Healthcare Service Improvements and Clinical Setting

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The purpose of this essay is to focus upon a service improvement initiative, proposed within a chosen clinical setting; with the main discussion being aimed towards improvement within healthcare services. The main aim will be to demonstrate the process that will be used, whilst developing the development strategy and referring to relevant evidence and references that will support this change. 

The chosen service improvement will be the All Wales Pain Assessment tool, used alongside current pain assessments, within the National Early Warning Sign (NEWS) charts, as it stands and in use with patients who are cognitively impaired, following a brain injury, basing it throughout a neuro ward. A given rationale for chosen improvement will be demonstrated, supported with discussion of the improvement procedures, and written in subheadings using the PDSA framework. Proposed by Craig, through introducing healthcare service improvements, they can advance the delivery of care, cut costs, update the services available and importantly, reduce the amount of clinical errors reported. 

Along with this, there is also a positive input for the multi-disciplinary team involved, resulting in patient outcome benefits and excellent display of quality of care. The Royal College of Nursing wrote that quality of healthcare can be discussed and remembered using the TEPEES framework, ensuring quality within healthcare is appropriate, effective, individual, well-organized, reasonable and safe. The Healthcare Quality Improvement Partnership demonstrates that health workers can show a widespread variety of quality improvement methods and tools, when shared underlying principles are identified. 

These principles could be acknowledged as being able to understand and breakdown the presenting issues, consider the patient pathway process and discussing whether this is able to be simplified, analysis of service demand and flow, and have the use of tools which are able to bring the change into place; including guidance and clinical engagement. As this essay states that implementation will occur throughout a chosen ward; and within line with The Nursing and Midwifery Council, confidentiality will be maintained throughout.

As suggested by Centres for Disease Control and Prevention, a cognitive impairment is when everyday life is affected through trouble remembering things, issues when trying to learn, inability to concentrate or make everyday life decisions. Mild and severe cases of cognitive impairment can be reported, with mild changes being known to be where an individual is till able to perform activities with minimal impact, whereas serve impairment can include loss of speech, insight and importance of something and independent living. In relation to the change agents proposed change to a ward of cognitively impaired patients, following a brain injury; CDC continue to state that a cognitive impairment is evident in patients who have suffered from a stroke, ongoing dementia and traumatic brain injury. 

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The change agent would introduce this improvement, in thought of it being a way of improving pain management for patients, post traumatic brain injury, and are cognitively impaired as a outcome. Patients who have suffered from a head injury, are known for experiencing chronic pain; with this being directly from brain damage, or from the spinal cord. It is known that brain injury can result in regular debilitating headaches, which can arise frequently and initially be lengthy. Pain in brain injury can also be from muscular injury, nerve damage or even bone breakage; resulting in nociceptive pain .

The service improvement that has been proposed, and which the change agent has chosen is to implement, is the use of the All Wales Pain assessment tool; which will be implemented to be used along side NEWS, within a setting where some patients suffer from a cognitive impairment. According to Corbett, Husebo, Wilco, Achterberg, Aarsland, Erdal and Flo considering all types of cognitive impairments when it comes to assessment of pain is vital, they suggest that when a patient has an inability to store memory, unable to verbalise, and struggle to display emotions, it is vital they receive adequate assessment, due to the difficulty they have in relaying their own pain expression. Implemented by the Welsh Health Circular (2019), the All Wales Pain assessment tool is built up by using four different tools, to create one document, which health professionals use appropriately to their appointed patient. 

The four tools involved are, PainAD, Abbey Pain Scale , Numerical Scale (0-10) and the Categorical Rating scale. Suggested by Paulson, Monroe, & Mion, when determining the pain of a patient with a cognitive impairment such as delirium or dementia, it is known to be known to be challenging. The Pain Assessment in Advanced Dementia, would be a useful tool to use, as an assessment of a patient’s behaviour is observed; breathing, vocalisation, facial expressions, body language and console level are all considered, and then scored from a range of 0, and 2 for each section, totalling to 10 overall. 

The Abbey Pain Scale is explained by The Department of Health as a way of measuring pain within patients who are unable to effectively verbalise and is commonly used within areas where patients are cognitively impaired. Just like PainAD, The Abbey Pain Scale considers patients pain from observations of facial expressions, body movements, vocalisations, and responses to pain. The Numeric scale is a commonly used pain scale in healthcare and measures pain through the use of a 0-10 rating scale. It was developed with the aim to measure the level of pain and promote action and communication within health care services. 

Although not directly focused to cognitive impairment patients, this scale can be asked to patients, or can even be handed to them to complete on a hard copy, making it a simple but effective way of detecting pain. Finally, the categorical scale is a tool that can be used when the patient is able to verbalise; as they will be able to state whether there is no pain, mild, moderate or severe pain present. This scale is a very efficient, quick and effective method assessing pain, with a known high validity of pain indicator, this is suggested by Bech, Lauritsen, Ovesen and Overgaard; where they state that cognitively impaired patients were using this scale with good results, due to the simplicity of it.   

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