APA Style 7th Edition

NURS 308

APA Assignment Overview

The intention of this assignment is to guide your development of formatting papers, references, and intext citations to align with the formatting used in nursing which is reflected in your textbook; American Psychological Association. (2020). Publication manual of the American psychological association (7th ed.). Washington, DC: Author.

Choose one of the two theses available for this assignment:

1. Relationship Between Codes Called and Shift Change

2. Education for Nurses: Compassion Fatigue

For this assignment,
you will be correcting
a paper that has multiple APA 7th edition errors. You will use the readings and YouTubes provided to guide you in this assignment.

Make a list of the errors you find OR highlight the errors on the document. (3 points)

Additionally, you will write a paper containing the following information about the thesis you choose:

1. one paragraph introduction of assignment associated thesis (1 point)

2. brief background of the assignment associated thesis using a direct quote from the article (will need to cite appropriately according to APA 7th edition formatting) (2 points)

3. paraphrase some background information from the assignment associated thesis (will need to cite appropriately according to APA 7th edition formatting) (2 points)

4. Create a reference for assignment thesis (2 points)

Please see Assignment Rubric for further grading details

Assignment Due Date:

Assignment to be submitted to the “APA Assignment Drop Box” by schedule indicated due date

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Relationship Between Codes Called and Shift Change

Gannon University, Villa Maria School of Nursing

The Research Process in Nursing

Dr. Snyder

January 25, 2022

Relationship Between Codes Called and Shift Change

The research paper I read was about an adverse occurrences during shift changes vs non-shift changes as a possible major cause of patient deterioration. Also, the writer used data and chart from a local hospital and studied. The benefit of the research is to inform policy and procedure improvements (Doe & Doe, 2022). Any ideas that are from a resource must include a citation of that resource. It can be one time, early in the paragraph. If the resource changes, you must add the new citation.

Background

The data and chart that were used were “100 charts from a local hospital and data analyzed” (Doe & Doe, 2022, p. #). Direct quotations must have a page number where the quote can be found.

Nurses play a critical role in patient care and responding rapidly when a patient’s condition deteriorated (Doe & Doe, 2022).

References

Journal Article with Two Authors. Thesis:

Doe, J., & Doe, J. (2022, May). Relationship Between Codes Called and Shift Change. (Italics) [Unpublished master’s thesis]. Gannon University.

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RELATIONSHIPS BETWEEN CODES CALLED AND SHIFT CHANGE

IN THE ACUTE CARE SETTING

Relat

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onship Between Codes Called

and

Shift Change in the Acute Care Setting

John Doe

Jane Doe

A thesis submitted in partial fulfillment

of the requirements for the degree of

Master of Science in Nursing

Gannon University

Villa Maria School of Nursing

May

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022

Abstract

This paper explores the time relationship of codes that are called in an acute care hospital setting. The researchers have explored adverse events during shift change as a potential primary instigator of patient deterioration, versus non-shift change. When care is not promptly given, various physiological changes can take place in a patient that can negatively affect their health outcome and put them at risk. Adverse events can occur quickly and unexpectedly as a result of a lack of care when staff are not able to adequately care for patients. Lack of care is explained as a deficit in the total care needed and the care received by a patient. This ultimately leads to a code being called by a nurse. One of those risks is inadequate and untimely care given by nursing staff. Detecting a patient change in status is key to the overall success of a hospital stay and is a significant contributor to the positive outcome of an acute care setting.

This research explores the timing of codes that are called in relation to shift change and non-shift change times. This study was conducted using a review of

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0 charts from a local hospital and data analyzed, to find a correlation between codes called and the shift change of nurses. The results have potential to guide policy and procedural changes.

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able of Contents

ABSTACT……………………………………………………………………………………………………i

CHAPTER 1- INTRODUCTION……………………………………………………………………

Statement of the Problem…………………………………………………………………….1

Purpose……………………………………………………………………………………………..1

Research Questions…………………………………………………………………………….1

Significance of the Problem…………………………………………………………………2

Theoretical Framework……………………………………………………………………….2

Definition of Terms…………………………………………………………………………….

