Management LP2

Recognizing resistance active vs passive

Active: direct, easier to recognize Passive: less direct, harder to recognize

AMA

A client who leaves a facility without a prescription for discharge is considered leaving against medical advice. -nurse should immediately notify the provider. Imperative nurse discusses risks of leaving with client. Client needs to sign a form relinquishing responsibility for any complications that arise from leaving AMA

Consultations

A consultant is a professional who provides expert advice in a particular area. A consult is requested to help determine what treatment/services the client requires Provide expertise for clients who require a specific type of knowledge or service (a cardiologist for a client who had a M.I) Nurses role regarding consultations: initiate necessary consults or notify the provider of client needs, provide the consultant with all pertinent information about the problem, incorporate the consultants recommendations into the clients plan of care

What is critical pathways?

A critical or clinical pathway or care map can be used to support the implementation of clinical guidelines and protocols; these tools are usually based on cost and length of stay parameters mandated by prospective payment systems (Medicare and insurance) -case managers often initiate critical pathways, but used by many members of the team -when a client requires treatment other than what is typical or requires a longer length of stay it is documented as a variance, along with information describing why the variance occurred

What is brain writing?

A strategy to encourage the free flow of ideas

Three competencies of Leadership

Ability to diagnose, ability to adapt, ability to communicate - leadership is defined by actions; is a dimension of nursing practice

Magnet recognition program

American nurses credentialing center awards magnet recognition to health care facilities that provide high quality care that attract and retain well qualified nurses. -facilities must creat a culture that uses 14 foundational forces of magnetism and model five key components which include: empirical data showing quality care results, development of innovation improvements or generation of new knowledge, exemplary nursing practice, a culture of empowerment, and transformational leadership -facility must submit documentation to the ANCC that demonstrates adherence to ANA nurse administrator standards -after documentation that the standards have been met, an onside appraisal is conducted. Facility that meets the standards is awarded magnet status for a 4 year period

What is collaboration with the inter professional team?

An inter professional team is a group of health care professionals from various disciplines. Collaboration involves discussion of client care issues in making health care decisions, especially for clients who have multiple problems. —> the specialized knowledge and skills of each disciple are used in the development of plan of care that addresses multiple problems

Example of refreeze

Become comfortable with the "new you"

Transfers

Clients can be transferred from one unit, department, or one facility to another. Continuity of care must be maintained as the client moves from one setting to another - the use of communication hand off tools (PACE, I PASS) - provide written and verbal report of the clients status and care needs: medical dx, demographic info, overview, diet, allergies, advanced directives, family involvement, vitals, medications, alterations that can precipitate an immediate concern

Formal Negotiation

Collective bargaining —> national labor relations act —> collective bargaining contract Pro: right to fair treatment Con: separates management from staff

What is the nursing role in case management

Coordinating care, particularly for clients who have complex health care needs Facilitating continuity of care Improving efficiency of care and utilization of resources Enhancing quality of care provided Limiting unnecessary costs and lengthy stays Advocating for the client and family

Nursing management and the nursing union are having differences on several issues. There may be a need for negotiation. Which of the following is a serious disadvantage to using collective bargaining to resolve this conflict?

Creating an adversarial relationship between staff and management

Planned change: variables that affect collaboration

Enables inter professional team to replace unproven methods with evidence based ones -might be proactive way to improve care quality; might be required by regulatory board -variables that affect whether change can fully take place include individual and organizational willingness, competing demands, and whether the change is meaningful -changes in technology are more readily accepted than social change -include people who will be affected by the change in the planning process to decrease resistance

Florence has two team members who continually criticize each other, despite repeatedly being told to stop. Which approach is the most appropriate for this situation?

Engage in an informal negotiation process —> when disagreements first arise, problem solving may be sufficient. If the situation has already developed into a full blown conflict, negotiation, either informal or formal, may be necessary.

Florence has two team members who continually criticize each other despite being told to stop. Which approach is the most appropriate for this situation.

Engage in problem resolution

Communication tools

Ex: SBAR, PACE, I PASS, BATON, Five P's Nurses might also communicate interprofessionally through electronic means (email) Some facilities permit text messaging- never send confidential information via text

Natural phenomenon

Expected: growing up and leaving home, graduating from college and beginning a career Unexpected: sudden illness, change in financial status

Followership

Followership and leadership are complementary roles Effective follower= valuable employee — becoming a better follower: communicate problems and offer solutions, invest interest and energy in the work, support new ideas and directions, explain areas and rationalizes for disagreement, listen carefully and reflect, continue to learn and share the learning

Generational differences team members: variables that affect collaboration

Generational differences influence the value system of the members of an inter professional team and can affect how members function within the team. -Veterans -Baby Boomers -Generation X -Generation Y -Generation Z

How can you increase your staffs receptivity to an important change in procedures?

