NUR 415 Test #2

How to have Effective Delegation

- Both RN and UAP fully understand their roles - Creating a plan to evaluate how both patients and delegatees are doing through the work period is critical - Frequent, planned check-ins to monitor progress - How often depends on knowledge of and experience with delegatee - Number of delegatees and patients for whom the delagator is accountable - Layout/geography of unit - Stability/acuity of patients - Other resources available to staff

What do ethics committees do?

- Help with complex issues in healthcare organizations - Provide structure and guidelines for potential problems - Serve as open forums for discussion - Function as true patient advocates by placing the patient at the core of the committee discussions

How can the nurse leader change old mindsets held by the organization or staff?

- Scenario planning - consider and design multiple scenarios and alternatives - Focus on short-term goals - Be willing to challenge old ideas - Encourage experimentation and pilot testing - Work in teams across functional groups i.e. interdisciplinary to foster collaborative problem solving - Magnet organizations are typically more flexible and adaptive and can respond better to rapid change

5 main causes of malpractice for nurses:

1. Failure to follow standards of care 2. Failure to use equipment in a reasonable manner 3. Failure to communicate 4. Failure to assess and monitor 5. Failure to act as a client advocate

Delegation: RN vs LPN vs UAP

Go review the practice slides and case studies in week 5 (delegation part II power point). Slides 11-50. Also see handout in class.

Three Basic Steps of Time Management

Three Basic Steps 1. Plan and prioritize 2. Ranks and complete tasks 3. Reprioritize **This is a cyclic process**

Institutional Licensure

most professional nursing organizations oppose this move strongly because they believe that it has the potential for diluting the quality of nursing care. Some professionals have advocated shifting licensure, and thus accountability, from individual practitioners to an institution or agency

Strategies to Facilitate Change

1. Know your people 2. Communication 3. Training 4. Early Adopters 5. Performance Appraisals 6. Set priorities 7. Accountabilities and Priorities Challenges: - May be initial reluctance and resistance- Common when personal security is threatened i.e. elimination of a position

Causes of Malpractice for Nurses: 4. Failure to assess and monitor

4. Failure to assess and monitor, including failure to: - Complete a shift assessment. - Implement the plan of care. - Observe the client's ongoing progress. - Interpret the client's signs and symptoms.

When do you fill out an incident report? What should you include?

An incident report should be filed whenever an unexpected event occurs. - The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, staff member or visitor—is injured or involved in a situation with the potential for injury, an incident report is required. (ex. falls, medication errors) -Document a factual account of what happened - Any statement that a patient makes may help to clarify his state of mind, as well as his own contributory negligence.

3. An RN discusses delegation with a new nurse. Which of the following statements by the new nurse indicates an understanding of the meaning of delegation? a) Delegation means the nurse is able to explain the nursing actions and results. b) Delegation occurs when an RN assigns a specific function or aspect of patient care to an LPN/LVN or UAP. c) Delegation occurs when an RN assigns a task that the RN does not have time to complete to another staff member. d) Delegation means being obligated to complete the work.

B

The RN assigns a patient diagnosed with a myocardial infarction to another registered nurse. The patient receives the wrong medication by the assigned RN. The assigning nurse knows that which one of the following is true? a) When an RN assigns care of a patient to another RN, only accountability is transferred. b) When an RN assigns care to another RN, both accountability and responsibility are transferred. c) When an RN assigns care to another RN, only responsibility is transferred. d) The assigned RN does not have accountability or responsibility.

B

-Fidelity -Respect for Others

FIDELITY...keeping one's promises or commitments. Nurse managers must follow through with what they say they will do RESPECT FOR OTHERS...acknowledges the rights of individuals to make decisions and to live by these decisions. Nurse managers reinforce this daily in their interactions

Incident Reporting

Incident reporting- incident reports are records of all events that are not part of routine medical care. -These documents DO NOT get entered into the medical record. The report is a risk management or administrative document and not part of the patient's record. -Hospital administration will usually have list of events whose occurrence requires that filing of an incident report.

Negligence vs Malpractice

Negligence: - Standard definition is "conduct that is lacking in care" - Generally used with nonprofessional behavior Malpractice: - Professional Negligence - Failure of a person with professional education and skills to act in a reasonably prudent manner. - Must be a dereliction of professional skill - Dereliction is defined as "abandoning possession" which is sometimes used in the phrase "dereliction of duty."

