for high performance and identified characteristics they shared, among them leadership that sets direction, a culture that values staff, close attention to patients, interdependent teams, good use of information and a habit of improving processes. From this research, the Dartmouth group developed a practical assessment that sorts what a unit is and does into five headings, each beginning with P, that move from why the unit exists, to whom it serves and who serves them, to how the work flows and what results it keeps producing. The framework is useful for a CNL because it keeps attention on the whole microsystem rather than on a single problem the assessor already cares about.

Purpose

The unit's stated purpose, drafted with staff during the assessment, is to help adults recover mobility and independence safely after orthopedic and general surgery. Most staff described the purpose in terms of getting patients up and home, which fits the surgical population but says little about preventing complications that delay that goal.

When asked what the unit is best at, staff named early mobility and discharge teaching; when asked what it struggles with, several mentioned skin breakdown in frail patients, although none saw it as the unit's shared responsibility.

Patients

Over the past year the unit averaged 28 patients a day with a median length of stay of 4.1 days. About 38% of admissions were elective hip or knee replacements, 22% were hip fractures and 40% were general surgery patients. The median age was 71, and hip fracture patients had a median age of 83. About 12% of patients developed delirium during their stay.

Bergstrom et al. (1987) built the Braden scale, which scores risk across six areas: how well the patient senses discomfort, skin moisture, activity, mobility, nutrition and exposure to friction and shear. Scores range from 6 to 23, with lower scores indicating greater risk. A review of 200 consecutive admissions found that 31% scored 18 or below on admission, a threshold commonly used to flag risk in older adults, and 74% of hip fracture patients did so.

Table 1. Patient Profile, Previous Twelve Months

Note. Figures are illustrative for the composite unit.

Professionals

The unit employs 58 registered nurses and 18 nursing assistants, with each nurse carrying five patients by day and six overnight. Two orthopedic hospitalists co-manage surgical patients, two physical therapists and one occupational therapist cover the unit on weekdays, a dietitian is available half-time and a single wound nurse covers four units. Registered nurse turnover last year was 18%, and four in ten night nurses were within their first two years of practice. The unit's skin champion position has been vacant for eight months.

Processes

Policy requires a Braden assessment on admission and daily, repositioning at least every two hours for at-risk patients and heel offloading for patients scoring 18 or below. Audits during the assessment told a different story. Braden scores were documented within eight hours of admission for 82% of patients, but only 61% of at-risk patients had repositioning documented every two hours across a full shift, and heel offloading devices were in place for 3 of 11 at-risk patients observed on one day. Hip fracture patients spent a median of six hours on emergency department stretchers before reaching the unit, and no skin check was documented at transfer for most of them. Dietitian referrals for low nutrition scores averaged three days.

Patterns

Four quarterly prevalence surveys identified 7 of 112 surveyed patients with a stage 2 or deeper injury acquired on the unit, about 6%. Five of the seven were on heels, and six occurred in hip fracture patients. Lyder et al. (2012) reported that about 4.5% of Medicare inpatients in a national sample developed a pressure injury during their stay, and those patients had longer stays and higher mortality. The unit's prevalence exceeds that figure despite a younger overall population, driven by its hip fracture patients. Other patterns included daily safety huddles that rarely mentioned skin and a culture in which staff saw pressure injuries as the wound nurse's responsibility.

From Assessment to Focus

Read together, the five dimensions converge. The patient profile shows a large, high-risk group of older hip fracture patients. The professionals section shows a thin wound nursing resource, a vacant champion role and many inexperienced night nurses. The processes section shows gaps in repositioning, heel offloading and emergency department handoffs. And the patterns section shows injuries concentrated on the heels of exactly these patients. The assessment therefore points to one focus: preventing heel pressure injuries in older patients after hip fracture surgery. That focus came from the data, not from a prior interest, and it sits squarely within the CNL's reach because it depends on coordination across the emergency department, nursing, therapy and nutrition.

Limitations

Prevalence surveys are snapshots, and seven injuries is a small number from which to draw firm patterns. Audits were done on a few days by the assessor, which may have influenced staff behavior. The purpose statement was drafted during the assessment and may not reflect a shared view. These limits will shape the project's measurement plan, which will add monthly incidence tracking to quarterly prevalence.

Conclusion

The 5P assessment shows a unit with a clear purpose, a high-risk population, stretched specialist resources and process gaps that line up with its most common harm. It gives the capstone a focus that the microsystem itself selected.

References

Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210. https://doi.org/10.1097/00006199-198707000-00002

Lyder, C. H., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N. R., & Hunt, D. R. (2012). Hospital-acquired pressure ulcers: Results from the national Medicare Patient Safety Monitoring System study. Journal of the American Geriatrics Society, 60(9), 1603-1608. https://doi.org/10.1111/j.1532-5415.2012.04106.x

Nelson, E. C., Batalden, P. B., Huber, T. P., Mohr, J. J., Godfrey, M. M., Headrick, L. A., & Wasson, J. H. (2002). Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. The Joint Commission Journal on Quality Improvement, 28(9), 472-493. https://doi.org/10.1016/S1070-3241(02)28051-7