Professional Documents
Culture Documents
Introduction
for surgical facilities to prevent postoperative complications and increase recovery rates for
patients. ERAS protocol is a system that guides the patient through their surgery from their initial
within the hospital. ERAS protocols include optimal patient and family education prior to
admission, less pre-procedure fasting, oral hydration two hours before anesthesia, and return to
normal diet and activities the day of surgery. Anesthesia is applied using a multimodal approach
in an effort to decrease the use of opioid drugs. The use of ERAS has been found to decrease
surgical complications related to the use of opioid analgesics. Opioids have been seen as the drug
of choice for postoperative pain, but these drugs often cause side effects like respiratory
depression, nausea, and constipation, that can cause more harm in the long-term health of the
patient.
Implementation of ERAS protocols have been proven to lead to better patient outcomes,
increased patient satisfaction, and a reduction in the cost of care for postoperative patients
(Brady, Keller, & Delaney, 2015). On the Medical-Surgical Unit of St. Mary’s Hospital, ERAS
protocol is being implemented for radical cystectomy and abdominal surgery patients. ERAS
protocols are allowing intake of solid food, ambulation, and discharge to take place at a faster
rate. Postoperative pain is primarily controlled through epidurals, IV lidocaine infusions, and
oral nonsteroidal anti-inflammatory drugs (NSAIDs). If pain is still high after the application of
NSAIDs, low-dose narcotics can be given. The narcotics are not be administered routinely, only
Heart
Nurse leaders bring people together and empower others to initiate action and take part in
projects. A leader has the power to influence the intentions and beliefs of others through their
own motivation. Since nursing is a field centered around caring, a good nurse leader must lead
with their heart. Some leaders are self-motivated, while others are motivated by the best interest
of the group. The caring nature of nursing requires selfless motivation. Motivation should come
Having clear motivation makes it easier for others to see why they should follow you in
the first place. A bond of trust between a manager and their workers will ultimately lead the way
for productivity and commitment towards goals. If you lead with honesty, your words won’t be
questioned and people won’t have doubts. Having forgiveness towards others and acting in a
graceful manner is a way to empower your workers to take initiative. If you have a reputation for
losing your temper when mistakes are made, your staff will be too afraid to take initiative and get
things done on their own. As a manager it’s important to be understanding when mistakes are
disciplinarian may seem like a good idea in the short-term, but in the long-term people will be
afraid to act on their own and overall productivity of the unit will suffer.
Head
In order to get other people on board with your ideas and beliefs, a leader needs to be
someone that can be depended on. The head domain of leadership gives the leader a sense of
self. Before the leader can take action, they must be able to clearly define their purpose, vision
for the future, and values. It’s a leader’s job to keep the group on task and remind them of the
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bigger picture. A leader is a mentor to their peers and needs to be willing to teach and
A nurse manager is someone who assumes leadership over an area or unit of a hospital.
It’s the nursing manager’s job to delegate care among the nursing and supportive staff within the
unit, and provide proper supervision. The nurse manager sets goals and guidelines for their staff
to work towards. The nursing staff should feel empowered and supported by their nursing
manager. Communication within the interdisciplinary team should be encouraged, and nurses
should feel like their manager will stand up for them if need be. Nurses need to feel secure
within their workplace and know that someone will have their back when they advocate for their
patients.
Leaders need to convey that they are invested in their employees and have the workers’
best interests in mind. People want to feel nurtured and respected by their manager. Manager’s
need to introduce new ideas and change as opportunities for growth. Having a positive attitude
and encouraging others to share their ideas will prompt people to follow you. It’s important to
remind workers of the unit’s vision, and maintain following throughout a process of change.
Reminders of the vision and values will keep workers on taks and reorient them to the purpose of
their work.
Hands
difficult process for everyone involved, and it’s a nurse manager’s job to be an agent of change.
When change is abrupt, it can cause confusion, fear, discord, and negative emotions. Managers
must be ready to deal with negative emotions and refocus the group towards the goal. Despite
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having a career in a dynamic field, many nurses see change as a negative occurrence and are
inflexible. Nurses often fear that changes will bring an increase in their workload. It’s a
manager’s job to help workers see the benefits and necessity of change.
Communication ahead of time is a crucial component for initiating change. The staff need
to be properly warned and educated about an upcoming change, in order for implementation to
be successful. Months in advance, the nurse manager should hold unit meetings about the
upcoming ERAS protocols being implemented to the unit. Since pain management is often a
difficult task for nurses, the leader needs to be prepared to explain why pain management
through NSAIDs, rather than opioids, is a good thing for the patient and the nursing staff.
The nurse manager could explain that the sedating effects of opioids make it difficult for
the client to stay awake and ultimately delays ambulation time. Delayed ambulation time, as well
as the constipating effects of opioids, set patients up for bowel obstruction and abdominal pain.