Negligence and Malpractice- Nurse Manager responsibility

Nurses must be knowledgeable of the laws in their state regarding negligence and the scope of practice for RN. Nurse managers must also be knowledgeable of the laws regarding negligence and malpractice as these are major causes of action brought against nursing staff. Role of the nurse manager is to guide and counsel their employees as well as provide mentoring and consultation.

Types of Change: - Planned (linear) - Non-linear

Planned (linear) - Occurs in a linear way - directional and sequential manner when guided by effective change agents - Deliberate effort to make something happen - Change agent focuses on specific goals and incremental steps needed to attain the goals - Most useful for low-level changes in a stable environment i.e. reorganizing nursing unit supplies - Can be a really big change that is planned out over long time i.e. implementation of electronic medical record Non-linear - Change that is more complex and usually occurs in accelerated and uncertain environments - Change agent focuses on the environment and monitors how it is working - Anticipates possible scenarios and solutions to problems (what if?)

When delegating to unlicensed personnel, do you also need to delegate the prioritization of the tasks? Why or why not?

YES prioritization is important! According to step 2 of the delegation process you need to identify priorities of what you are delegating. Different patients have higher priorities than others and it keeps the nurse on track with time management to effectively provide care For example, if a nurse needs a blood pressure before giving a medication the UAP's priority would be to get the BP

The MORAL Decision-Making Model

-M- massage the dilemma: collect data about the ethical problem and who should be involved in the decision-making process -O- outline options: identify alternatives, and analyze the causes and consequences of each - R- review criteria and resolve- weigh the options against the values of those involved in the decision. This may be done through a weighting or grid -A- affirm position and act- develop the implementation strategy - L- look back- evaluate the decision making

How do nurse managers ensure adherence to standards?

1) Review performance - Perform or review all employee performance evaluations for evidence that standards are met. 2) Provide monitoring - Ongoing chart audits for standards of care documentation 3) Check-staff knowledge - Review standards with employees

Code of Ethics for Nurses: Steps 1, 2, and 3

1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual... 2. The nurse's primary commitment is to the patient, whether an individual, family group or community. 3. The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient.

Assignment vs Delegation

Assignment: - Refers to the transference the authority, responsibility, and accountability - Responsibility - the obligation to accomplish task. - Accountability - accepting ownership for the results or lack of results - i.e. RN to RN Delegation: - The process of transferring the authority and responsibility to another team member to complete a task- while keeping the accountability - i.e. RN to LPN or RN to UAP ***When RNs transfer care of their patient to another RN responsibility AND accountability is transferred ***When RNs delegate care to an UAP, responsibility is transferred, accountability is not

What is a change agent?

Change agent - person leading the change - Assist in the creation and management of change - Reach goals and outcomes

Daily Planning of Work How to Make a Time Efficient Work Environment

Daily Planning of Work 1. Identify key priorities 2. Determine desired outcome 3. Assess co-workers availability 4. Reprioritize Time Efficient Work Environment 1. Gather supplies 2. Group activities 3. Estimate time

What is liability?

Each person's responsibility and accountability for their individual actions (or omissions).

True Value vs Value Indicator

Four characteristics that determine a true value: 1. It must be freely chosen from among alternatives only after due reflection 2. It must be prized and cherished 3. It is consciously and consistently repeated (part of a pattern) 4. It is positively affirmed and enacted • If a value does not meet all four criteria, it is a value indicator • True values require that a person take action, whereas value indicators do not. • Values clarification includes examining values, assigning priorities to those values, and determining how they influence behavior so that one's lifestyle is consistent with prioritized values • Sometimes nurses have a different set of values than the organization has, and that can lead to stress and job dissatisfaction

Innovators Early adopters Early majority Late majority Laggards Rejectors

Innovators- change embracers. Enjoy the challenge of change and often lead change Early Adopters- open and receptive to change, but not obsessed with it Early Majority- enjoy and prefer the status quo, but do not want to be left behind. They adopt change before the average person Late Majority-Often known as the followers. They adopt change after expressing negative feelings and are often skeptics Laggards- last group to adopt a change. They prefer tradition and stability to innovation. They are somewhat suspicious of change Rejectors- openly oppose and reject change. They may be surreptitious or covert in their opposition. they may hinder the change process to the point of sabotage

Risk Management -what is it? -purpose?

