NURS 478 FINAL

Critical pathway

Predetermined courses of progress that patients should make after admission for a specific diagnosis or after a specific surgery

Types of planning

Proactive planning is key to success. Reactive planning: occurs after problem exists Inactivism: seeks the status quo. Would rather maintain the status quo than take a risk with a new way of doing things Preactive planning: utilizes technology to accelerate change; future-oriented Interactive or proactive planning: considers the past, present, and future and attempts to plan the future of an organization rather than react to it

Striking and ethics

Protection of professional practice Protection of patients Safety Living wage and benefits which supports strong community

Strategies for decreasing resistance

Provide factual information, slowly implement change, use committees (decentralizing) - give power to others when you can, open communication (at huddle) Rational - empirical: provide people with facts/rational (why we do this). Most effective Normative - re-educative: use the group norm (key members/leaders to launch change) Power - coercive: authoritarian, memo stating this is what is happening Steps in change: assess, implement, evaluate

5 elements of professional negligence

1. Duty to use due care defined by the standard of care - care should be given under circumstances (what the reasonable prudent nurse would have done) 2. Failure to meet standard of care (breach of duty) - not giving the care that should be given under the circumstances 3. Foreseeability of harm - the nurse must have reasonable access to information about whether the possibility of harm exists 4. A direct relationship between failure to meet the standard of care and injury can be proven. Patient is harmed because proper care is not given 5. Injury: actual harm results to the patient

4 steps in progressive discipline

1. Informal reprimand or verbal warning 2. Formal reprimand or written warning 3. Suspension from work without pay 4. Termination

Magnet status forces

1. Quality of nursing leadership 2. Organizational structure 3. Management style 4. Personnel policies and programs 5. Professional models of care 6. Quality of care 7. Quality improvement 8. Consultation and resources 9. Autonomy 10. Community and the hospital 11. Nurses as teachers 12. Image of nursing 13. Interdisciplinary relationships 14. Professional development The term magnet is used to denote organizations who are able to attract and retain nurses. It is not an award, but a credential recognizing nursing excellence. With magnet status, well-qualified nurse execs are in a decentralized environment, with organizational structures that emphasize open, participatory management. It is autonomous, self-managing, self-governing climates that allow nurses to fully practice their clinical expertise, has flexible staffing, adequate staffing ratios, and clinical career opportunities. This leads to a professional practice culture in all aspects of nursing care. Magnet status is compliant with standards in the ANA's Scope of Standards for Nurse Administrators

Options to improve staffing

10 or 12 hour shifts Premium pay for weekend work Part-time staffing pool for weekend shifts and holidays Cyclical staffing: a set staffing pattern is repeated every few weeks Job sharing Allowing nurses to exchange hours of work among themselves Flextime: allows employees to select the time schedules that best meet their personal needs while still meeting work responsibilities Use of supplemental staffing from outside registries and float pools Staff self-scheduling: nurses in unit work together to construct their own schedules. Fill out several weeks in advance and nurse manager reviews it On call Shift bidding, which allows nurses to bid for shifts rather than requiring mandatory overtime Alternatives: agency nurses, travel nurses, flextime, self-scheduling, float pools, ANA toolkit

Nurse union legislation

1974 Healthcare Amendments: provided collective bargaining rights to employees of non profit hospitals. Hospital services are seen are "essential" services and thus nurses are "essential" workers and thus MUST provide a 10 day notice of intent to strike before being able to strike. Passage of these amendments cause an increase in unionization of RNs across the country National Labor Relations/Wagner Act: amended to extend coverage and protection to employees of non profit hospitals. Labor relation in the healthcare industry required special considerations. Senate Labor Committee sought to fashion a mechanism which could ensure the needs of the patient would be met during contingencies arising out of labor disputes. New law represented a sound and equitable reconciliation of these competing interests Taft-Hartley Amendment: returned some power to management; resulted in more equal balance of power between unions and management Kennedy Executive Order: amended the Wagner Act to allow public employees to join unions Amendments to Wagner Act: allowed nonprofits to join unions National Labor Relations Board Ruling: allowed nurses to form their separate bargaining units

Differentiated practice

3 distinct nursing roles ADN, BSN, Masters competencies Paradigm shift is that each nurse is not the whole of nursing, but INSTEAD contributes to the whole of nursing

McGregor's Hot Stove Rule

4 elements make discipline fair and growth producing as possible 1. Forewarning 2. Immediate consequences 3. Consistency 4. Impartiality

Formal grievance process

A grievance occurs when the employee and manager perceive "fair/just differently" The discrepancy can be resolved by a formal means: a grievance procedure The steps are outlined in administrative policies or union contracts Typically entails progressive lodging of complaints up the chain of command Difference not settled in formal grievance process, generally proceeds to arbitration

Vicarious liability

A legal doctrine that holds the employer legally responsible for the acts of its employees Not dependent on employer negligence Employers: hospital, school district, non-profits, health departments, etc. It is not the supervisor It is called indirect liability because the employer is indirectly responsible for the harm

Volunteer Protection Act 1997

A volunteer of a nonprofit organization or governmental entity is not liable for harm caused by an act or omission done in the scope of responsibility on behalf of the organization. This applies if the volunteer was properly authorized or licensed, if such authorization is needed In AZ, a volunteer is immune from civil liability in any action based on an act or omission resulting in damages if volunteer acted in good faith and within scope of official functions and duties for a non profit corporation or non profit organization, hospital, or governmental entity. Exception: willful, wanton, or grossly negligent misconduct

Unions representing healthcare employees

AFL-CIO: Umbrella federation for 55 US unions, representing around 12.5 million men and women National Nurses United: found in 2009, 185,000 members across all states. Largest union and professional association of RNs United Food and Commercial Workers: 1.2 million working people in the US and Canada. Supports full and part time workers that belong to more than 400 local unions. Represents workers in grocery and retail stores and healthcare. Service Employees International Union: 1.2 million members. Primarily healthcare workers. Hospital, homecare, nursing homes, pharmacies, freestanding clinics, and other healthcare settings

ABLE

Act now to address conflict, cynicism, don't wait Bolster your belief in all team members and show they are appreciated and important Lead through example. Show staff that you use the same behaviors you expect from them through all interactions Expect excellence and empower your employees to achieve goals they set