While decreased opioid pain relief seems like more work on the nurses, it will ultimately
decrease the need for future interventions related to abdominal pain and constipation. Quicker
recovery rates and less postoperative complications will decrease the overall burden on the staff.
Habits
Nursing managers need to be able to take care of themselves as well as their workers.
Finding a moment of solitude within a busy workday is important for nurse managers to center
themselves. Getting away from the group is essential to maintaining good temperament and
having a balance between work and personal life. Solitude and prayer are good ways for
managers to take a timeout and evaluate how they’re doing, and what they could be doing better.
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When leaders engage in reflection, it allows them to see the bigger picture of what they are doing
Having a sense of spirituality can be a beneficial quality for a nurse leader to have.
Spirituality can be a way for individuals to reflect and self-actualize. Spiritual scripture can guide
leadership actions and give the person a sense of fulfilment. Engaging in spiritual beliefs often
leads people to look inwards and work on becoming an improved version of themselves.
Nurse managers should treat others as they would wish to be treated; it's important to
display and accept unconditional love. Unconditional love fosters the way towards development
of supportive relationships. It’s important for leaders to seek supportive relationships within the
workplace, as well as within their personal life. Having friends from other units, as well as the
unit you work on, is important to having a good head on your shoulders in a nursing career.
Nurse managers model the way to success and act as a role model for everyone else on
the unit. Even though the nurse manager isn’t someone who routinely cares for patients, its
important that they attend all of the education meetings along with the other staff so that they can
continue to be a resource for best practice and supervision. The nurse manager should be making
daily rounds on the surgical patients and making note of their progress to compare data and
evaluate the effectiveness of ERAS protocol. Hard work and accomplishments should be
In order to maintain the progress of a project, the leader needs to keep reminding the
group of why they started in the first place. Once the hard work begins on a project, it can be
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tempting for everyone to quit and leave things how they were before. People might even question
whether or not the change is necessary if it doesn’t seem beneficial to them. The nurse manager
should keep reminding the nurses that ERAS protocols are instilled to prevent further
complications after surgeries, and that this will ultimately mean less work for them. The nursing
staff should also be reminded that ERAS is an evidence-based practice that leads to better
outcomes for the patient. With the current opioid crisis occurring in the U.S., it would be
worthwhile for the nurse manager to emphasize the importance of decreased opioid
ERAS protocol is a new way of caring for surgical patients; it challenges past surgical
procedures and brings a better, safer management of care to the field of nursing. Leaders are
always looking for ways to improve. Even after a goal is reached, a good leader should ask “how
can we do even better next time?” Nurse managers should always be on the lookout for
opportunities for growth and success. ERAS allows patients to be discharged earlier, without an
increased readmission rate. This change in surgical protocol was brought to the unit from a
higher administrative level, therefore it’s the nurse manager’s job to ensure that this change is
carried forth. The nurse manager needs to be enthusiastic and passionate about this change for
the future, and encourage others to work towards an improved nursing unit.
The nursing leader should also encourage others to join committees and share their ideas
for change. ERAS protocol requires that every healthcare team member knows the guidelines
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and standards of practice throughout each step of the patient’s surgical care. It’s essential that
postoperative nurses understand the role of the preoperative and perioperative nurse as well.
ERAS protocols hold every healthcare team member accountable for the care that they provide to
Nurse leaders need to be encouraging their staff while they learn and apply new
knowledge on the floor. A good nurse manager highlights areas of excellence, while delicately
pointing out what could be improved. When a manager shows that they’re invested in the growth
and development of their staff, people are more likely to react positively to challenging
opportunities. A nursing manager is always encouraging their staff to continue their nursing
education.
When success has been met, it’s important for the leader to acknowledge it. Showing
staff members personal recognition of their performance, will instill good work ethic. Pizza
parties and other celebratory events are ways to show your staff that you care and appreciate all
of the hard work that they do. Having outings outside of work are also good ways to build
The main purpose for a manager to encourage the heart, is to get everyone focused on the
results of their work. Leaders have the responsibility of bringing everyone closer together. The
biggest thing that a nurse manager can do to encourage the heart is to smile and be pleasant
everyday. The nurse manager should be eager to seek out what people are doing right, rather than
wrong.
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ERAS protocols merge the pieces of preoperative, intraoperative, and postoperative care.
The nurse’s role in ERAS protocol is to educate patients and help develop equilibrium across the
interdisciplinary team. ERAS education empowers patients and their caregivers to fully
participate in the recovery process. Discharge planning begins at the earliest phase of the hospital
experience, so that discharge isn’t rushed and patients feel more prepared when it’s time to leave
The education of nurses and other interdisciplinary team members is also crucial for the
success of ERAS implementation. Enhanced recovery pathways help to outline and explain the
care process in detail from every level of care. Care pathway resources are available in binders at
the nurses’ station and each staff member is required to participate in continuing education
courses. Care for ERAS surgical patients is standardized. Each patient is expected to ambulate
the night of surgery, and there are set medication orders. Criteria for discharge and any
surgery. On the Medical-Surgical unit of St. Mary’s Hospital, the majority of ERAS care is
involved with the postoperative phase. General nursing care includes postoperative vitals signs
every four hours, transitioning to every eight hours after the first 24 hours following surgery. For
patients with epidurals, vitals will be taken every two hours for the first four hours, and then
every four hours until the epidural is removed. Continuous pulse oximetry and capnography is
used for epidural patients during the first 24 hours after surgery.