Is a process that identifies, analyzes and treats potential hazards within a given setting. The purpose of risk management is to identify potential hazards and eliminate them before anyone is harmed or disabled. Incident Reporting

RN vs LPN

LPNs care for physiologically stable patients with predictable conditions -See week 4 (nurse practice act and delegation part 1) power point slides 10-12

-Purpose or Mission Statement - Philosophy - Goals and Objectives - Policies & Procedures - Rules

Purpose or mission statement - Explains why the organization exists - Identifies what is unique about the organization Philosophy - Flows from the purpose or mission - Delineates the set of values or beliefs that guide the actions of the organization - Many be several levels of philosophy - Organizational level, nursing services level, unit level Goals and Objectives - These are the "ends" to which the organization is working - The goals and objectives "operationalize" the philosophy - Goals - the desired result to which effort is directed - They will change with time and require periodic reevaluation and prioritization - Objectives - more specific They identify how and when the goal is to be accomplished Policies and Procedures (P& Ps) Policies - plans that are reduced to statements or instructions that direct organizations in their decision making - They explain how goals will be met and guide the general course and scope of organizational activities Rules - Plans that define specific action or nonaction - Generally included as part of P and Ps - Usually allow only 1 choice so are fairly inflexible

Code of Ethics: purpose?

Purpose: 1. Inform the public of the minimum standards acceptable for conduct by members of the discipline and assist the public in understanding a discipline's professional responsibilities. 2. Outline the major ethical considerations of the profession. 3. Provide guideline for its members 4. Serve as a guide for the discipline's self regulation 5. Provide a basis for ethical decision making

The 5 R's of Clinical Delegation

The 5 Rights... 1. The right task 2. Under the right circumstances. 3. To the right person. 4. With the right directions and communication. 5. Under the right supervision and evaluation.

Forecasting

involves trying to estimate how a condition will be in the future. Forecasting takes advantage of input from others, gives sequence in activity, and protects an organization against undesirable changes

The Patient Self Determination Act

requires health-care organizations that received federal funding (Medicare/Medicaid) to provide education for staff and patients on issues concerning treatment and end of life issues. Includes education about advance directives, durable power of attorney

-Ethics -Applied Ethics

• Ethics- the systematic study of what a person's conduct and actions should be with regard to self, other human beings, and the environment; it is the justification of what is right or good and the study of what a person's life and relationships should be, not necessarily what they are - Ethics is a system of moral conduct and principles that guide a person's actions in regard to right and wrong and in regard to oneself and society at large • Applied Ethics- requires application of normative ethical theory to everyday problems.

-Joint Liability -Charitable Immunity -Vicarious Liability -Respondeat Superior

• Joint Liability- the nurse, physician, and employing organization are all held liable. This has become the current position of the legal system • Charitable Immunity- nurses were rarely held accountable for their own acts, and hospitals were usually exempt due to this. Some states have it so that a charitable (nonprofit) hospital cannot be sued by a person who has been injured as a result of a hospital employee's negligence. Thus, liability is limited to the employee • Vicarious Liability- employers were held liable for their nurse's acts under this concept • Respondeat Superior- form of vicarious liability. Means "the master is responsible for the acts of his servants" - Nurses need to remember that the purpose of respondeat superior is not to shift the burden of blame from the employee to the organization but rather to share the blame, increasing the possibility of larger financial compensation to the injured party

-Tort -Unintentional Tort -Intentional Tort -Assault -Battery -False Imprisonment -Defamation (libel vs slander)

• Torts- legal wrongs committed against a person or property, independent of a contract, that render the person who commits them liable for damages in a civil action • Unintentional Tort- professional negligence • Intentional Torts- a direct invasion of someone's legal rights. Ex. Assault, battery, false imprisonment, defamation... • Assault- conduct that makes a person fearful and produces a reasonable apprehension of harm. "Threatening a person with the present ability to carry out the threat." • Battery- an intentional and wrongful physical contact with a person that entails an injury or offensive touching. - If there was a threat but no physical contact, the charge is simple assault. When there is a physical injury, no matter how slight, the charge is simple assault and battery •False Imprisonment- the restraint of a person's liberty of movement by another party who lacks the legal authority or justification to do so. • Defamation- communicating to a third party false information that injures a person's reputation. - When defamation is written it is called libel. - When it is spoken, it is called slander.