Patient classification systems

Acuity vs. Workload Eating Grooming Excretion Comfort General health Treatments Medications Teaching and emotional support Categories 1-4 Category 1: feed self Category 2: need some help in preparing food tray Category 3: cannot feed self but is able to chew and swallow Category 4: cannot feed self and may have difficulty following

Factors to identify appropriate model

Acuity, staff availability, staff experience, financial means Key identifier of each model: total patient care, functional nursing, team nursing, modular nursing, primary care nursing, differentiated practice, case manegement

Bureacracy

Advantages: clear lines of authority, authority and responsibility clearly defined, clear rules and regulations, task specialization and division of labor, impersonality of relationships, technical efficiency, promotion based on competence Disadvantages of bureaucracy: predisposed to authoritarian leadership style, use of rewards and punishment, competition for the advancement of an individual interest, aloofness secondary to specialization, faceless decision-making, lack of flexibility and accountability, impersonal management, and establishment of organizational barriers

Closed units

All staff members on a unit make a commitment to cover all absences: fill all needs with own staff In return for not being pulled from the unit in times of low census

Team nursing

Ancillary personnel collaborate in providing care to group of patients under direction of Prof nurse. Extensive communication needed. Focus is on individual patients (not populations) of patients Typically uses nurse leader who coordinates team members of varying educational preparation and skill sets in the care of a group of patients RN team leader role: manager of care, team supervisor, coordinator of care, care provider, advocate, interprofessional team member RN team leader functions: develops/evaluates POC, assures quality outcomes, resolves problems encountered by team, conducts patient care conferences

Effective performance appraisals

Appraiser is viewed with trust/respect: avoid surprises in the appraisal conference Based on standards that all employees are held accountable: aware of how information is obtained for each level Employees must know in advance what happens if standards are met Appraiser should be those who directly supervise the employee Positive feedback is shared Employee's past experience with performance appraisals (positive and negative) will affect the outcome Coach and communicate informally on a continuous basis: little new information at the appraisal meeting

Reportable misdemeanors

Assault and related offenses Theft and related offenses Fraud, deceit, and related offenses Abuse, neglect, exploitation of a child or vulnerable adult and related offenses Sexual assault and related offenses Drug and/or alcohol and related offenses Arson and related offenses Animal abuse, cruelty, and related offenses Per AZ NPA, RNs must report these charges if they know or suspect that another nurse has not self reported Encourage self reporting

Legislative mandates

Assembly Bill 394 passes in 1999 by California Nurses Association Mandatory staffing ratios California: Med-surg: 1:5 Step down: 1:3 Peds: 1:4 ED: 1:4 L&D: 1:2 Critical care: 1:2 Postpartum couplets: 1:4 Not required by all states Goal: to improve patient care

Nurse navigators

Assists patients and families to navigate the complex healthcare system by providing information and support as they traverse their illness

Authority, responsibility, accountability

Authority: the official power to act and direct the work of others Responsibility: related to job assignment and must be accompanied by enough authority to accomplish the assigned task Accountability: moral responsibility that accompanies a position

Harassment

Based on race, color, religion, sex, national origin, age, disability and genetic information Illegal when: enduring the behavior becomes condition of continued employment. Is severe or pervasive. Creates a hostile work environment

Chapter 18 key concepts

Because human beings have constant needs and wants, they are always motivated to some extent. However, what motivates each human being varies significantly Managers cannot intrinsically motivate people, because motivation comes from within the person. The humanistic manager can, however, create an environment in which the development of human potential can be maximized Maslow stated that people are motivated to satisfy certain needs, ranging from basic survival to complex psychological needs, and that people seek a higher need only when the lower needs have been predominately met Skinner's research on operant conditioning and behavior modification demonstrates that people can be conditioned to behave in a certain way based on consistent reward and punishment system Herzberg maintained that motivators or job satisfiers, are present in the work itself and encourage people to want to work and to do that work well. Hygeine or maintenance factors keep the worker from being dissatisfied or demotivated but do not act as true motivators for the worker Vroom's expectancy model says that people's expectations about their environment or a certain event will influence their behavior McLelland's studies state that all people are motivated by three basic needs: achievement, affiliation, and power Gellerman states that most managers in organizations overmanage, making the responsibilities too narrow and failing to give employees any decision-making power or to stretch them often enough McGregor points out the importance of a manager's assumptions about workers on the intrinsic motivation of the worker There appears to be a perceived threshold beyond which increasing reward incentives results in no additional meaning or weight in terms of productivity Offering rewards in defined categories, even when the categories are meaningless, can increase motivation, because the very act of segmenting these rewards appears to motivate people to perform better and longer Positive reinforcement is one of the most powerful motivators the manager can use and is frequently overlooked. Must be specific or relevant to a particular performance. Must occur as close to the event as possible. Should be continuous The supervisor or manager's personal motivation is an important factor affecting staff's commitment to duties and morale The success of a motivational strategy is measured by the increased productivity and benefit to the organization and by the growth of the person, which motivates him or her to accomplish again Managers can enhance the work of their staff by providing them with opportunities to experience challenges that make their jobs exciting

Civility

Behavior that shows respect toward another person, makes that person feel values, and contributes to mutual respect

Staffing plan considerations

Benchmarking Ratios Patient classification HPPD Regulatory requirements Skill mix Staff support Historical considerations

Janet Quinn one degree of change (self care)

Break down into basics and make simple change goals that are realistic Builds confidence and validation

Mission statement

Brief statement (3 or 4 sentences) identifying the reason the organization exists. A well written statement identifies what is unique about the organization. The statement should also have the capacity to drive action over time. In other words, mission statements can become powerful decision making tools when they become a template of purpose for the organization's activities

Flexible budgeting

Budgets that flex up and down over the year depending on volume

Productivity

Can be measured by volume of services delivered

Centralized vs de-centralized decision making

Centralized: few managers at the top of the hierarchy make most decisions De-centralized: decision making is diffused throughout the organization, and problems are solved by the lowest practical managerial level. Usually, this means that problems can be solved at the level which they occur