3

Assumptions………………………………………………………………………………………

4

Limitations………………………………………………………………………………………..4

Chapter 2

– REVIEW OF LITERATURE……………………………………………………….

Introduction………………………………………………………………………………………

5

In Hospital Patient Safety……………………………………………………………………6

Inter-hospital and Intra-hospital patient transfers……………………………………

7

Intra-hospital transport policies……………………………………………………………

8

Correlation of Admission and Codes…………………………………………………….

9

Change of Shift Transfers…………………………………………………………………..

11

Summary………………………………………………………………………………………….12

CHAPTER 3- METHODS……………………………………………………………………………

Introduction……………………………………………………………………………………..13

Selection of Participants……………………………………………………………………13

Instrumentation………………………………………………………………………………..13

Data Collection………………………………………………………………………………..13

Data Analysis…………………………………………………………………………………..14

Summary…………………………………………………………………………………………14

CHAPTER 4- RESULTS………………………………………………………………………………

Description of Chart Review……………………………………………………………..15

Findings………………………………………………………………………………………….16

Chapter 5- DISCUSSIONS, CONCLUSIONS, AND RECOMMENDATIONS……

Discussion………………………………………………………………………………………18

Conclusions…………………………………………………………………………………….19

Recommendations……………………………………………………………………………20

REFRENCES……………………………………………………………………………………………22

APPENDICES……………………………………………………………………………………………

Appendix A: Data Collection Tool……………………………………………………26

Chapter 1

Statement of the Problem

Adverse events are unpredictable and unfortunately occur for some patients during their hospital stay. If an adverse event occurs to a patient during their admission, the hospital staff initiate an emergency code that alerts certain staff that they are needed emergently. This study seeks to examine whether more emergency codes are called during shift change versus non-shift change. The potential reasons for the increase in emergency codes during shift change can vary but the researchers will focus on two. A nurse may be distracted and the result could be a decrease in the nurse’s awareness of a declining patient. When a patient transfers to another unit during shift change, the probability of delayed care increases even more, and their health status can decline (Vazquez, C. 2015).

Purpose of the Study

The purpose of this study is to examine if more adverse events occur to patients during shift change versus non-shift change times. Furthermore, this study will examine the types of adverse events that happen during shift change.

Research Questions/Hypothesis

Research Question: What is the patient impact during shift change on the incidence of adverse events and code situations?

Hypothesis: More adverse events and code situations occur during shift change versus non-shift change times.

Significance of the Study

Nurses have an important role in caring for patients and acting quickly when a patient’s health status declines. One of the main goals for a nurse during the shift, is to make sure that all patients are stable and safe. A normal shift for a nurse in a hospital is 12.5 hours and includes many duties and responsibilities. The hospital environment is very busy, if not hectic. Simple mistakes can happen, for even the most detail oriented, hardworking nurse. At the end of the workday, a nurse has had multiple patients’ assignments that they cared for in a shift. The nurse is required to facilitate physician orders, chart, and pass medications to patients among other daily tasks. When a nurse is tired, i.e. at the end of a shift, responses may not be as quick and a nurse may not notice if a patient’s health status is starting to deteriorate. Initial decline of deterioration is a critical junction where more adverse events might be observed. Unfortunately, during shift change when patient observation is at its lowest, it may be too late to notice changes and codes are called.

Theoretical Framework

Florence Nightingale’s Environmental Model focused on environmental factors that would influence a patient’s health outcomes. Nightingale identified certain elements that had a

substantial contribution towards a patient’s recovery. These elements included ventilation, warmth, light, noise, bedding, cleanliness, nutrition, and social considerations (Ali, 2017).

Nightingale’s research focused on benefits that were directly related to patients’ positive outcomes which were affected by the environment. These risk factors that contribute to a patient’s decline during shift change, are in large determined by the patient’s environment and the environment of the hospital staff. Structuring the environment for a patient’s optimal positive outcome is in large the standard that Nightingale set (Ali, 2017). When nurses are not free to provide this type of environment for their patients, the outcomes will be directly affected.

Definitions

Adverse Events: An event that caused harm to a patient. (“Spotlight on…Adverse Events”).

