Running head: LEADERSHIP STRATEGY ANALYSIS

Leadership Strategy Analysis

Jennifer Edson
Matthew Green
Kelle Aikens
Anna Ingersoll

Ferris State University

LEADERSHIP STRATEGY ANALYSIS

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Abstract

Positioning of patients in the operating room can cause significant tissue and nerve damage in
even relatively short surgeries. In order to create the best outcomes for patients, and
interdisciplinary team consisting of a neurologist, an anesthesiologist, 5 nurses from various
specialties, physical therapy, and occupational therapy. This team will observe surgeries over a
week. Using the information they gather, they will develop a plan for educating the positioning
protocol. They will present this protocol to management and administration along with a plan
for evaluating the outcomes.

LEADERSHIP STRATEGY ANALYSIS

Leadership Strategy Analysis

All disciplines of different units have issues and weaknesses in at least one problem area,
if not more. In the operating room, sometimes positioning a patient can cause issues post
operatively such as skin breakdown, retina detachment, patient falls, and nerve damage to name
a few. Proper patient positioning is essential for safe, successful surgical procedures
Positioning, combined with anesthesia and its physiologic effects, can result in patient harm if
safety factors are not paramount (Rothrock, 2009, p. 144). It is possible to improve these
outcomes with education and mindfulness of the operating room team.
Clinical Need
Some patients have unfortunate outcomes postoperatively because of improper
positioning or padding to a nerve area; however, skin breakdown can be a big factor for long
surgeries, physical force and awkward positioning (for surgical sites that are hard to get to).
Patients who undergo a procedure that requires a long operative time are at risk for pressure
necrosis of skin and underlying tissue. Studies have shown that a pressure of just 70 mm Hg
applied for a period of 2 hours or longer can result in irreversible tissue ischemia (Ellsworth &
Iverson, 2006, p. 215). Pressure points has added pressure from the gravity of their own weight.
The surgical draping and equipment are extra-added weight to those pressure points.

The skin

causes shearing when skeletal systems are not in synch. Sliding the patient across the bedding
on to the surgical table can cause friction. Pressure ulcers are defined as, a localized injury to
the skin and/or underlying tissue, usually over a bony prominence (Rothrock, 2009, p. 145).
Peripheral nerves can be injured during positioning, resulting in impaired sensory
function or motor function, or both. The basic injuries to peripheral nerves in clinical practice
are stretch-related injuries, compression, and lacerations (Rothrock, 2011, p. 150).

LEADERSHIP STRATEGY ANALYSIS

Comorbidities can place a patient at higher risk; however, proper positioning and padding can
help deter potential nerve injuries.
Eyes can be injured during positioning which can result in anything from corneal
abrasions to blindness. Pressure that is directly placed on the globe of the eye can have serious
consequences for patients who have had cataract surgery. If the pressure on the eye is greater
than arterial pressure, inflow of oxygenated blood is stopped and retinal ischemia and blindness
ensue (Ellsworth & Iverson, 2006, p. 217), this sort of injury is most commonly found in prone
position. Crush or compression injuries can happen to the genital area. Compression injury
may include edema, hematoma, and pressure necrosis to the scrotum/labia majora, as well as
neurapraxia of the pudendal nerve. Limiting the duration of traction to less than 2 hours and
generous padding of the perineal post to more than 9 cm in diameter have been recommend to
help decrease the incidence of perineal injury during hip arthroscopy [and anterior approach of a
total hip arthroplasty] (Gerken, 2013, para. 11)
Morbidly obese patients also create a different level of injuries from positioning in
surgeries as well. Some of those injuries include sciatic nerve palsies from the bed tilting, deep
vein thrombosis, pulmonary embolism, ventilation impairment, perioperative ulnar nerve palsies,
brachial plexus neuropathies, postoperative back pain, and pressure ulcers (Rothrock, 2011).
Interdisciplinary Team
To help resolve potential positioning injuries a team was created to observe positioning in
the operating room. This team consists of a neuro surgeon, an anesthesiologist, 5 RNs (one
from: orthopedics, general, plastics, gynecology, and neuro), an occupational therapist (OT), and
a physical therapist (PT). There will be a week of observation of positioning in each specialty
team. It would be to simply observe and notice any potential problems and any weaknesses.

LEADERSHIP STRATEGY ANALYSIS

There were 5 nurses chosen for the interdisciplinary team because one is from each
specialty. The nurse most knowledgeable from his or her own specialty team has been chosen
for the team. They would witness how things should be, uncertain of, or what have been
standard positioning measures for certain procedures. An Anesthesiologist is required on the
team because they are experts at positioning of the neck and the knowledge they hold regarding
positioning and lung capacity, etc. during each position. A Neuro Surgeon was chosen, because
he or she is an expert on nerves and proper positioning. An Occupational therapist and a
Physical therapist was chosen because they know the proper degrees of safe abductions and
adductions for limbs.
After observation in each surgical team, they will meet and compare notes, and create a
book for each team describing proper positioning for each surgical position for that team
observed (and others not observed). Another memo would go to each specific team and it will
note the weakness the interdisciplinary team observed, so the members on each specific team can
be aware of proper positioning for each position, including beach chair, prone, supine, lateral,
and those used with traction beds such as a fracture table. With these informative and
educational materials provided the patients have better chances for greater outcomes.
Data Collection Method
Data will be collected from the interdisciplinary team by using a few collection methods.
The data will show that the higher rates for peripheral nerve injuries such as ulnar neuropathy
occur in 26% of open-heart surgeries. Lower extremity neuropathy occurs in 1.5% of patients.
Ulnar neuropathy injury occurs in 0.46% in noncardiac surgeries. Peripheral nerve injuries occur
in 16% of all adverse outcomes of all surgeries (Shubert, 2008).