Key concepts of chapter 8

Change should not be viewed as a threat but challenge and a chance to do something new and innovative Change should be implemented only for good reason Because change disrupts the homeostasis or balance of the group, resistance should be expected as a natural part of the change process The level of resistance to change generally depends on the type of change proposed. Technological changes encounter less resistances than changes that are perceived as social or that are contrary to established customs or norms Perhaps the greatest factor contributing to the resistance encountered with change is a lack of trust between the employee and the manager or the employee and the organization It is much easier to change a person's behavior than it is to change an entire groups behavior. It is also easier to change knowledge levels than attitudes Change should be planned and thus implemented gradually, not sporadically or suddenly Those who may be affected by change should be involved in planning for it. Workers should thoroughly understand the change and its effect on them The feeling of control is critical to thriving in a changing environment Friends, family, and colleagues should be used as a network of support during change The successful change agent has the leadership skills or problem solving and decision making as well as good interpersonal skills In contrast to planned change, change by drift is unplanned or accidental Historically, many of the changes that have occurred in nursing have affected the profession are the results of change by drift People maintain status quo or equilibrium when both driving and restraining forces operating within any field simultaneously occur. For change to happen, this balance of driving and restraining forces must be altered Emerging theories such as complexity science suggest that change is unpredictable, occurs at random, and is dependent on rapidly changing relationships between agents and factors in the system and that even small changes can affect an entire organization Organizations are preserved by change and constant renewal. Without change, the organization may stagnate and die

Lewin's thoughts

Change should only be implemented for good reason Change should always be gradual All change should be planned, and not sporadic or sudden All individuals who may be effected by the change should be involved in planning for the change Change to solve the problem Change to make work procedures more efficient Change to reduce unnecessary workload

Change agents

Characteristics: enjoy learning, comfortable with resistance/don't take personally, active, extroverted, can easily articulate the why, good communicator

Types of performance appraisal tools

Checklists: weighted, forced, and simple Essay Self-appraisal: portfolio Peer review: select one/manager can select one. 360 degree: reviews from different shifts/departments of employees that you can encounter with your work Management by objectives (MBOs): employee sets personalized goals, measure own performance

Strategies to create an environment of self-discipline

Clearly written and communicated rules and regulations Atmosphere of mutual trust: non-threatening environment Judicious use of formal authority Employee identify with organizational goals

PATHS Projects

Clinical ladder programs for nurses provide advancement opportunities for nurses who desire to remain at the bedside EBP project with implementation on unit. Formal clinical research project. Professional publication Practice improvement: team building or collaborative practice projects. Implement practice changes or standards. Quality improvement using Plan-Do-Study-Act methods. Clinical documentation improvement. Ethics or clinical practive development. Policy and procedure revisions. Service excellence project Resource management: charge person, mnage unit staffing schedules, supply or inventory management project, accreditation readiness project. Unit operations project: improve department efficiency, lean process improvement, organize supplies or equipment, improve communications Staff development and education: formal mentoring relationship, preceptor effectiveness, unit education programming and delivery: formal class, staff development education for department, mini clinical briefings. Multidisciplinary education and training program. Patient education development

Informed consent

Common law: unwritten law based on precedent; used when there is no other law Mature minor doctrines: legal principle which allows minors to make decisions if they can show they are mature enough to make a decision State law: age of consent and exceptions Federal law: title X of the Public Health Service Act and HIPAA Supreme Court decisions: right to privacy when seeking contraception and abortion

Organizational culture

Consists of a system of symbols and interactions, and may include sum total of values, language, past history of "sacred cows", formal and informal communication networks, and the rituals of organization. One can't see or touch this, as this is essentially invisible, but very real nonetheless. Culture is the soul and personality of the institution It is the basis of the corporate values and mileu.

Controllable vs noncontrollable

Controllable expenses can be controlled by the manager, whereas noncontrollable expenses cannot

Moral decision making model

Crisham: developed decision-making model incorporating the nursing process and principles of biomedical ethics Massage the dilemma: collect data about the ethical problem and who should be involved in the decision-making process Outline options: identify alternatives, and analyze the causes and consequences of each Review criteria and resolve: weigh the options against the values of those involved Affirm position and act: develop the implementation strategy Look back: evaluate the decision making

Criteria

Decisions made must meet state and federal labor laws and organizational policies Staff must not be demoralized or excessively fatigued by frequent or extended overtime requests Long-term as well as short-term solutions must be sought Patient care must not be jeopardized Mandatory OT

Ethical dilemma

Defined as making a choice between two or more equally undesirable alternatives The individual who must solve an ethical dilemma is the only person who can ascertain if actions taken were congruent with personal values Self-awareness is vital in ethical decision making, as it is in other aspects of management

Inpatient unit

Designated location in which staff is able to provide care to patients 24 hours a day, 7 days a week The number of FTEs needed to meet the staffing plan are calculated by patient care needs (by shift and 24 hours) and nonprouductive time - calculate amount of additional staff needed to provide for days off and benefit time Scheduling considerations: patient needs (measured by PCS and changes in needs), volume, and experience/capability of staff Evaluation of staffing/scheduling effectiveness: patient outcomes, nurse staffing and nurse outcomes, attain target productive hours

Performance appraisals

Determine how well employees are performing their job. Measure actual behavior, not intent Require accuracy and fairness: supportive data Completed correctly: develop and motivate staff Completed poorly: discourage and demoralize staff Past experiences can be emotional: not relaxed, highly charged Trait rating scales: knowledge of job - excellent, good, satisfactory, fair, poor Job dimension scales: teach 2 CPR classes in a year - teaching 2 classes (2), teaching 1 (1), none (0) Behaviorally anchored rating scale: utilizes barcoding when administering medications: physical observable skill

Chief goal of ethics

Determine right from wrong Collect, analyze, and interpret data State the dilemma Consider choices of action Analyze the advantages and disadvantages of the situation Make the decision

Direct vs indirect liability

Direct: Individual liability: negligent supervision Corporate liability Indirect: vicarious liability

Discipline vs punishment

Discipline: constructive - assists employees growth. Training/molding the mind or character to bring about desired behaviors Punishment: undesirable event that follows unacceptable behavior Constructive discipline: foster employee growth, supportive and corrective manner, employee should understand that punishment is because of actions and not who they are as a person. Primary focus: self directed in meeting organizational goals Destructive discipline: includes the use of threats and fears to control behavior Self-discipline: rules are internalized - part of person's personality. Highest and most effective form of discipline. Possible only if subordinates know the rules and accept them as valid

Professional codes of ethics

Do not have the power of law. They do function as a guide to the highest standards of ethical practice for nurses Administration practice published by the ANA specific to nurse-manager role

Driving and restraining forces for mandatory staffing ratios

Driving: needed because RNs and patients are negatively affected with high ratios. Decreased RN health and safety and decreased patient outcomes. Bad image in the news. Restraining: difficult to fill slots because nursing shortage, not all RNs have equivalent abilities and experience. Not all RNs have equivalent abilities and experience. Cause conflicts between nurses and hospitals. Costs money.

