Running head: LEADERSHIP PROJECT PAPER

Leadership Project Paper

Tim Efremidis
Bon Secours Memorial College of Nursing
NUR 4144: Servant Leadership
Mrs. Dowling

LEADERSHIP PROJECT PAPER

2
Leadership Project Paper

Having been placed on a joint replacement unit for my clinical immersion, I noticed that
there are several Quality Improvement (QI) projects that have been implemented. One of the
most interesting QI projects I have become familiar with is the incidence of delirium with hip
fracture patients. Although the pathophysiology of delirium in this patient population is not fully
understood, the fact that the incidence of delirium is so high is cause of concern. More than 40%
of the fracture patients have experienced delirium (Jung, Meucci, Unruh, Mor, & Dosa, 2013).
One of the factors that are associated with good outcomes for patients with hip fractures is the
early detection of delirium (Carpintero, et al., 2014). This QI project revolved around focusing
on early detection of delirium in hip fracture patients. The goal is to have a policy in place that
begins detection of delirium in these patients as early as the Emergency Department. Viewing
this QI project as a nurse manager would certainly be a challenge, but has the possibility of
yielding very good patient outcomes. In this following paragraphs I will explain, using the four
domains of leadership and the five exemplary leadership practices, how I would implement this
QI project.
Four Leadership Domains
Heart
As Blanchard & Hodges (2005) noted in order for your responsibility to be genuine in
nature and for other to truly appreciate it, it must be motivated by the benefit of others rather
than self-interest. Often times when a new policy is unveiled, managers simply provide the
policy and expect others to implement it and follow it simply because it is required. Utilizing the
heart, I would really spend time educating the staff as to how this QI project is going to help us

LEADERSHIP PROJECT PAPER

create a policy of screening fracture patients for delirium during their hospital stay, in order to
improve patient outcomes and prevent mortality. The heart should lead us to understand that
what we are trying to do is in the best interest of those we care for and to prevent further
complications.
Head
The following step in being a good servant leader as a manager is establishing buy in
from your staff and members of the inter-professional team that may play a role in identifying
delirium in the fracture population. Utilizing evidence-based research may be a great way to
help others see that this QI project is empirically sound. Patients who were hospitalized for hip
fractures and who experienced delirium, amongst other negative factors, had a 25.9% mortality
rate within 12 months of hospitalization (Tarazona-Santabalbina, et al., 2012). As a manager I
would utilize this data to make a real life example. I would state that, One of the four patients
each of your cares for with hip fractures, will die within a year of you caring for them as a result
of delirium and other negative factors associated with hip fractures. Providing an example that
brings the numbers to life is key in establishing the trust and desire of the staff to take this QI
project seriously and want to be the hands of the project.
Hands
The hands are the culmination of the heart and the head (Blanchard & Hodges, 2005).
Having really put in the effort to implement this QI project and implement it in practice, the next
thing I would do as a manager is to be the example. This would require me to care for patients
and use personal examples of caring for patients and utilizing any tools necessary to detect
delirium in the hip fracture patient population. Research suggests that fracture patients with pre-

LEADERSHIP PROJECT PAPER

existing cognitive decline had a much higher incidence of delirium (Slor, et al., 2012). Knowing
this I would make it a point to encourage staff to be extra vigilant in screening for delirium in
patients with documented cognitive decline. The tool that is proposed to help detect delirium in
this population is the Confusion Assessment Method (CAM). The CAM has a 90-95%
specificity in diagnosing delirium (Waszynski, 2001). As a manager, utilizing the hands, I would
print out the CAM and allow staff to review it and practice it prior to administering it on a
patient. I would also review it with them on the electronic medical record system under a
training environment so that they are aware of how to access it and what it looks like in practice.
Habits
Knowing that health care is a dynamic and evolving setting, I would be prepared to
encounter non-adherence to this QI project by staff. Instead of immediately reprimanding staff, I
would implement good habits by taking time to reflect and better understand if there are barriers
to implementing this project. I would then question any staff not adhering to using the CAM
scale in this population and listen to what their rationale behind not using it is. I would also
utilize habits to understand that regardless of how good the CAM is in detecting delirium there
may be situations where delirium is missed and leads to bad outcomes and even death in patients.
I would utilize prayer to overcome these difficult obstacles and continue to study and find way to
further improve practice and prevent delirium and mortality associated with delirium in hip
fracture patients (Blanchard & Hodges, 2005).
Five Exemplary Leadership Practices
Model the way

LEADERSHIP PROJECT PAPER

The first step a leader must take along the path to becoming an exemplary leader is
inward (Kouzes & Posner, 2013, p. 24). I believe that in order for someone to be a good
nursing manager, they must be able to lead by example. If I were a manager in charge of
implementing this new QI project, I would be acting upon all the new assessments while caring
for patients alongside my team of nurses. I believe that you cannot be an effective nurse
manager if you are not acutely aware of the population and culture you are leading. As a
manager, this would allow me to really make changes in the implementation of the project, in
order to help avoid implementation failure.
Inspire a Shared Vision
As a manager I would be very energetic and visionary with my words when
implementing this project. I would use statistics and real stories to help paint the picture of what
we are trying to achieve as a team. I would also be sure to take into account any staff input and
utilize it to help build the vision and implementation of how the actual process of assessing for
delirium in hip fracture patients would look. Inspiring a shared vision is important in really
putting an idea into life and into practice.
Challenge the Process
As with many other implementation strategies, comes the cost of what is needed to
implement a QI project. For this project, I would attempt to transform the way our electronic
record uses the CAM scale. I would attempt to collaborate with administration and IT to
implement a hard stop within the charting system that would alert a practitioner to utilize the
CAM scale if a diagnosis of hip fracture has been charted. Challenging the process may not be
one giant step, but rather many smaller steps that in totality lead to a great change (Kouzes &