Give them time to learn the new procedure

What are nurse qualities for effective collaboration?

Good communication skills, assertiveness, conflict negotiation skills, leadership skills, professional presence, and decision making and critical thinking skills

Theories-Human relations based

Human relations- based management —> Douglas McGregor —> Theory X: people do not want to work very hard —> Theory Y: the work itself can be motivating

How can you resolve a problem?

Identify the problem, generate possible solutions, choose the best solution, implement the solution, evaluate.

In what situation would a personal change probably be the hardest to make?

If the benefits will be realized years from now

When is it most appreciate to dictate (order) change?

In an emergency

Documentation to facilitate continuing of care

Includes: graphic records that illustrate a trend (vitals), flow sheets that reflect routine care completed and other care related data, nurses notes that describe change in client status or unusual circumstances, client care summaries that serve as quick references for lip client care information, nursing care plans that set the standards for the care provided (must be individualized), all documentation should reflect the plan of care.

What type of resistance to a change is the hardest to overcome?

Resistance based upon fear of losing ones job

Nursing and respiratory departments both experienced job cuts. The nurse manager notices that members of his staff are having more trouble getting a fast response from a respiratory therapist. What source of conflict is probably operating here?

Work intensification

The nursing and respiratory departments have both experienced job cuts. The nurse manager notices that staff members are having trouble getting fast responses from the respiratory therapist. What source of conflict is probably operating here?

Work intensification —> staffing shortages and emphasis on cost reduction often result in work intensification, a situation in which employees are required to do more in less time

Managing up

Work with higher-ups to obtain the best results Keep managers informed Show appreciation

What is the nurses role in collaboration/coordinating care?

- coordinate the inter professional team -have a holistic understanding of the client, health needs, and health care system -Provide the client with the opportunity to be a partner in the development of the plan of care -provide information during rounds regarding status of client -provide an avenue for the initiation of a consult r/t a specific health care issue -provide a link to post discharge resources that might need a referral

Behavioral change strategies: variables that affect collaboration

-members of the inter professional team can be resistant to change. Three strategies a manager can use to promote change include: —> rational-empirical: manager provides factual information to support the change. Used when resistance to change is minimal —> normative-reeducative: manager focuses on interpersonal relationships to promote change —> power-coercive: manager uses rewards to promote change. Used when individuals are highly resistant to change

Discharge planning

-the nurse conducts discharge planning with both the client and clients family -serves as a starting point for continuity of care. -comprehensive discharge plan includes a review of the client information: religious or cultural beliefs, ability to perform ADL, current health and prognosis, mobility status and goals, etc. -assess the need for additional services (home health, PT, OT)

Implicit bias affects our understanding in an unconscious manner. A persons ability to recognize these biases can improve communication with patients and colleagues alike. What is true about implicit bias?

1. Implicit bias forms during a lifetime 2. Implicit bias can influence clinical decision making and treatment 3 implicit bias contributes to an individuals social behavior 4. All of the above Answer: all of the above

The hospital has recently reorganized; therefore, several departments were closed. The patient census on the unit has increased. The staff have always had a strong team spirit, but the nurse manager knows that workflow changes can cause conflict. What can the nurse manager do to reduce the possibility of conflict among her team?

1. Monitor the quality of patient care 2. Ensure that supplies and equipment are readily available 3. Assess the equity of nursing assignments 4. All of the above Answer: all of the above

Which of the following issues may be addressed in a collective bargaining agreement?

1. Shift differentials 2. Safe working environment 3. Grievance procedures 4. All of the above Answer: all of the above

As Jane speaks with the team, she learns why the staff members have had difficulty following policies. Which of these would be considered barriers to effective communication?

1. The charge nurse is unavailable to help the nurses when they have questions about policies 2. Some staff are afraid to ask particular charge nurses for help for fear of retribution 3. The use of acronyms is confusing to staff members who are new to the unit 4. All of the above. Answer: all of the above

When designing a technical change, which of the following should be considered?

1. Will it work better than the old way? 2. Is this change needed? 3. Is there a simple way to do this? 4. All of the above Answer: all of the above

What is case management

Coordination of care provided by an inter professional team from the time a client starts receiving care until they no longer receive services -managed care of the client through collaboration of the health care team in acute and post acute settings -goal is to avoid fragmentation of care and control cost -collaborates with the inter professional health care team during the assessment of a clients needs and subsequent care planning and follows up by monitoring the achievement of desired client outcomes within time parameters -may be a nurse, social worker, or other health care professional -do not usually provide direct client care -usually oversee a caseload of clients who have similar disorders or treatment regimens -coordinate resources and services for clients whose care is based in a residential setting

If an informal negotiation session becomes too highly emotional, what should the nurse manager do?

Deal with the feelings first

Differences in status and authority within the health care tam can generate conflict. What is the most common cause of conflict?