Chemical impairment in nursing

Drug or alcohol abuse: Demerol, oxycodone, OxyContin, Vicodin, alcohol Majority of disciplinary actions by licensing boards are related to misconduct from chemical impairment: misappropriation of drugs for personal use. Sale of drugs/drug paraphernalia to support the nurse's addiction Chemically impaired employee: time/attendance issues, being absent from work without good explanation, extend lunch hour, excessive sick leave or request for days off, staying late for no apparent reason, consistent tardiness/being late, disappearing frequently from the unit without explanations Confronting the chemically impaired RN/Staff: gather as much evidence as possible, immediate confrontation, denial of the impairment or use of defense mechanisms should be expected; manager should not nurture or counsel employee, manager should outline plan for employee to overcome chemical impairment

Disciplining the unionized employee

Due process for unionized staff that management must provide union staff with a written statement outlining disciplinary charges and the reasons for the penalty Unionized staff must be disciplined according to specific, pre-established steps and penalties within an established time frame Detailed records: misconduct and counseling attempts

7 rules for leading change

Eliminate anyone who opposes to change immediately - No Keep the pace of change high at all times - Yes Make sure everyone understands change reason - Yes Keep informed through change process - Yes Don't allow modifications once change process is on its way - Yes and No Demonstrate why change is beneficial - Yes Work environment is not changing, change is the work environment - Yes

Marginal employee

Employees who meet minimal standards Contribute very little to the unit and organizational efficiency Strategies to deal with marginal employees: transfer to another unit, offer coaching, offer early retirement, dismissal

Types of employees

Engaged: passion - drive innovation and move organization forward. Connection to the company Not engaged: checked out, time but not energy into work Actively disengaged: acting out their unhappiness

Strengthening frontline nurse investment in organizational goals

Establish greater line of sight Create a culture of shared responsibility Providing external motivation Translating insights into action Instilling accountability among frontline staff or more specifically, strengthening individual nurse in- vestment in organization goals is crucial to organiza- tional success. Beyond a commitment to providing excellent care to their individual patients, frontline nurses must feel a personal stake in larger institutional performance to meet the increasingly complex challenges posed by healthcare delivery reform. Center researchers found that organizations that have successfully established greater accountability among frontline staff (and as a result, report strong quality, safety, and patient experience outcomes) have implemented 3 primary strategies: establishing greater line of sight, creating a culture of shared responsibility, and providing external motivation.

Ethics

Ethics is the systematic study of what a person's conduct and actions should be with regard to self, other human beings, and the environment Justification of what is right and wrong System of moral conduct and principles that guide a person's actions in regard to right or wrong

Systematic problem-solving/decision making model

Nursing process: assess, diagnose, plan, implement, and evaluation This is a form of decision-making tool Individuals forget at times to include alternatives or to evaluate the results in decision making The structured approach to problem solving is: data gathering, multiple alternatives are analyzed and used to problem solve. Even if it is a poor outcome you can reflect back on what you have done and maybe come up with an alternative

Leaders and organizing care

Evaluates care delivery model periodically If considering change, reviews existence of resources and support Considers the staff and support during the change Inspires and ensures models to promote professional nursing practice Inspires and ensures models promote professional nursing practice Management perspective requires a focus on: unit philosophy conducive to change, uses an EBP approach, match of model to patient care needs, maximizes resources for optimal outcomes, considers organizational goals/cost-effectiveness

Why strategic plans fail

False assumptions Not knowing overall goal Not enough alternatives Inadequate time or other resources Low motivation levels Sound strategies not used Inadequate delegation of authority Not recognizing organizational goals and needs Planning too narrow in scope - not recognizing community, legal, and licensing requirements

Nursing cost

Fiscally, nursing is viewed as a cost center that does not independently generate revenue Ongoing efforts to measure and establish the cost of the various components of nursing care are challenging and not well defined Consequently, nursing cost is narrowly associated with budgeted and actual nursing care hours per patient day, a measure of time rather than a measure of type or level of care Nursing hours per patient day - NHPPD

Fixed vs variable budgets

Fixed expenses do not vary with volume, while variable expenses do

Types of organizational structures

Flat design vs tall: flat occurs when there are few layers in the organization. Decentralizes the organization. Tall structures have many reporting layers illustrating the chain of command. Flat would be when all nurses reported to DON Matrix organizations: designed to focus on both the product and the function. Have a formal vertical and horizontal chain of command. Have fewer formal rules and fewer levels of the hierarchy. Can cause slow decision making due to information sharing. Can produce confusion and frustration for workers because of dual-authority hierarchal design

Incremental budgeting

Flat-percentage increase method: simplest method for budgeting. By multiplying current-year expenses by a certain figure, usually the inflation rate or consumer price index, the budget for the coming year may be projected. Downside: easy, but inefficient fiscally because there is no motivation to contain costs and no need to prioritize programs and services

Philosophy

Flows from the purpose or mission statement and delineates the set of values and beliefs that guide all actions of the organization. It is the basic foundation that directs all further planning toward that mission. Statements of philosophy can usually be found in policy manuals.. The organizational philosophy provides the basis for nursing philosophy at the unit level and for nursing services as a whole

Formal vs. informal structure

Formal structure: provides framework for defining managerial authority, responsibility, and accountability. Roles and functions are defined and systematically arranged, different people have differing roles, and rank and hierarchy are evident Informal structure: unplanned and covert, with informal authority and lines of communication. People need to be aware that informal authority and lines of communication exist in every group, even when they are never formally acknowledged. Nearly all settings have an informal leader and structure

