Comment 1 Development of an evidence-based practice project must include the direct and indirect impact that will be encountered through implementation. Staff retention of newly hired nurses specific to the night shift is the focus of my project and its impact on the nurses, facility and community that is served. According to published reports, a supportive work environment, especially between managers and employees, creates a strong deterrent to nurses leaving an organization by improving perception of organizational support, employee engagement, team cohesion, and connection to the mission of the health-care setting (Kurnat-Thoma, Ganger, Peterson, & Channell, 2017). Financial aspect staffing cost/turnover cost Hospital staffing turnover is projected to 5% to 5.8% of total hospital annual operating budget and is largely driven by the loss and necessary replacement of qualified nurses according to Waldman, J., Kelly, F., Arora, S., Smith, H. (2010). Proposal direct impact hospital revenue/staffing costs, Proposal indirect impact patient outcomes, positive healing environment perception by staff/patients Quality Aspect High turnover in any industry can be a concern, especially those that are customer-centric. Industries that deal with peoples health are in an even more precarious position. Institutions with high attrition must consider how a revolving door of care providers affects the quality of care an institution is able to provide, and the satisfaction of patients with their overall experience according to Arena (2018). Proposal direct impact Separation Costs Continued benefits, temporary labor, overtime to existing employees Recruitment Costs Job description, posting on job boards, screening candidates, interviewing candidates, assessing candidates Onboarding Costs Orientation and training of new hire Proposal indirect impact Loss of productivity Lack of staff while positions are being filled Increased pressure on existing staff to cover and pick up the extra work often leading to burnout Patients receiving less attention Pressure on current staff to train and then gel with the new employees Lack and lag of knowledge with new employees concerning institutional practices, workplace norms, team behaviors, and patient knowledge, familiarity, and care experience Clinical aspect unit cohesiveness/patient care Many nurses leave their positions because of negative experiences with heavy or unrealistic workloads and due to feeling unheard and undervalued. Clinical nurses’ sense of disempowerment can be related to lack of leadership interventions. Clinical nurses may feel that managers are insensitive to their staffing needs, don’t support employee well-being, and don’t invest enough in staff education or clinical advancement according to Linnen and Rowley (February 2014). Proposal direct impact nurses will see themselves as stewards for their unit. Nurses are leaders by virtue of their responsibilities; for them, empowerment isn’t a privilege, but a professional necessity (Linnen and Rowley, 2014). Proposal indirect impact – Nurse advancement – Staff participation in policy and governance – Leadership support – Adequate staff and resources – Nurse/physician relations Comment 2 My mentor is a wound care nurse and my proposal is about quality improvement and how it affects pressure ulcers. After discussing with my mentor, we discussed that a financial aspect for developing an evidence-based practice project would be a reduction in billing for treatment, such as special ointments, creams, and dressings that are billed to the patient, patients payer source, and facility. A quality aspect would be an improvement of the quality of care. Evidence-based practice would prevent the development of pressure ulcers and/or improve the healing of current pressure ulcers. A clinical care aspect would be understanding who the target population is and what type of facility they are in. My proposal would directly impact all of these aspects because treating these types of wounds can be very costly to not only the patient or patients payer, but also the facility. The facility usually has a house supply of basic dressings and wound care supplies, such as calcium alginate with and without silver, different types of dressings, collagen, etc. Over time, this can become very costly because dressing changes need to be done on a daily basis and as needed. To improve healing and prevent wound development, evidence-based studies have proven that turning patients at least every two and keeping them clean and dry significantly decreases the development of pressure ulcers. The use of preventive materials (types of mattresses, positioning devices, etc.), characteristics of the residents (personal preference of preventive materials, presence of existing ulcers, and positioning), protocols based on four themes (observation of the skin, frequency of repositioning and postures, use of support surfaces, and elevation of heels also helps as well (Beeckman, Clays, Van Hecke, et al., 2013). Comment 3 6DQ1 Proposed solution to address issue of staff retention Implementation of Mentor/Mentee partnership program that addresses the perception of job expectations from the viewpoint of new staff. How this idea relates to how the unit runs and aid in transforming perception to reality in the workplace. Solicitation of nurses feedback regarding orientation/mentoring process, satisfaction with job description, and reasons for job change or shift changes if any in past year. How this proposal has changed since I began My proposal has changed to include adding a more inclusive program to orient and mentor newly hired staff that includes a broader spectrum of resources. Leadership, peer, and instruction involvement in a process that develops confidence, and well-being in nurses and that provides follow through that lasts through a full year of mentorship. What led to current perspective and direction Seeing the frustration in nursing staff that are left on the unit to fill in the empty spots where new nurses have left or changed shifts due to feelings of lack of support and comradery. Building an orientation program that respects the individual needs of nurses and that places nurses in a position to be confident and feel supported throughout their orientation. Also, to understand what is expected in the job that they have been hired for and that they will have a source or resource that will be available for continued feedback. Comment 4 My proposed solution would be to increase quality improvement for the residents in Windsor Rosewood Care Center and decrease the incidence of pressure ulcers. Implementation would be based on evidence-based practices, such as turning at-risk patients at least every two hours, keep them clean and dry, and make sure they are getting enough nutrition, and for those that have diabetes, help manage it better. Based on my research, there are many ways to increase quality improvement in nursing homes. One article used a pay-for-performance plan by performing regular inspections and assessments based on a Minimum Data Set and Online Survey, Certification, and Reporting data. It provided information about how clinical weights, staffing ratios, and inspection deficiencies impact clinical outcomes (Konetzka, Skira, & Werner, 2018). Another article by Hartmann, Mills, Pimentel, Palmer, Allen, Zhao & Snow (2018), provided valuable information about how patient-staff interaction plays a significant role in clinical outcomes. Nurses are constantly in contact with their patients and how they interact with one another can have a positive or negative on patient outcomes. Medication can only go so far, but caring for the well-being and meeting the needs of their patients emotionally can help them get better, and/or ease their suffering and pain. I have also learned that efforts need to be made on all organizational levels and all health care professionals must work with one another. My proposed solution has changed in that I was focused quality improvement as a whole, such as wounds, falls, and diseases (pneumonia, catheter-associated infections, and respiratory illnesses). After writing what my PICOT question was on one of the threads, the instructor suggested that I need to be more specific. I decided to write a solution about wound care and falls because my mentor is a wound care nurse and many of the residents are at risk for falls. Then this past week, I decided that I should focus on just pressure wounds because many of the residents are at great risk and it continues to be a very big problem. There is also a lot of valuable information that I have learned from scholarly articles and implement the ideas into my own nursing practice.