Code: An emergency situation in a hospital in which a patient has a change in status, requiring a special team of providers (sometimes called a ‘code team’) to rush to the specific location and begin immediate intervention (Stoppler, 2017).

Rapid Response: When a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside

Shift: Defined in research as 6:45 a.m. – 7:30 a.m. and 6:45 p.m. – 7:30 p.m.

Shift Change: The time when responsibility and accountability for the care of a patient is transferred from one nurse to another. (Griffin, 2010).

Shift Report: The communication that ensues during shift change is linked to both patient safety and continuity of care giving (Griffin, 2010).

Limitations

The research and data collection will take place in one hospital. A small chart review was done with 100 patients in the same geographical area at a large metropolitan facility. The patient population has a variety of comorbidities and admitting diagnosis limiting the researcher’s ability to narrow the reason for a deteriorating condition.

Assumptions

It is assumed the research as gathered is representative of the general population. It will

include patients with varying health status, comorbidities, age, and admitting diagnosis.

Chapter 2

Introduction

Every minute is important in the care of a patient. Nurses are trained to monitor, treat, and advance patients’ health status. Patients that come to an acute care setting in modern day, are disadvantageously more health compromised than that of the generations before them. The precedence of comorbidities in society has grown exponentially. As of 2009, approximately 75 million people in the United States are living with 2 or more comorbidities, that negatively impact their activities of daily living and require ongoing medical attention (ANA, 2011). Considering the fast pace of medical facilities and the urgency of a nurse’s profession, it is understandable that nurses always need to be keenly aware of their patients’ health status considering the complexity of health problems.

Nurses are trained in critical thinking and to use evidence-based practice to extend care to those they are taking care of. This is important in nursing practice as it allows a nurse to individualize a patient’s care and use clinical decision making to further positive outcomes (Jensen, 2017). When a nurse’s attention is diverted away from patients’, these skills are not being used in the appropriate manner. One distractor that can alter a nurses’ attention from patient monitoring during shift change, is the transfer of a patient onto a unit during shift change.

Transfers happen continuously in the hospital. It could be argued that one of the most dangerous times to transfer a patient can be during a nursing shift change. A nursing shift change can take thirty minutes or more, depending on the population that is being cared for. When a patient is transferred to a new unit during shift change, mistakes are more likely to occur due to staff attention being diverted (Kulshrestha, A., and Singh, J., 2016). Another aspect that is equally important is the environmental impact of transfer that can negatively impact a patient’s health during transfer to a unit, which often happens at shift change.

The purpose of this research will be to examine adverse events that can occur during shift change, that make it difficult for nurses to complete critical tasks in a timely manner to ensure the safety and health of patients. This paper will examine why patients are more vulnerable to the adverse events and safety concerns during shift change, in the acute care setting that leads to a code.

In Hospital Patient Safety

Deviation in vital signs, respiratory rate, blood pressure, temperature, heart rate, and cerebral awareness, can be a strong predictor of in-house mortality. A 2005 Australian study found that attention to these important vital parameters, decreased mortality rates in the acute care setting. While in an ICU/IU unit, these vital signs are regularly recorded and brought to the attention of physicians when abnormal. In a medical surgical nursing floor, vital signs are not

taken as often and many times it is by a Personal Care Technician that will report their findings to a nurse. Depending on staff, these important vitals may only be passed on for report purposes.

The lack of consistent vital sign monitoring can leave a patient in a vulnerable position regarding their health. When shift change takes place, the patient is being observed even less by nursing staff. This lag in time could allow for these physiological changes to go unnoticed and adverse events occur.

Bunkenborg (2014) through Lund University offered a hypothesis that patients not only deteriorate according to their clinical state, but that a vast majority of patients may deteriorate due to the sub-optimal clinical management they receive from healthcare professionals. Patient safety includes monitoring patients that are at risk for cardiac arrests. Cardiac arrests can have warning signs up to 48 hours in advance of an arrest and when this arrest occurs, codes are called.