Disrespect and incivility

__________ focus on the total health of a patient, extending beyond the data collected in the health care providers office

E H R - focus on the total health of a patient extending beyond the data collected in the health care providers office

What are some forms of electronic communication?

EMR/EHR, computer on wheels/workstation on wheels, email, text, social media

The EMR has many advantages compared with paper charting. It helps track data through time and can help monitor things such as preventative care in primary care practices. Jane is the office nurse in a local practice. She is meeting a new patient for the very first time who informs her that he was recently hospitalized. Jane pulls up the patients EMR and sees no information regarding his recent hospital stay. How could this have happened?

EMRs are usually practice or hospital specific, so the patients information would not be accessible to Jane

Effective manager: important decisions

Employee evaluation, resource allocation, hiring and firing, planning for the future, job analysis and redesign

Hierarchical include on decision making: variables that affect collaboration

Influence by facility hierarchy -in centralized hierarchy, nurses at the top of the organizations also chart make most decisions -in a decentralized hierarchy staff nurses who provide direct client care are included in the decision making process. Large organizations benefit the use of decentralized decision making because managers at the top of hierarchy do not have first hand knowledge of unit level challenges or problems. - decentralized decision making promotes job satisfaction among staff nurses

What are qualities of an effective leader?

Integrity, courage, positive attitude, initiative, energy, optimism, perseverance, generosity, balance, ability to handle stress, self-awareness - behaviors include: setting priorities, thinking critically, solving problems, respecting and valuing individuals, skillful communication, vision for the future, developing oneself and others.

ISBARR provides a framework for communicating critical client information. ISBARR is an acronym for:

Introduce, situation, background, assess, recommend, read back

Bedside shift report is one of the things that jane reviews at the staff meeting. She stresses the way she would prefer the report to start. Which of these would be the most important to share with the oncoming nurse?

Introducing the client and his or her diagnosis to the oncoming nurse

Referrals

Is a formal request for a service by another care provider. It is made so that the client can chess the care identified by the provider or the consultant -care can be provided in acute setting or outside the facility -clients being D/C from health care facilities to their home can still require nursing care -discharge referrals are based on client needs in relation to actual and potential problems can be facilitated with the assistance of social service, specially if there is a need for: specialized equipment (cane), specialized therapist (PT, OT), care providers (home health, hospice) Knowledge of community and online resources is necessary to appropriately link the client with needed services —> Nurses role: begin discharge planning upon admission, evaluate client/family competences, involve client and family in care planning, collaborate with other health care professionals, complete referral forms to ensure proper reimbursement

You are working on the trauma unit today, and your new patient with a femur fracture complains of leg pain and seems a little diaphoretic and short of breath. You assess the patient and prepare to contact the surgeon. In preparation for contacting the physican you:

Jot down notes about the situation as it is presented to you, review the patients history, focus your assessment, and determine what you need for the patient

What are some effective nurse manager knowledge and skills?

Leadership, professionalism, advanced clinical expertise, human resource management expertise, financial management, ability to coordinate and document patient care

Example of change

Learn ow to do things differently

Lewins change theory: variables that affect collaboration

Lewins change theory is a common model for promoting planned change which has three stages: 1. Unfreezing: need for change is identified or created 2. Change/movement: strategies (driving forces) that overcome resistance to change (restraining forces) are identified and implemented 3. Refreezing: the change is integrated and the system is re-stabilized Lewins theory has been adapted into a stages of change model for individual change with five stages 1. Precontemplation: no intent to change is present or has been considered 2. Contemplation: individual considers adopting a change 3. Preparation: individual intents to implement the change in the near future 4. Action: individual implements the change 5. Maintenance: individual continues the new behavior without relapse

Jane is a new nurse manager who will be holding her first staff meeting tomorrow. She has learned that the staff members have not been following important patient care policies. What is the most important communication skill that she should use at the meeting?

Listening

What are some barriers to communication?

Low health literacy, cultural diversity, cultural competence, inter professional communication education, implicit bias

Which management theory posits that people do not want to work hard and must be pushed to do so?

McGregors Theory X —reflects a common attitude among managers that most people do not want to work very hard and that the managers job is to make sure that they do

Effective manager: interpersonal skills

Networking, conflict negotiation and resolution, employee development, coaching, rewards and punishments.

Social media is commonly used to update friends and groups on things we have going on in our lives. Health care organizations routinely use social media to promote medical facts, services, and recognitions. What is important for nurses to remember when deciding to post something work related on social media?