Workload measurement tool

Formula in use where all nursing and ancillary staff are treated equally for determining hours of nursing care No differentiation is made for differing acuity levels of patients NCH/PPD = Nursing Hours worked in 24 Hours/Patient Census

Determination of staffing needs

Full-time equivalents (FTEs) are measure of the work commitment of a full time employee Hours worked and available for patient care are designated as productive hours Hours for benefits such as vacation, sick time, and education time are considered non-productive hours Direct care: is time spent providing hands-on care to patients Indirect care: time spent on activities that are patient-related but are not done directly to the patient Nursing hours per patient day: a standard measure that quantifies the nursing time available to each patient by available nursing staff. Reflects only productive nursing time available 28 patients on unit 7 RNs x 2 shifts = 14 RNs 14 RNs working 12 hour shifts = 168 hours available 168 hours/28 patients = 6 HPPD

Goals and objectives

Goals and objectives are the ends toward which the organization is working. All philosophies must be translated into specific goals and objectives if they are to result in action. Therefore the goals and objectives "operationalize" the philosophy. There is increasing evidence concering the value of including admin and all workers in setting organizational goals. Goals should be measureable and realistic and should delineate the desired end product

Preparing nursing departments for work stoppage

Had to make a detailed plan for the striking process and orientation of contingency nurses Assess labor needs Scheduling: contingent labor agency - orientation for these nurses Charge nurse: appointed one of the remaining staff nurses Hand off: between outgoing strike nurses and contingency nurses - had to make sure there was no ill-will Unit-based orientation: for contingency nurses Departmental information systems training Rapid responses and codes: management staff

Potential conflicts

Having a professional organization that also serves as a collective bargaining agent Conflicts within professional nursing organizations American Nurses Association States Nurses Associations (SNA): provide collective bargaining services, have memberships comprised mostly of staff nurses covered by collective bargaining agreements. Few managerial nurses are members of a SNA that engages in collective bargaining

Challenges related to planning

Healthcare reform Rapidly changing technology Increasing government regulation of healthcare Scientific advances

Discrimination in the workplace

Hiring, firing, demoting, promoting, training, wages, benefits, and disciplining employee based on any of the following categories: Age, race, ethnicity, citizenship, disability, sex, sexual orientation, gender identity, gender expression, marital status, religion, accents, pregnancy and children, genetic information, whistle blowers, political association, people represented by a union, military service

Integrity article

How leaders can show and encourage integrity: Model appropriate behavior Ensure comprehensive ethics education for nurses at all levels Create effective structures and processes to support transparency Promote systematic ethical decision making Promote accountability

Leading the change

Identify the problem (Force Field Analysis) Identify optimal outcome solution and the desired outcome objectives Identify constraints, capabilities, resources, and claimant groups Identify and explore potential solutions/then choose best solution Plan the implementation process Implement the solution for a given time Evaluate the outcome

Factors influencing joining a nurse union

Increase the power of the individual Increase nurses input into organizational decision making Elimination of discrimination and favoritism Nurses social need to be accepted Employers would be required to accept employees as equal Nurses believe it will improve patient outcomes and quality of care

Economics and nursing unionization

Increased union activity is related to a healthy economy and high demand for nurses When nursing vacancy rates are low, union membership and activity tends to decline Rapid downsizing and restructuring in the 1990s left many nurses feeling that management did not listen to them or care about their contribution to patient care

Why ethics is becoming a greater force in management decision making

Increasing technology, regulatory pressures, and competitiveness among healthcare providers National nursing shortages Reduced fiscal resources Costs of supplies and salaries The public's increasing distrust in the healthcare delivery system, and with different institutions Values and norms of nursing professions Clinical nurses have a different ethical responsibility than a manager Management is a discipline and not a profession, but has norms and values of the organization Organizations also have to follow the norms e.g. society, JCAHO, Medicare, Physicians, etc. There is a difference between personal, organizational, subordinate, and consumer responsibilities, great potential for nursing managers to experience intrapersonal conflict about the appropriate course of action Ethical decisions: the manager must have knowledge of ethical principles and frameworks. Organizations must have ethics committees, institutional review boards, and professional code of ethics. Clinical nurses must also be aware of the ethical principles, frameworks, and different committees to deal with ethical dilemmas

Intrinsic vs extrinsic motivation

Intrinsic: internal drive to do or be something. Aspiration Extrinsic: motivation enhanced by the job environment or external rewards

Informed vs expressed consent

It is within the scope of practice of the RN to obtain informed consent for treatments and procedures that the RN will perform It is within the scope of practice of the RN to witness signatures on documentation indicating understanding of informed consent provided by other practitioners, such as physician assistant, nurse practitioner, and physician (expressed consent) It is NOT within the scope of practice of the RN to obtain informed consent for medical treatment plans

Personnel budget

Largest of budget expenditures because healthcare is labor intensive

Termination

Last resort: necessary employees who continue to break rules despite warnings Difficult for employee, manager and unit. Cost is enormous in terms of: managerial/employee time and unit morale

Functional nursing

Members are trained to complete certain tasks Completion of specific tasks by different nursing personnel

Planning hierarchy

Mission Philosophy Goals Objectives Policies Procedures Rules

Force Field analysis

Model in proceeding with change using numerical scale. Positive - proceed to change Negative - do not proceed to change

Legal responsibilities of the manager

Monitoring patient care, auditing medical records, staff education, best practice standards; disseminating research, chain of command, communication - healthy work environments, creating safe environment for reporting poor/unsafe care

Types of ethical issues

Moral issues: includes moral uncertainty, moral conflict, moral distress, moral outrage, and ethical dilemmas Moral uncertainty/moral conflict: individual is unsure which moral principles or values apply Moral distress: knows the right thing to do but organizational constraints make it difficult to take the right course of action (pt wants DNR, doctors want to continue with care) Moral outrage: witnesses the immoral act of another, but feels powerless to stop it (physician gives inadequate care, and has been reported several times, and nothing has been done)

Rule breaking

Most common reason for discipline. If rule is consistently broken as: whose rule is it? Do we still need the rule? Staff morale is jeapordized when staff are not disciplined Any desirable conduct should merit further action