Correlation of Admissions and Codes

An important aspect of shift change is the circumstances surrounding a nurses’ duties. A study was conducted by Jennings, Sandelowski, and Higgins (2013) that reviewed ethnographic research of admissions. The data was taken from observations: 21 formal interviews, one medical unit and one surgical unit. The admission and discharge records were collected over one year. The article defined the four different types of admissions according to the patients’ point of entry to a nursing unit. The first point of entry is direct, with a patient admitted following a physician referral. The second is admittance through the emergency department, third is post

anesthesia care unit, and the fourth is transfer-in house (Jennings et al, 2013). Nurses recognized that direct and emergency room admissions were the most intense, because staff had to start from

the beginning. The study determined that patient admittance during change of shift was more disruptive than any other function a nurse serves (Jennings et al, 2013).

Jennings et, al. (2013) observed that there were considerably more admissions occurring during the shift change and less occurring at non-shift change times. This could be because physicians are rounding and discharging patients during the day. Nurses expressed that patient turnover during shift change was very disruptive, especially near the time of shift report handoff (Jennings et al. 2013). Admissions were also compared to codes because they needed to be attended to immediately (Jennings et al, 2013). Comparing an admission to a code situation gives the value of how much work and effort goes into monitoring patients during shift change.

Change of Shift Transfers

Critical information needs to be collected and documented on each patient. It could be argued that when patients are transferred during shift change, patient information may not be collected in a timely manner due to the interruption of the transfer. Griffiths, Heisey, and Hittie (2012) studied data that was collected over four days on an acute care level floor. Of thirty-eight admissions, thirteen of them were noted to have arrived during shift change. The effect on timeliness of admission assessments, first medication administration, and skin assessment upon arrival to unit was studied and compared. The results showed that when transfers occurred during shift change it took longer to perform admission tasks, then if a patient was transferred at non-

shift change times. During shift change, it took the nurse 110 minutes to document the patient’s admission assessment. It took over 140 minutes to administer the patient’s first medication. It took over 110 minutes to document the patient’s skin assessment. In comparison, when a patient

was transferred all other times of the shift, it took the nurse 40 minutes to do an admission assessment, 100 minutes to administer the patient’s first medication and 60 minutes to document a skin assessment on the patient (Griffiths et al., 2012). These findings were significant enough to cause the authors to recommend more research in the area of the timing of shift change transfers.

A study conducted by Kulshrestha, A., and Singh, J.(2016), examined the physiological changes that can occur when patients are transferred intra-hospital to establish risks versus benefits. Patient’s potential life changing physiological risks during transfer can include complications such as airway, breathing, circulation, and neurological status which should be addressed promptly upon arrival to a unit. Factors during transfer that can elicit a physiological change in patients are, the noise level, vibration, and temperature. These factors elicit responses such as anxiety, hypertension, and arrhythmias, which can be life threatening and lead to a decline in patients’ health status which can initiate a code.

Alamanou, D., Hero, B. (2014) stressed that the process of intra-hospital transfer is considered to adversely affect the patient’s condition, whose weakened body tries to counteract the physiological adjustments caused by environmental changes. The frequency of complications

for patients during intra-hospital transfer was found to be 76.1%. (Alamanou, D., Hero, B. 2014) which could be short term, long term, and in some circumstances require immediate intervention.

The nurse’s role is particularly important in intra-hospital transfers as they assess the health status, provide continuing health care, stabilization and monitoring of patients (Alamanou, D., Hero, B. 2014). During shift change, nurses have limited ability and time to properly assess,

stabilize and react to events that have occurred during intra-hospital transfer. Patients are vulnerable at this time as attention may not immediately be given. The study concluded that more research needs done on the stabilization of patients. Progress has been made in reducing adverse events when patients are transferred onto a unit, 44% of transfers still concluded in adverse events. (Alamanou, D., Hero, B. 2014) When patients are transferred with a safe arrival, allowing nursing staff to assess and implement interventions, patient outcomes are more favorable. If patients are transferred during a change of shift, nurses no longer can safely assess and implement interventions that have a more favorable outcome in patients.

Summary

The concept of transferring patients during shift change, can have adverse outcomes for patients and the incidental patients on the unit. Research has indicated that a critical link between nurse availability at shift change and patient outcomes are related. Many factors can affect the nurses’ ability to safely monitor their patients. The transfer of patients’ intra-hospital during shift change as linked to codes being called, is significant enough for more research to be warranted.