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General pain management follows two regimens. Epidural pain management and
lidocaine infusions are used for open cases, and laparoscopic cases are placed on lidocaine
Tramadol and Oxycodone can be given via epidural as needed for pain. Nurses need to perform
dermatome checks for epidural patients, and each patient receiving a lidocaine drip must be
administered immediately after surgery for DVT prophylaxis. It’s always given in the abdomen,
but distal to surgical sites. Entereg and Ondansetron are given to restore bowel function and
reduce nausea and vomiting after surgery. Ativan 0.5 mg is available every six hours as needed
for anxiety. Lactated Ringer’s solution is continued into the first postoperative day at 75 mL/hr.
On the first postoperative day, low fiber diets are implemented as the patients will
tolerate, and patients are out of bed for all meals and at least six hours total each day.
Ambulation is expected to be three times a day, for at least 50 feet each time. Each patient will
be consulted by a Wound Ostomy and Continence Nurse, and urostomy stents will be irrigated if
clots arise. On the second postoperative day, the lidocaine drip is to be discontinued. Surgical
dressing changes and ostomy teaching also takes place on this day. On postoperative day three
until discharge, epidural use is discontinued. Lactated Ringer’s solution is discontinued if the
patient is tolerating their diet and taking in adequate fluid hydration. Discharge is considered if
the patient is passing flatus, tolerating their diet, has a stable hemoglobin count, has pain under
Upon discharge, the patient will be instructed to schedule a follow-up appointment with
their surgeon seven days later. The patient should also plan to see their primary care provider as
needed. Nurses reinforce discharge teaching and utilize handbooks and instructional videos.
Discharge medications include oral Acetaminophen 1000 mg every six hours for the first 24
Outcomes Evaluation
The use of ERAS protocols has improved patient care efficacy, advanced recovery, and
reduced the length of stay for surgical patients. Reduced length of stay has not compromised
readmission rates for surgical patients, and the overall cost of care for these surgical patients has
been reduced (Brady, Keller, & Delaney, 2015). Multiple aspects of ERAS protocols have
contributed to the accelerated recovery rates of patients. High carbohydrate and protein drinks
given the day of surgery prevent complications that can arise due to dehydration and electrolyte
imbalances. After surgery, cortisol levels rise in a response to stress causing the body to fall into
a catabolic state. Carbohydrate loading before surgery helps to prevent muscle breakdown and
According to Pang, Groves, Venugopal, Noon, and Catto (2017), ERAS protocols have
also reduced the amount of blood loss and transfusion rates. Contrary to past surgical protocols,
ERAS patients do not undergo bowel preparation before their procedure. Bowel preparation has
been thought to prevent bacterial exposure during the surgical procedure. However, research
indicates that mechanical bowel preparation can increase the risk for exposure to infection during
surgery (Melnyk, Casey, Black, & Koupparis, 2011). Bowel preparation causes liquefaction of
the stool and increases the risk of intestinal contents spilling into the abdomen during an open
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procedure. Bowel preparation can also cause electrolyte imbalances and dehydration during the
operation. The need for fluid replacement increases the use of IV fluid administration and
In order to measure the effectiveness of ERAS protocols, care measures are given
through specific order sets. Standardized nursing interventions make it easier to keep track of
patient outcomes and and develop auditing tools for quality improvement. Specific sets of
medications also cut down on pain management choices. Standardized pain management has
provide uniform care on all levels of surgery. Education is crucial for each person involved in the
patient’s care, including the patient and their caregivers. One of the biggest barriers to ERAS has
been patient noncompliance during the postoperative phase. It’s up to ERAS nurses to be leaders
and help empower and coach their patients throughout the recovery process. Nurses need to
encourage their patients to ambulate and push through the pain that follows a surgical procedure.
Even though ERAS pain management might seem insufficient in comparison to traditional
opioid interventions, it has been proven to show an overall improvement in patient outcomes and
recovery rates.
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Reference
Brady, K. M., Keller, D. S., & Delaney, C. P. (2015). Successful implementation of an enhanced
Jankowski, C. J. (2017). Preparing the patient for enhanced recovery after surgery. International
Melnyk, M., Casey, R. G., Black, P., & Koupparis, A. J. (2011). Enhanced recovery after surgery
Pang, K. H., Groves, R., Venugopal, S., Noon, A. P., & Catto, J. W. F. (2017). Prospective