State Minors' Consent Law

Most states: 18 for most healthcare Exceptions vary by state: mental illness, contraception, pregnancy, substance abuse, homeless teens, emancipated teens, legally married Laws not always intuitive Usually tied to privacy/confidentiality Follow your organizations' policy Best practice: include minors and parents in medical consent and decisions whenever possible

Ethics committees

Multidisciplinary teams: chaplain, doctors, nurses, social worker, case manager, and sometimes this includes patients Institutional review boards: of your organization will also look at the situation especially if there is a incident (sentinel event), and determine the process Using the ethical frameworks do not solve the ethical problem but assist individuals involved in the problem to clarify their values and beliefs There is legal and ethical issues, although they are not the same and this can be difficult for committees Legal controls are generally clear and impartial Ethical controls are unclear and individualized Ethical decision making for a nurse leader: Professional approach Eliminate trial and error Focuses on proven decision-making models Organizational problem-solving processes

Zero based budgeting

Must rejustify their program or needs every budgeting cycle. Does not assume that because a program has been funded in the past

Professional licensure

Must report a felony or undesignated offense within 10 days after the conviction The applicant or licensed offender must report (BEST) Licensees, certificate holders, and healthcare institutions who have any information that a licensee was or may be a threat to public health or safety Failure to report could be disciplinary action by AZSBON for unprofessional conduct

Caclulating nursing care hours per patient day

NCH/PPD = Nursing care hours worked in 24 hours/patient census Multiply total number of staff on duty each shift by the hours each worked in their shift. Each shift total is added together Then divide this number by the patient census

Extending liability

Negligent supervision (individual and direct liability) Unbalanced or inadequate staffing Failing to act upon reports Unreported unsafe care Failing to assign the right duties to the right staff person/providing oversight Failing to ensure that supervised staff know and follow policies and procedures Corporate liability (direct liability) principles Hospitals have the duty to: Use reasonable care in maintaining safe and adequate facilities and equipment Formulate adequate policies to ensure quality of care for patients Oversee all persons who practice within its walls Select and retain competent physicians and staff. Corporate liability: a hazardous environment, improperly functioning equipment, inadequate or inaccessible policies and procedures, insufficient staffing, a problem with a procedure for credentialing staff

Non-nursing tasks vs professional nursing activities

Non-nursing: taking VS, transport, preparing meals, getting supplies and equipment Nursing: interpreting VS, assessing/monitoring physical conditions, IV drugs, therapy, planning for discharge

Case management

Nurses address patients individually Identify most cost effective providers, treatments, and care Can be assigned inpatient or outpatient Need broad scope of knowledge May use critical pathways as a tool for outcomes/interventions

Total patient care

Oldest mode and history of this also called case method As patients could be assigned as cases. Nurses assume total responsibility. Widely used

Patient classification systems

PCS is the tool most broadly used to identify nursing cost PCS = measurement tool to determine nursing workload for specific patient or group of patients, over specified time period Patient acuity: is the measure of nursing workload that is generated for each patient Example of PCS: Rates the amount of effort required for a patient by measuring their ability to perform ADLs, number of meds, amount of monitoring needed, and how many lines or tubes they have Level 1 requires 2 hours/day of care Level 5 requires 20 hours/day of care Patient classification data is a valuable source of info for all organization levels. Staff and managers use data day to day to plan staffing for the next 24 hours Central staffing office monitors census and acuity on all units and deploys nursing resources to the areas in most need Variances in using classification system data: manager required to write a variance report for anything higher than $1000 in budget Unit level: acuity data is essential in preparing for month-end justification for variances in staff numbers Organizational level: acuity data can be used to cost nursing services for a specific patient population and global patient types Forecasting: acuity data is also used in preparing nursing staffing budgets for the upcoming fiscal year

Planning

PPlanning is really important and precedes all other management functions. Planning is a proactive and deliberate process that reduces risk and uncertainty. With effective planning, the manager must identify short and long term goal and changes needed to ensure that the unit will be able to meet their goal. Identifying short and long term goal requires leadership skills such as vision and creativity, flexibility and energy, data gathering, forecasting, and transformation of ideas into action Without adequate planning, the management process fails, and organizational needs and objectives cannot be met

Ethical principles

Paternalism: limits freedom of choice. The authority to make a decision for another person Utility: the good of many outweighs the needs of the individual Justice: treating people fairly Veracity: telling the truth Fidelity: keeping promises Confidentiality: respecting privileged information

Factors that influence nurse staffing needs

Patient acuity: communicate patient needs Admissions: think about these ahead of time Discharges: time consuming for nurse Transfers: could be leaving and freeing up a bed Procedures: nurses have to bring patients places (CT) Professional Nurse skill level & expertise: not too many new grads on 1 shift Physical space: not enough rooms, assigning patients near each other to 1 nurse Availability to technological support: need computers for charting and in room for meds

Capital budget

Plan for the purchase of buildings or major equipment, which include equipment that has a long life, is not used in daily operations, and is more expensive than operating supplies

Strategic planning

Planning has many dimensions, including time span and complexity or comprehensiveness. Complex plans are long-range or strategic plans Strategic planning typically examines an organization's purpose, mission, philosophy, and values/goals in the context of its external environment Complex plans are long-range or strategic plans Clearly defines the purpose of the organization Establish realistic goals and objectives Identifies external constituencies and determine their assessment of the organization's purposes Clearly communicates the goals to the constituents Develops a sense of ownership of the plan Develops strategies to achieve the goals Ensures that the most effective use is made of resources Provides a base from which progress can be measured Successful strategic planning: start planning at the top Keep planning organized, clear, and definite Do not bypass levels of people Have short and long-range plans and goals Know when to plan and when not to Keep target dates realistic Gather data appropriately Be sure objectives are clear Remember, interpersonal relationships are important Strategic planning should include: a clear statement of the organization's mission, the identification of the agency's external constituencies or stakeholders, the determination of the agency' purpose and operations, the agency's strategic goals and objectives, typically in a 3 to 5 year plan. The development of strategies to achieve goals

Span of control

Refers to number of people directly reporting to any one manager and determines the number of interactions expected of him or her. Too many people reporting to a single manager delays decision making, whereas too few results in an inefficient top-heavy organization

