Nursing Leadership

*RIGHT TASK-repetitive, non-invasive, doesn't require much supervision *RIGHT CIRCUMSTANCES:-Do not assign a patient who is unstable *RIGHT PERSON-make sure delegate is competent and operating within their scope of practice. Check facility's job description or the individual's skill competency checklist *RIGHT DIRECTION AND COMMUNICATION-communicate specific details of task, timeline for completion, and expectation for communicating the findings back to you *RIGHT SUPERVISION AND EVALUATION- intervene if needed, provide feedback. if delegate reports results outside the expected range, assess patient and re-check yourself!

5 rights of delegation

A=airway-ensure patent airway. Stabilize cervical spine if neck/head trauma is suspected B=breathing-assess for respirations C=circulation-check heart rate, blood pressure, capillary refill D=disability-assess patient's level of consciousness E=exposure-assess patient's body for trauma, exposure to heat/cold.

ABCDE principle in nursing

Intrapersonal conflict

An individual's internal struggle/conflict *Ex-Should I apply for an ICU position even if it means I will have to work nights for a while?

Interpersonal conflict

Conflict between two or more people. *Ex-bullying is a form of interpersonal conflict that may result in lateral violence (ex: a more experienced nurse verbally abuses, sabotages, and/or undermines a newly licensed nurse).

*diet and activity restrictions *detailed instructions/teaching for procedures at home (such as wound dressing changes). Allow for return demonstration! *list of medications, when to take them, precautions regarding medications *s/s of complications, when to seek medical attention *follow-up appointment information *names, numbers of providers and community resources.

Discharge Instructions: Discharge planning starts at ADMISSION.

*make time to prioritize and plan at the beginning of each shift. *complete charting as soon as possible after intervention *DO NOT WAIT until the end of your shift to chart your assessments or interventions *Group tasks for a single patient (or for multiple patients in the same location) to prevent repeated trips to supply room. *complete difficult or time-consuming tasks early in the shift (when energy is higher) *perform non-essential tasks later in the day *complete tasks before starting new ones *know when to delegate and ask for help *do not help other team members with low priority tasks when you still have outstanding tasks.

Efficient nursing practice for time managment.

Laissez-faire (hint: lazy)

Leader provides little direction, planning. Emphasis is on group decision-making. Team results may be lacking.

cooperating/accomodating

Negotiation Strategies: Lose-win solution. One party gives up what they want (caves in) and allows the other party to get their desired solution

Competing/coercing

Negotiation Strategies: Win-lose solution. One party gets desired solution at the expense of the other party

collaborating

Negotiation Strategies: Win-win solution. Both parties put aside individual desires and work together to define a mutually agreeable solution

compromising

Negotiation Strategies: both parties give up something and come to a compromise

avoiding/withdrawing

Negotiation Strategies: both parties refuse to acknowledge or work on resolution to conflict

smoothing

Negotiation Strategies: one party attempts to keep the peace by complimenting the other party. Conflict remains unresolved.

*bathing, dressing, ambulating, toileting, *feeding patients without swallowing precautions *positioning *vital signs *bed making *specimen collection *I&Os *basic CPR

OK to delegate to CNA

medication administration *enteral feedings *urinary catheter insertion *suctioning *tracheostomy care *wound care *reinforcement of patient teaching

OK to delegate to PN

*information about routine care found in the medical record *information about the patient's visitors (unless it directly affects the clients care) *subjective comments or negative statements about a patient

Patient transfer: hand off report. DO NOT include

*immediate needs and priorities *allergies, advance directives, diet/activity restrictions *recent changes related to the patients condition *time of the patient's last does of pain medication

Patient transfer: handoff report DO include:

*collect data over time (throughout year) *allow for employee self-appraisal before review *include peer evaluations (other RNS) *go through a performance checklist *compare RN against standards (not other RNs) *discuss employee goals *an employee who does not agree with the evaluation can make written comments on the evaluation and/or make an appeal

Performance Review: key points

ASSESS before taking ACTION *Ex: patient reports dyspnea. Check O2, listen to breath sounds BEFORE notifying provider. *Ex: check patients blood sugar BEFORE giving insulin

Prioritization of patient care part 1

Prioritize UNSTABLE over STABLE patients: Patients with expected findings for their medical diagnoses are stable. They are NOT the priority. *Ex: COPD patient with SPO2 in low 90s, stroke patient with facial drooping, MS patient with ataxia are all STABLE (Not the priority)

Prioritization of patient care part 2

Prioritize ACUTE over CHRONIC conditions: *Ex: A patient with an acute condition (ex: abnormal vital signs or urine output <30ml/hr) takes priority over a patient with a chronic medical condition (ex: pressure ulcer)

Prioritization of patient care part 3

Prioritize SYSTEMIC over LOCAL issues: *Ex: A patient with systemic symptoms (ex: fever, hypotension, tachypnea, tachycardia) takes priority over a patient experiencing local symptoms (ex: leg pain and eythema).

Prioritization of patient care part 4

Prioritize interventions using ABCDE framework: *Ex: Administering O2 as ordered for a patient with dyspnea is prioritized OVER giving a patient pain medication. HINT: Administering pain medication is RARELY the priority.

Prioritization of patient care part 5

Prioritize using Maslow's hierarchy of needs: *Ex: Physiological needs take precedence over need for shelter, love, self-esteem, etc

Prioritization of patient care part 6

Choose LEAST invasive interventions FIRST: *Ex: Move patient at risk for falls near nursing station (and use bed alarm) instead of placing restraints

Prioritization of patient care part 7

Process used to improve quality of care and/or correct performance deficiencies on a unit or team. STEPs: 1. Establish BEST PRACTICE GUIDELINES or bechmark/goal against which nursing care will be measured 2.develop plan for collection of data 3. collect data 4 compare data against benchmark. If benchmark is not met, perform root cause analysis 5. identify/analyze potential solutions, select one to implement. 6. implement solution (ex: corrective action, education) 7. reevaluate issue at predetermined time to evaluate effectiveness of solution

Quality Improvement Steps

*unusual trends on the unit should be reported to the quality improvement team *if there is a quality issue on the unit (ex: increased infection rates, insufficient nursing documentation, poor meeting attendance) the first step is to ASSESS causative factors before taking any action *audits are a good way to obtain quantitative data on factors related to a quality issue *if a patient has a complaint about nursing care on your unit, first ASSESS the patient's feelings and clarify his/her expectations before taking action

Quality Improvement key points

Patient education, any task that requires nursing judgment, nursing assessment, blood transfusions

RN should not delegate:

stage 1: (Latent conflict): no conflict yet, but high likelihood it will occur *stage 2: (Perceived conflict): an individual believes that a problem exists, but the other party is unaware of a problem. *stage 3: (felt conflict): an individual has an emotional response to a conflict *Stage 4: (manifest conflict): both parties are aware of the conflict, and action is taken to resolve conflict. *stage 5: (conflict aftermath): conflict is resolved, with either positive/negative results.

Stages of conflict

*serious offenses (ex: working under the influence of alcohol or drugs) should result in immediate dismissal *for less serious offenses, provide progressive discipline: verbal reprimand FIRST the written reprimand, THEN suspension, THEN termination

disciplinary action: Key points

authoritative

leader dictates decisions for the team, uses penalties and/or coercion to promote behavior change

democratic

leader involves team members in decision-making process Characterized by team cooperation, resulting in higher quality results