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After completing this program I am more aware of evidence-based practices and their effects on nursing care. I am also able to think about what is ethically correct in my practice.
This change project has shown me just how much planning goes in to any change that relates to nursing practice. There are many intricate steps to change practices based on evidence. One must find valid evidence that shows pertinent information to the problem. Sometimes it is quite difficult to find sufficient evidence. I struggled finding enough evidence to support my proposed change. There simply isn’t much research being done on surgical ‘never events’. Good supporting evidence is something I will never take for granted. “Best evidence includes empirical evidence from randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion” (Titler, 2008).
Ethically, surgical ‘never events’ should never occur as it is our duty as health care professionals to protect our patients from harm. Since most ‘never events’ are harmful to the patient it is our duty to prevent them to the best of our abilities. Since I work in a surgery department this aspect of my change project has changed my outlook on my career. I will do my due diligence to ensure that I follow Universal Protocol and other measures to ensure my patient is correct with the correct procedure and site.
My outlook on my career also changed when I learned that the culture of nursing sometimes does not encourage staff to speak up when there is an issue or error. Oftentimes surgical ‘never events’ occur due to a simple error or overlooking something or that someone saw a mistake or had a concern and did not speak up. Or if someone made a mistake and knew it but chose not to say anything. The culture is often geared toward punishment of mistakes rather than learning from them. I will always put my best foot forward and speak up whether I have made a mistake or someone else has made a mistake. Advocating for patients shouldn’t depend on whether you will be penalized for a mistake or not.
Titler, M. (2008). The Evidence for Evidence-Based Practice Implementation. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
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