Research suggests that the varying factors that contribute to patient decline and potentially a code being called can be reduced with changes in protocol. Tools that can be useful according to this research, are that float pool nurses be utilized during shift change to provide admission care or a floating charge nurse to monitor patients. More research in conjunction with established research can guide appropriate times for transferring patients and minimizing a deterioration in health status.

Chapter 3

Methods

 This research project was focused on determining if more adverse events occur to patients leading to a condition being called during shift change.

Selection of the Participants

The selection of participants was a random chart review selected independently, with an equal chance of participation at a 400-bed tertiary care hospital and was representative of the entire population. Data did not show identifiers. This was ensured because name, age, and diagnosis were not recorded or documented during the chart review. Consent was not obtained for the chart review, and no exclusions were made based on gender and age.  A convenience sampling was used to retrieve data by trained nurses in a master’s degree program.  

Instrumentation

A retrospective chart review was utilized. The data that was collected is the time, type of event (code blue or rapid response), and diagnosis of adverse event. 

Data Collection

Permission was obtained from a local hospital in which the study was conducted. Information collected was the timing of a code called and the type of code.

Data Analysis

A review was performed on patients’ records that experienced a change in condition. Data was collected to determine the time that the adverse event occurred, what the change in

condition was titled, and what the diagnosis of the adverse event indicated. The hypothesis of the data collection was that more patients have a change in condition during shift change versus during non-shift change times. A dependent variable in the data collection was the patient’s change in condition during an inpatient hospital admission and the independent variables were the time of the adverse event.  

Summary

The charts being reviewed were from a local hospital. The data was collected from charts that have a documented adverse event with change in condition. The data was reviewed to determine if the authors’ research question and hypothesis is correct.  

Chapter 4

Results

The subjects for this chart review were obtained from one large medical center in Northwestern Pennsylvania. The inclusion criteria were as follows; time of the event, the unit that the event occurred on, the type of code called during the time frame, and if CPR was initiated. Exclusion criteria does not apply to this study. The sample size was 100 codes called during shift change.

Description of the Charts That Were Reviewed

The charts reviewed consisted of 100 codes that were called from January 1, 2019 to January 27, 2019. The age that was reviewed is 18 years and above with no identifiers. Four criteria were collected from each chart: if the code was called during shift change, what type of unit it was called in, if CPR was initiated, and if the code was cardiac related (code Blue).

Findings

GRAPH 1: Timing of Codes

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Graph 1 shows that of 100 codes examined, 85 (85%) occurred during non-shift change times.

GRAPH 2: Origin of Codes

Graph 2 shows that more codes are called in non-critical units.

GRAPH 3: Type of Code

Graph 3 shows that of all the codes called, rapid responses are called more than code blues.

Rapid response is a code not including the need for CPR.

Chapter 5

Discussions, Conclusions, and Recommendations

This chart review/quantitative study was conducted to identify the correlation between shift change and codes, and how less time at the bedside can contribute to a rapid decline in health compromised patients. The review was conducted at a 423-bed metropolitan hospital in western Pennsylvania that has 3 ICU unit’s, 1 Respiratory/Medical Surgical IU unit, and 11 medical surgical units, with one emergency department.

Discussion

Individual chart reviews were conducted to answer the question: What is the patient impact during shift change on the incidence of adverse events and code situations? The chart review consisted of 100 codes that were called from January 1, 2019 to January 27, 2019. The sample size was small but important information was identified from these charts. A larger chart review may give the researchers a more balanced look at timing of the codes and how that affected the patient’s condition. One limitation of the study was that the researchers limited the chart review to one month. This gave the researchers a restricted view of the overall codes called in a fiscal year.

In the review, a lower percentage of patients had a code called during shift change. This was contradictory to the hypothesis of the researchers, although information was gained on placement and type of code that was called. Codes were called at a significantly higher rate in a regular medical surgical unit than an ICU or IU unit where critical care and hospitalist physicians are more readily available to intervene in a patient’s health care management. Additionally, the type of code that was called in an ICU/IU unit versus a medical surgical unit was more likely a code blue/cardiac event. This could be related to the acuity of the patient in the ICU/IU.