Organizational structure

Refers to the way in which a group/organization is formed, its lines of communication and its means for channeling authority and making decisions

Nursing boundaries

Respecting patient's dignity Right to self-determination Delegating tasks appropriately Practicing good judgment Accepting accountability in practice Alleviating suffering - this can be a grey area Being attentive to patients interests Working within the nurse practice acts and nursing standards of practice Nurse-to-nurse relationships, nurse-to-physician, nurse-to-patient, multidisciplinary collaboration Self care/development boundaries- advancing knowledge/research, competencies, self-respect and professional growth

Driving and restraining forces for goal of returning to school

Restraining: low energy, limited finances, unreliable transportation, time with family already impacted Driving forces: opportunity for advancement, status, enhanced self esteem, supportive family

Operating budget

Second most significant component in the hospital budget Reflects expenses that change in response to the volumes of service, such as the cost of electricity, repairs and maintenance

AZSBON Chemically Addicted Nurses Diversion Option

Self-referral Licensure renewal/application Employer referral Legal agencies/other regulatory or community referral Purpose: provide for the public's safety and welfare through early detection, treatment, and monitoring of chemically dependent nurses Re-entry into practice guidelines: consistent to random urine testing for toxicology/alcohol screens Assigned to day shift for first year Provided evidence of ongoing involvement with support groups - attend meetings weekly Cannot use psychoactive drugs Should be paired with successfully recovering RN whenever possible Encouraged to seek individual counseling/therapy and a structure aftercare program

Incident reports

Should be filed whenever there is an unexpected event Are part of the patient's legal medical record Are considered confidential communications among hospital personnel Can be used as evidence in a lawsuit Must be reviewed and signed by patient

Steps to start a union

Simple starting point: talk to a few co-workers who you think may be interested in organizing. Discuss workplace issues, what is involved in organizing a union and making plans to contact the union. Union rep meets with small group: answers questions and helps develop a comprehensive organizing plan Leadership and building and organizing committee: leaders identified, organizing committee created representing all units, all shifts, all racial/ethnic/gender diversity. Begin organizing committee training: work hard to educate selves and co workers, warn of impending management anti union campaign, must understand union policies and principles of democracy and ranking and file control. Basic info about the workplace is gathered: workplace structure - departments, work areas, jobs, shifts. Employee information: name, address, phone, shift, job title, department for each worker. Employer information: other locations, parent company, product(s), customers, union history. Adopt an issues program: usually issues have been identified by nurses but work needs to be done on best ways to communicate to nurses. Sign up majority on union cards: need 30% before going to NLRB (usually unions won't go to election until they have 60-70% of appropriate bargaining unit signing cards Win the unit election: must have 50% +1 to win. Must be an appropriate bargaining unit Negotiate a contract: election is void if negotiation takes longer than a year. Employer uses delay tactics. Recognition clause (for union): employer recognizes union as sole bargaining unit for the purpose of establishing wages, house and conditions of employment. Management clause (for employment): identifies how much autonomy the employer has on day to day operations. Make it your union!

AACN standards for healthy work environment

Skilled communication True collaboration Effective decision making Appropriate staffing Meaningful recognition Authentic leadership

Modular nursing

Small team - assignments happen based on geographic location Mini-teams typically an RN and unlicensed workers to provide care to a small group of patients, usually centralized geographically

Values

Sometimes healthcare policy makers tend to focus on technology, cost analysis, and cost effectiveness. However, values have tremendous impact on the decisions people make. people should carefully examine their value system and recognize the role that it plays in decisions, conflicts, and perceptions. According to McNally 4 characteristics determine a true value: Must be truly chosen among alternatives only after due reflection Must be prized and cherished Is consciously and consistently repeated (part of a pattern) Positively affirmed and enacted When nurses experience dissonance between personal and organizational values, the result may be interpersonal conflict and burnout

Resistance to change

Sources of resistance Types of resistance: Active: embracing, positive Passive: resistant, scared of change, passive aggression

Primary care nursing

Specific patients are allocated to one nurse Assumes 24 hour responsibility for patients from admission to discharge. Associate RNs when off duty.

Centralized staffing

Staffing decisions are made by personnel in a central office or staffing center Strengths: provides organization-wide view of staffing needs, which encourages optimal utilization of staffing resources. Staffing policies tend to be employed more consistently and impartially. More cost-effective than decentralized staffing. Frees the middle-level manager to complete other management functions Limitations: provides less flexibility for the worker and may not account for a specific worker's desires or special needs. Managers may be less responsive to personnel budget control in scheduling and staffing matters

Disciplinary conference

State the problem clearly Ask employee why there has been no improvement Explain disciplinary action Describe the behavioral change Get agreement to and acceptance of plan

SWOT

Strengths: internal attributes that help an organization to achieve its objectives Weaknesses: internal attributes that challenge the organization in achieveing its objectives Opportunities: external conditions that promote achievement of organizational objectives Threats are external conditions that challenge or threaten the achievement of organizational objectives SWOT rules: be realistic about the strengths and weaknesses of your organization. Be clear about how the present organization differs from what might be possible in the future Always apply SWOT in relation to your competitors Keep SWOT short and simple Remember that SWOT is subjective

Possible issues with the evaluator of the performance appraisals

Subjectivity Tendency to be lenient Inadequate record keeping "Recency effect" Halo effect: 1-2+ behaviors influence all other aspects of the employee's performance Horns effect: negative aspect of the employee's performance to influence the overall appraisal Central tendency effect: rate all employees as average

Types of the ethical theories

Teleological theory: needs and wants of individual are diminished, the greatest good for greatest number people Deontological theory: judges whether the action is right or wrong regardless of the consequences. Uses duty-based reasoning and rights-based reasoning Duty-based reasoning: ethical framework some decisions must be made because there is a duty to do something or refrain from doing something Rights-based reasoning: belief that some things are person's just due. Rights are different from needs, wants, or desires. Some individuals believe in the truth only Ethical relativism: individuals make decisions based only on what seems right or reasonable according to their value system Ethical universalism: ethical principles are universal and constant, that ethical decision making should not vary as a result of individual circumstances or cultural differences