LEADERSHIP PROJECT PAPER

Posner, 2013). As a manger these small changes are the victories of acquiring administrative
approval to implement the QI project, collaboration with the IT department to transform the
medical record system, establishing an implementation that will ensure success by the staff,
assessing the data after a period of time, and determining whether the data is sufficient to
promote a policy creation or change.
Enable Others to Act
For any QI project to be implemented properly, it takes many partners to act together. As
a manager I would ensure that establishing and maintaining trust with my employees was a
priority. This can be made possible by creating an environment of we rather than I and
you. The stronger the staff, the stronger the unit, and the stronger the leader I would become.
I believe that the strength of a manger is measured by the success of their team. Its important to
empower those around me in order to ensure that the implementation of this QI project is a
success. The project requires that every staff member be hyper vigilant in identifying patients
with hip fractures and noting that a CAM assessment is both necessary and useful. Ideally the
staff would also remind each other of completing this assessment in order to promptly identify
and treat delirium in this patient population and further avoid complications that can lead to
higher mortality rates.
Encourage the Heart
I believe that as a manager, encouraging the heart could potentially be the most important
of all five of the practices. The climb to the summit is arduous and steep (Kouzes & Posner,
2013, p. 120). As a good manager I would ensure that my staff knew that my expectations of
them are the same expectations I have of myself and of my own performance as a nurse.

LEADERSHIP PROJECT PAPER

Providing a clear direction of how to implement the QI project is the first and most important
step of presenting this project and ensuring its success. As successes occurred, I would publicly
recognize staff that utilized the CAM scale properly to all of their peers. I would also have a
launch party within our work environment to promote the use of the CAM scale and to get
everyone excited about it. Furthermore, I would continue to do everything I could to inspire staff
and keep them interested in the outcomes of this QI project.
Professional Implications
One of the major implications of this QI project is that it could potentially fail in the
implementation process. To help combat this, I would ensure that staff are educated in the
process and have had the opportunity to learn and question the process before being asked to
implement it into their practice. Another aspect of this implementation failure is that leadership
tends to overlook implementation as a cause of failure and is likely to discard the entire QI
project if initially it does not succeed. Utilizing all of the research presented and establishing
buy in with the staff are two key factors in helping ensure that implementation failure does not
occur.
Another possible implication is that failure of the QI project as a whole. As a manager, I
would openly disclose that this QI project is not guaranteed to work. As any other QI project
that is implemented, we must ensure that no harm is done to the patients as a result of
implementing a new practice. Having established trust with the staff and continuing to provide
education on the topic of delirium in hip fracture patients, it is much more likely that the staff
will not lose respect for their manager if a QI project is not successful. Often, we learn more
from our failures than we do from our successes.

LEADERSHIP PROJECT PAPER

8
Outcomes Evaluation

This QI project of early detection and treatment of delirium in patients with hip fractures
is solely evaluated on the patient outcomes. As earlier stated, research supports the use of the
CAM scale to detect delirium in a patients. The research also clearly showed that the presence of
delirium could lead to high rates of mortality for up to 12 months after hospitalization. In the
acute phase, we should monitor and document the presence of delirium while the patients were
hospitalized. This data will help us to compare the incidence of delirium with the systematic use
of assessing for delirium versus the incidence of delirium in this population as previously
recorded. Ultimately, we could also compare the long-term data and mortality of patients who
did experience delirium but were diagnosed and treated promptly. If the data shows an
improvement after the implementation of this QI project, it could transform the way we practice
and treat the hip fracture population and ultimately lead to better patient outcomes. Regardless
of the QI project, our number one goal must always remain to provide safe, quality, evidencebased care to all of our patients.

LEADERSHIP PROJECT PAPER

9
References

Blanchard, K. & Hodges, P. (2005). Lead like Jesus. Nashville, TN: Thomas Nelson.
Carpintero, P., Caeiro, J., Carpintero, R., Morales, A., Silva, S., & Mesa, M. (2014).
Complications of hip fractures: A review. World Journal of Orthopedics, 5(4), 402-411.
Jung, H., Meucci, M., Unruh, M., Mor, V., & Dosa, D. (2013). Antipsychotic use in nursing
home residents admitted with hip fracture. Journal of the American Geriatrics
Society, 61(1), 101-106.
Kouzes, J. & Posner, B. (2013). The Student Leadership Practices Inventory (2nd ed.). San
Francisco: Jossey-Bass
Slor, C., Witlox, J., Adamis, D., Meagher, D., Ploeg, T., Jansen, R., . . . Jonghe, J. (2012).
Predicting delirium duration in elderly hip-surgery patients: Does early symptom profile
matter? Current Gerontology and Geriatrics Research, 2013, 1-9.
Tarazona-Santabalbina, F., Belenguer-Varea, A., Rovira-Daudi, E., Salcedo-Majiques, E.,
Cuesta-Peredo, D., Demenech-Pascual, J., . . . Avellana-Zaragoza, J. (2012). Early
disciplinary hospital intervention for elderly patients with hip fractures - functional
outcome and mortality. Clinical Science, 67(6), 547-555.
Waszynski, C. (2001). Confussion assessment method (cam). Best Practices in Nursing Care to
Older Adults, 1-2.

I pledge Tim Efremidis