LEADERSHIP STRATEGY ANALYSIS

The interdisciplinary team will collect data by using a line chart to allow the ability to see
the connection between variables and show a trend over time (Yoder-Wise, 2010). They will
have separate data from types of surgeries, the surgical position used, and adverse positional
injuries that may have occurred. All data collected will be compared to surgeries that had no
adverse injury outcomes related to positional injuries to determine the occurrence frequency. In
addition to the line chart the interdisciplinary team will use a fishbone diagram by writing the
specific problem on a line and brainstorming and connecting the causes to the problem (YoderWise, 2011).
Established Outcomes
The team will establish a standard of care based on evidence-based practices. This will
include goals for improvement identified from that data collected. Data will be used against
national averages to determine the departments expected goals. Using the proper position
specific to the type of surgery will be key to preventing an injury. By using the most up to date,
evidence based scientific positions and practices established and recommended by the American
Society of Anesthesiologists standards, guidelines, and statements. The goal will be to decrease
all positional injuries.
Implementation Strategies
Implementation of the new positioning techniques begins with the basic information
provided in the interdisciplinary meeting following the observation of surgical procedures.
Using this information, a very specific protocol should be designed and presented to the
administration of the hospital in order to gain support for these changes.
When presenting the information to administration, the protocol, and any impact on the
budget should be provided in writing. It is also necessary to supply expected outcomes and the

LEADERSHIP STRATEGY ANALYSIS

plan for measuring these outcomes. An outline of plans to educate management and staff nurses
on the changes including a specific timeline for each stage of implementation will help gain the
support of administration (Gallagher-Ford, et. al., 2011). Gaining the support of administration
will ease the process and also allow for any necessary budget changes.
Evaluation
Before any evaluation can occur, goals and objectives must be clearly defined. It is
important to know if the goals were met, but also why and how they were met. What was it
about the implementation process that made it successful or not so successful? Understanding
the details of success will not only help make changes to the current implementation plan, but
will also be useful in future changes to any protocol.
The experimental model has been used since the early 1900s for scientists in many
different areas of research including nursing. The downfall of this model is that it does not allow
for feedback within the implementation process. Feedback within the process would mean
continual changes to the protocol used for improvement. With the experimental model, the
feedback comes after the implementation process is completed, requiring an entirely new design
with re-implementation. This can be a lengthy process and it not always beneficial to the patient
population (McCoy & Hargie, 2001).
What is used for nursing research today is a mix of models based mostly on the
formative-summative model. The goals and objectives are formed along with indicators for
measuring these goals and objectives. There is generally a cost-benefit analysis done as well
(McCoy & Hargie, 2001). This type of experimental model allows for changes to be made
during any part of the implementation process. This makes it easier to make improvements and
is more beneficial to the patient.

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Conclusion

With careful observation of the current positioning practice in the operating room, and
suggestions from the interdisciplinary team, a new protocol will be put in place. Continuing to
make improvements during the implementation process of this new protocol will create positive
outcomes for the patients and will allow for further improvement in the future.

LEADERSHIP STRATEGY ANALYSIS

References
Ellsworth, W. A., & Iverson, R. E. (2006). Patient safety in the operating room. Seminars in
Plastic Surgery, 20, 214-218. http://dx.doi.org/10.1055/s-2006-951578
Gallagher-Ford, L. M., Fineout-Overholt, E. B., Melnyk, B., & Stillwell, S. (2011). EvidenceBased Practice, Step by Step: Implementing an Evidence-Based Practice Change. AJN,
American Journal of Nursing, 111(3), 54-60.
Gerken, S. (2013). Preventing positioning injuries: An anesthesiologists perspective. AAOS
Now. Retrieved from http://www.aaos.org/news/aaosnow/jan13/managing7.asp
McCoy, M. & Hargie, O.D.W. (2001). Evaluating evaluation: Implications for assessing quality.
International Journal of Health Care Quality Assurance, 14(7), 317-327. Retrieved
from: http://0search.proquest.com.libcat.ferris.edu/docview/229615504?accountid=10825
Rothrock, J. C. (2011). Alexanders care of the patient in surgery (14th ed.). Pennsylvania:
Elsevier.
Schubert, A. (2008). Positioning injuries in anesthesia: An update [Electronic version]. Advances
in Anesthesia, 26, 31-65. doi:doi:10.1016/j.aan.2008.07.009.
Yoder-Wise, P.S. (2010). Leading and managing in nursing (5th ed.) St. Louis, MO: Elsevier,
Inc.