Chapter 24 key concepts

The employee performance appraisal is a sensitive and important part of the management process, requiring much skill Because of past experiences, performance appraisal interviews are highly charged, emotional events for more employees and managers When accurate and appropriate appraisals are performed, outcomes can be positive and employee growth can result Performance appraisals are used to determine how well employees are performing their job. Therefore, appraisals measure actual behavior and not intent Job descriptions often produce objective criteria for use in the performance appraisal There are many types of appraisal tools and methods, and the most appropriate one to use varies with the type of appraisal to be done and the criteria measured The employee must be involved in the appraisal process and view the appraisal as accurate and fair to result in employee growth Peer review as a performance appraisal tool has great potential for developing professional accountability but is often difficult to implement because it requires risk taking to avoid becoming simply an exercise of advocacy Self-appraisal is not easy for many employees because they often undervalue their own accomplishments or feel uncomfortable giving themselves high marks MBO has been shown to increase productivity and commitment in employees Unless the appraisal interview is carried out in an appropriate and effective manner, the appraisal data will be useless Showing genuine interest in an employee's growth and seeking his or her input at the interview will increase the likelihood of a ppsitive outcome Performance appraisals should be signed Informal work performance appraisals are an important management function In performance management, appraisals are eliminated. Instead, the manager places his or her efforts into ongoing coaching, mutual goal setting, and the leadership training of subordinates Leaders should routinely use day to day coaching Workplaces are increasingly encouraging employees to provide feedback regarding the quality of their supervision

Staffing

The process of determining and providing the acceptable number and mix of nursing personnel to produce a desired level of care to meet the patient's demands Why is scheduling so difficult in nursing? It does not fit traditional business cycle. There is erratic and unpredictable healthcare demand. High-level expertise is required 24/7. Stress of job requires balanced work-recreation schedule. Staffing mix varies with acuity

Factors to resistance

Their flexibility to change Their evaluation of the immediate situation The anticipated consequence of the change Their perceptions of what they have to lose and gain Because change disrupts homeostasis or balance of the group, resistance should always be expected Often due to: feel situation won't be effective, selfish (how will it help me?), need to understand information Young organization is characterized by high energy and low resistance to change How one responds to change, the amount of stress it causes, and the amount of resistance it provokes, can be influenced by YOUR leadership

Generational differences that impact staffing needs

Veteran generation: into the status quo, do not go for rapid change. Seek employment in structured settings Baby boomers: traditional work values, materialistic, willing to work long hours, workaholics. Caring for parents and for children. Generation X: lack interest in lifetime employment in one area. Less economically driven Generation Y: millennials, optimism, self-relationship oriented, social consciousness, volunteer mindedness. Act entitled but work well in teams, eco-awareness

Organizational climate

This is how individuals perceive the organization Their perception may be accurate or inaccurate, and people in the same organization may have different perceptions about the same organization

Stakeholders

Those entities in an organization's environment that play a role in the organization's health performance, or that are affected by the organization. May be both internal and external. Every organization should be viewed as being part of a greater community of stakeholders

Levels of management

Top level: board of directors, CEO, administrators Middle level: nursing supervisors, department heads First level: team leaders, charge nurse, primary care nurses, case managers

Considerations: Policies

Type and length of staffing cycle used Time and location of schedule posting When shift begins and ends, day of week schedule begins Weekend off policy; tardiness policy Low census procedures Mandatory OT Policy for trading days off; days off request procedures Absenteeism policies Policy regarding rotating to other units Procedures for vacation time and holiday time requests Emergency request policies Transfer request policies Need policies that address: sick leave, vacations, holidays, call-offs for low census, on-call pay, tardiness and absenteeism Do not violate labor laws, union contracts, state and national laws

Kurt Lewin

Unfreezing (acknowledge change needed) -> movement of change -> refreezing

Decentralized staffing

Unit manager responsible for covering all scheduled staff absences, reducing staff during periods of decreased census, adding staff during high census, prepping schedules Strengths: manager retains greater control over unit staffing. Staff are able to take requests directly to their manager. Provides greater autonomy and flexibility for individual staff member. Limitations: can result in more special pleading and arbitrary treatment of employees. May not be cost-effective for organization since staffing needs are not viewed holisitically. More time consuming for the unit manager

Interprofessional teams

Use of these teams increases likelihood that care will be comprehensive and holistic Implementation problems may occur with these teams when one discipline perceives their perspective is more important than other team members. Responsibility of teamwork and collaboration often falls to the nurse

Service line organizations

Used in some large institutions to address the shortcomings that are endemic to traditional large bureaucratic organizations Sometimes called care-centered organizations Smaller in scale than large bureaucratic systems Overall goals determined by larger organization, but the service line decides on the processes to be used to achieve these goals

Forecasting

Using available historical patterns to assist in planning strategically Forecasting examines present clues and projected statistics to determine future needs

Most common changes in healthcare

Usually related to: Organizational restructuring (how care is provided) Ex: amount of staff members Quality improvement. Ex: new bundles, Cerner Employee retention. Ex: burnout prevention, bonuses, nurse residency programs

Structure

Why structure is important: no matter where you may begin your first job; you will be a part of a nursing healthcare organization. Having an understanding of how the organization functions and accomplishes its work, meets its goals, and operates productively, will be essential for your success in that system Advantages of organizational chart: maps lines of decision-making authority, helps people understand their assignments and those of their coworkers, reveals to managers and new personnel how they fit into the organization, contributes to sound organizational structure, shows formal lines of communication Disadvantages of organizational chart: does not show the informal structure of the organization, does not indicate the degree of authority held by each line position, may show things as they are supposed to be or used to be rather than as they were, possibility exists of confusing authority with status Organizational chart: solid lines represent formal relationships, lines of communication, and authority. Solid horizontal lines represent communication between people with similar spheres of responsibility and power but who have different functions. Solid vertical lines between positions denote the official chain of command and the formal paths of communication and authority Org chart will show you where to go for questions, who is in charge, and who has the power to do something about issues/concerns

Budget preparation

Yearly cycle Fiscal year: when the budget starts to when the budget ends (tax year) Calendar year

Our role as new grads

You will be expected to: Revise old procedures Find new wars to improve Improve evaluation process, promotion process Participate in QI projects Prepare for accreditation visits