Nurses should NEVER post protected health information on a social media site

Hand off or change of shift report

Performed with the nurse who is assuming responsibility Describes current health status of client Informs the next shift of pertinent client care information Provides the oncoming nurse an opportunity to ask questions or clarify the plan of care Should be given in a private area to protect client confidentiality - report to the provider changes in client status, recommendations, clarification of prescriptions

Communication and continuity of care

Poor communication can lead to adverse outcomes, including sentinel evens (unexpected death or serious injury of a client) Communication regarding the client status and needs is required anytime there is a transfer of care Contain details on what to communicate when transferring client care

TJC attributes 80% of all medical errors to:

Poor hand off communication

Who is responsible for accepting, transcribing, and implementing physician orders?

Professional nurse

Pathway to excellence recognition

Program of practice standards to promote a positive practice environment using evidence based standards -acute or long term care facilities can apply for recognition with this program -process includes an application process and adherence to 12 standards of practice along with an independent survey of the facility

Example of Unfreeze

Recognize the need for change

What is continuity of care?

Refers to the consistency of care provided as clients move through the health care system. It enhances the quality of client care and facilitates the achievement of positive client outcomes -continuity of care is desired as clients move from: level of care to another (icu to med/surg), facility to another (acute care to skilled nursing care), unit/department to another (pacu to post surgical unit) -nurses are responsible for facilitating continuity of care and coordinating care through documentation, reporting, and collaboration -a formal written plan of care enhances coordination of care between urges, inter professional team members, and providers. Nurses are also acting as a representative of the client and as a liaison when collaborating with the provider and other members of the health care tam. The nurse serves in the role of client advocate by protecting the rights of clients and ensuring that client needs are met —> admission, transfer, discharge, post discharge prescriptions, initiation, revision, evaluation of plan of care. Reporting the clients status to other nurses and the provider. Coordinating the discharge plan. Facilitating referrals and the use of community resources. .

What is the nurse manager responsibilities?

Report to administration, coordinate many departments and care providers, supervise staff

Management

Requires high level of readiness —> do not accept managerial responsibility until skills are well developed Managerial skills —> leadership, foresight, organization, time management, accountability, authority —> tasks: planning, organizing, commanding, coordinating, controlling —> getting tasks done through others

The purpose of learning how to negotiate conflict is to:

Resolve conflicts more effectively

Theories-scientific management

Scientific management —> Frederick Taylor —> work analysis to improve efficiency —> incentivizing more work in less time

Informal negotiation

Scope the situation, set the stage, conduct the negotiation, agree on a resolution

Theories-Servant Leadership

Servant leadership —> Robert Greenleaf —> People have value as people, not just as workers —> "employee first," not "manager first"

A new nurse manager plans to implement a new scheduling process. This was met with resistance from the staff who were very happy with the current scheduling process. How can the nurse manager lower their resistance to this change?

Share information about the new schedule and discuss its impact on the unit

What is an example of a macro-level change?

Shift in Medicare payment policies —> macro changes are on a large scale, affecting virtually every health care facility

What is moral distress?

Situation that violates personal or professional ethics

________________ emphasizes the importance of understanding all the factors that affect a particular group of people in a particular environment.

Situational theory of leadership — recognize the complexity of work situations and encourage the leader to consider many factors when deciding what action to take

What are discharge instructions?

Step by step instructions for procedures to be done at home Medication regimen instructions Precautions Indications of medication adverse effects Names and numbers of providers and community services Plans for f/u care Nurses role: type of discharge (ama, prescribed by provider), date and time of DC along with who accompanied client and how they were transported (wheelchair, ambulance). Discharge destination (home, facility), summary of clients condition at DC, disposition of valuables, copy of clients discharge instructions.

Which of the following best describes what is most likely to be within a nurses comfort zone?

Tasks she has done many times before

Stages of team formation: variables that affect collaboration

Teams typically work through a group formation process before reaching peak performance 1. Forming: members of the team get to know each other. The leader defines tasks for the team and offers direction 2. Storming: conflict arises, and team members begin to express polarized views. The team establishes rules, and members begin to take on various roles 3. Norming: the team establishes rules. Members show respect for one another and begin to accomplish some of the tasks 4. Performing: the team focuses on accomplishment of tasks.

There has been a sudden increase in catheter associated UTI that must be addressed on Janes unit. What is the best way for Jane to persuade the staff to implement a new Foley catheter care protocol?

Tell a compelling story about why change is needed

_______ models of communication label individuals as communicators, not "senders" or "receivers."

Transactional — transactional models of communication differ from earlier linear models in that the transactional models label all individuals as communicators and not specifically as "senders" or "receivers"

True or False: A nurse manager must have human resource and financial management expertise, in addition to expertise regarding patient care

True

Which of the following is the best indication that a change has been integrated?

When no one talks about it anymore

Which is the best indication that a change has been integrated?

When no one talks about it anymore —> a change has been integrated once the refreezing stage is complete and the change has become the new norm

What is the most desirable result of a problem resolution?

Win-win

Effective followers are those who _________________

Are skilled and self-directed - an effective follower is pro-active, skilled, and self-directed; offers solutions; and communicates problems in a timely manner