LEADERSHIP PROJECT PAPER

Leadership Project Paper

NUR 4144 Professional Role Development: Servant Leadership
Browning Dailey
March 30, 2015

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Leadership Project Paper
In the Emergency Department at Memorial Regional Medical Center there has been an
average of six falls per month some without proper documentation leading to a quality
improvement project called the Post Fall Folder. One of the RNs on the unit was chosen to
head this committee and follow through on this project. She is very passionate about increasing
quality and safety on the unit and says this was a great way for her to contribute to her
profession. The shared governance approach is a way to promote leaders as well as involving
staff nurses in performance improvement of clinical care (Finkelman, 2012). This project is a
good example of shared governance on the unit. The general idea of the project is to implement a
new documentation process in hopes to decrease falls and increase compliance. The Post Fall
Folder is always located in POD-1 for easy access. Within the folder there are detailed
instructions including a flow sheet to tell the RN what the next steps should be when a fall has
occurred. The sequence of actions depends on the individual patient situation. Are they
conscious? Do they have any head /neck pain or neurological changes? There is a nice little
check list to help the RN remember all pertinent actions immediately post fall and begin
documentations, Connect Care, Schmid Scale, Quantros, and Critical Event Analysis Form. The
Critical Event Analysis Form is particularly helpful in looking back at why the fall occurred and
helps point out causative factors that can be improved upon for future prevention. In 2011 the
Joint Commission launched its Preventing Falls With Injury Project (Jointcomission.org). In a
similar way they utilized checklists, analysis, and validated fall scales to reduce the number of
falls in participating hospitals, in return increasing client safety and decreasing organizational
costs. The Emergency Departments Post Fall Folder mirrors the Joint Commissions efforts.

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In order to use my heart as the leader of the Post Fall Folder project I will consider the big
picture and think of the patients and how this will improve the quality of care we give on our
unit. Yes, the documentation is tedious and most nurses on the unit will dread having to do it
when a fall occurs on their watch. I will be there as their leader to assist them should they need it
and encourage them by sharing the reasoning behind this project. According to Blanchard and
Hodges (2005), a considerable barrier to being a great leader comes from self-motivated
intentions. By keeping the end results of improvement in mind and being there as a resource for
my team, I will take on the role of servant leader not self serving leader.
I will bring my head into the picture by sharing my vision of what great results we could
have if we all work together to accomplish this project. With my knowledge of past fall events
and poor documentation compliance, I will think of an easy way to implement increased
compliance thus coming up with the contents in the folder. I will educate my team so they will
know the new procedure. Portraying a vision and being able to teach and implement that vision
are all great leadership qualities that go along with using ones head (Blanchard & Hodges,
2005).
The use of hands and habits are also very important qualities in a successful servant leader.
One way to use hands in leadership is to be a supportive coach for your team members
(Blanchard & Hodges, 2005). I will give positive reinforcements and recognize publicly when
my team members follow through on goals with post fall documentation. I will gently redirect
individuals that may not be in complete understanding of the direction of our goals. I will
announce the new fall rate at the end of our project and celebrate when we have reached our goal
of decreased falls and increased documentation compliance. I will use habits by following
through with the post fall folder documentation myself as an RN on the unit. I will lead by

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example, practicing what I am preaching so to speak. I will be my team members support and go
to person when they need to express themselves.
According to Kouzes and Posner (2013) there are five leadership practices which servant
leaders can benefit from including, model the way, inspire a shared vision, challenge the process,
enable others to act, and encourage the heart. As the leader of the Post Fall Folder project I will
model the way by creating the folder, giving good education on how to implement the changes,
reviewing progress, and staying consistent. I will inspire a shared vision by explaining to my
team the big picture of creating a safer environment for our patients, lowering costs for our
organization, and ultimately making our jobs more credible and easier to do. I will be
challenging the process by suggesting the changes take place in documentation. I am essentially
coming up with a more innovative way to work our job on the unit when it comes to patient falls.
I will enable others to act by giving them the freedom to choose using of the post fall folder
contents. I will ask for volunteers to assist me when time comes to review incident reports
making them feel part of the project and using the time to teach as well. I will encourage the
heart by praising my team members publicly in huddle when they have done a good job with
documentation. I will celebrate with my team members when we have reached our goal of
decreasing falls and increasing compliance. We will post it up on our bulletin boards for all to see
and as a constant reminder of what we can do when we work together as a team.
The implications for professional nursing practice regarding this project include better
compliance with post fall documentation creating heightened awareness for fall prevention
measures on the unit. The idea is to obtain necessary documentation to be able to analyze these
events and use the results of analysis to improve patient safety outcomes. Nurses will have a
detailed instruction sheet and checklist to follow for post fall procedures.

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Prior to the Preventing Falls with Injury Project The Joint Commission reported
approximately 11,000 deaths in U.S. hospitals were due to patient falls (Jointcomission.org).
Upon completion of implementation strategies in various hospitals, The Joint Commission
reported a 62 percent reduction in injuries due to falls and a 35 percent reduction in falls overall
(Jointcomission.org). Using these statistics the Joint Commission is able to estimate a hospital
using similar fall prevention measures to save $1million annually (Jointcomission.org).
Reducing falls is not only a major undertaking in the hospitals; it is also a big concern in the
home. According to statistics, one out of every three older adults falls each year some resulting in
disabilities such as fear related to falling again, sedentary lifestyle, impaired function, and
decreased quality of life (healthypeople.gov). Healthy people 2020 has declared fall reduction as
one of its priority goals. We as healthcare providers must seek out opportunities such as the Post
Fall Folder Project to improve outcomes and increase the quality and safety of our patients.

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References
Blanchard, K. & Hodges, P. (2005). Lead like Jesus. Nashville, TN: Thomas Nelson.
Finkelman, A. (2012). Leadership and Management for Nurses: Core
Competencies for
Quality Care. (2nd ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.
Healthy People 2020. Older Adults. Objectives: Retrieved from:Healthypeople.gov
http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults/objectives
The Joint Commission. Preventing Falls with Injury Project: Retrieved
from:Jointcommission.org
http://www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=7
Kouzes, J. M., & Posner, B. Z. (2013). The Student Leadership Challenge: Student
Workbook and Personal Leadership Journal. San Francisco: Jossey-Bass.