Conclusions

According to the 2011 ANA Health and Safety Survey 62.2% of R.N.’s worked in an acute care setting with 100% of acute care nurses being involved in a code situation at some point in their career (Nursing World 2011). While there was not enough evidence to support the correlation between shift change and codes being called in an acute care setting, information was gleaned on the types of codes called in specific units. These findings can be used to further a study on unit specific codes and expectations of staff, implementing policy driven change as each acute care setting sees the need to increase patient positive outcomes in a code circumstance.

Recommendations

By performing another careful chart review with a large sample size, policy directing research can help guide placement of nursing leaders to help staff units during critical times of the day, i.e. shift change. Although the findings did not support the time association of codes called in the hospital setting, it gave valuable information on the location of codes. Research supported that medical surgical units called more codes than ICU or IU units. Findings have been recorded to initiate protocols in hospitals that may have not had them in place, and nursing websites have published data on protocols and roles for hospital staff during a code. This information, with more research, could potentially help specific units become better equipped to codes that the unit is more likely to encounter.

Further study could allow development of teaching for nurses on responding units to allow for additional training in codes, types of codes that are specific to units, and the types of responding personnel that are likely needed in that unit. A survey of nurses could gain information on code specific education that should take place in units and how this education could help facilitate a quicker response by nursing staff to intervene for greater positive patient outcomes.

References

Alamanou, D. G., & Brokalaki H., (2014) Intrahospital transport policies: The contribution of the nurse. Health Science Journal. Volume 8, Issue 1

Ali, Bibi Hajira Irshad & Mughal, Farida Bibi (2017). Enhancing Patient Well-Being: Applying Environmental Theory in Nursing Practice.

Code Blue in Hospital- What to Do When It’s Code Blue. (2015, November 14). Retrieved January 13, 2020, from

Code Blue in Hospital – What To Do When It’s Code Blue

Griffiths, K., Heisey, L., & Hittie, C. (2012). Change of Shift Admissions: Effect on Patient Care. Penn State Hershey Milton S. Hershey Medical Center.

Hill, C. R., Dickter, L., & Van Daalen, E. M. (2010). A Matter of Life and Death: The Implementation of a Mock Code Blue Program in Acute Care. Medsurg Nurs, 2010(19), 300–304. Retrieved from http://pubmed.ncbi.nlm.nih.gov/21189744/

Jennings, B.M., Sandelowski, M., & Higgins, M. K. (2013). Turning Over Patient Turnover: An Ethnographic Study of Admissions, Discharges, and Transfers. HHS Public Access, 36, 554-566.

Jensen, J. K., Skar, R., & Tveit, B. (2017). The impact of Early Warning Score and Rap

Response Systems on nurses’ competence: An integrative literature review and synthesis. Journal of Clinical Nursing, 27(7-8). Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.14239

Kulshrestha, A., & Singh, J. (2016). Inter-hospital and intra-hospital patient transfer: Recent concepts. Indian Journal of Anesthesia. Volume 60 (7).

Prince, C. R., Hines, E. J., & Heegman, D. J. (2014). Finding the Key to a Better Code: Code Team Restructure to Improve Performance and Outcomes. Clinical Medicine & Research, 47–57. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4453307

2011 ANA Health and Safety Survey. (2011). Retrieved January 13, 2020, from

https://www.nursingworld.org/practice-policy/work-enviroment/health-safety-survey

Vassar, M., & Holzmann, M. (2013). The retrospective chart review: important methological considerations. Journal of Educational Evaluation for Health Professions, 2013(10). Retrieved from

http://ncbi.nlm.nih.gov/pmc/articles/PMC3853868/#_ffn_sectitle

Appendix A

Code Blue Chart Review Tool

(page 1 only)

Review Site: Reviewers: Date of review:

Patient ID Code Blue called during ICU/ED/ IU unit Type of code/Was

(no identifiers) shift change? (yes of no) (yes or no) CPR initiated? (yes on no)

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