Causes of Malpractice for Nurses: 5. Failure to act as a client advocate

5. Failure to act as a client advocate, including failure to: - Question discharge orders when the client's condition warrants. - Question incomplete or illegible medical orders. - Provide a safe environment for the client.

Code of Ethics for Nurses: Steps 7, 8, and 9

7. The nurse participates in the advancement of the profession through contributions to practice, education, administration and knowledge development. 8. The nurse collaborates with other health professionals and the public in promoting...efforts to meet health needs. 9. The profession of nursing... is responsible for articulating values of the profession to its members.

-Autonomy -Beneficence -Nonmaleficence

AUTONOMY...Addresses personal freedom and the right to choose what will happen to one's own person Example where the nurse manager addresses autonomy: The legal doctrine of informed consent is a direct reflection of this principle. Also, progressive employee discipline because the employee has the option to meet delinquent expectations or take full accountability for his actions. BENEFICENCE...States that the actions one takes should promote good. Example: Nurse manager encourages employees take on new opportunities such as precepting and doing charge NONMALEFICENSE...States that one should do no harm Example: performance appraisal and protecting self esteem

SWOT Analysis

Strengths, Weaknesses, Opportunities, Threats Step 1 - define the desired end state or objective Step 2 - analyze the SWOTs Step 3 - Can the objective be achieved in light of these? Step 4 - If yes, proceed If no, a different objective is selected and the process repeats

Sources of Law: - Constitution - Statutes - Administrative Agencies - Court Decisions

•Constitution- a system of fundamental laws or principles that govern a nation, society, corporation, or other aggregate of individuals. The purpose of a constitution is to establish the basis of a governing system for the future and the present • Statutes- laws that govern. Aka statutory law or legislative law; laes that are passed by the state or federal legislators and that must be signed by the president or governor. -Ex. 51 (one for each state and DC) Nurse Practice Acts. Define and limit the practice of nursing, thereby stating what constitutes authorized practice as well as what exceeds the scope of authority • Administrative Agencies- given authority to act by the legislative bodies and create rules and regulations that enforce statutory laws. Ex. State Boards of Nursing • Court Decisions- aka Tort Law. Judicial or decisional laws are made by the courts to interpret legal issues that are in dispute.

- Complexity Science - CAS Theory -Chaos Theory

- Complexity Science has emerged from the exploration of the subatomic world and quantum physics and suggests that the world is complex as are the individuals who operate within it. Thus, control and order are emergent rather than predetermined - CAS Theory- an outgrowth of complexity theory, suggests that the relationship between elements and agents within any system is nonlinear and that these elements are the key players in changing settings or outcomes o Example: while an individual may have behaved one way in the past, CAS theory suggests that future behavior may not always be the same (not always predictable) - Chaos Theory- suggests that even small changes in conditions can drastically alter a system's long-term behavior (commonly known as the butterfly effect). Chaos theory is really about finding the underlying order in apparently random data

Process of Delegation

- Delegation occurs when an RN assigns an LPN/LVN or UAP to perform a specific function or aspect of care. - The assistive personnel provides help to the RN who is accountable for the care. - RN must be aware of the qualifications of the delegatee (LPN/UAP) - Authority is critical - Varies state to state - Nurse Practice Act - Educational preparation/certification

Unlicensed Assistive Personnel (UAPs)

- Differs state to state - Not uniform - Currently regulated by health or hospital divisions at the state level - NCSBN (National Council for State Boards of Nursing), 2005, and American Nurses Association (ANA), 2005, call for state boards of nursing to regulate UAPs.

What NOT to include in an incident report

- Do not offer a prognosis, speculate about who may have caused the incident, draw conclusions or make assumptions about how the event unfolded, or suggest ways that similar occurrences could be prevented. - Record clinical observations in the chart, not in the incident report - No opinion, finger-pointing, and conjecture - Make no mention of the incident report in the patient record. The report is a risk management or administrative document and not part of the patient's record. - If there IS a reference to it in the chart of a patient who files a claim, the patient's lawyers may argue that the report is part of the medical record and should be turned over to the legal team.

NC Board of Nursing

- Founded in 1903, - First Board of Nursing in the nation. - NCBON has licensed more than 140,000 RNs and LPNs statewide. - Majority of the members are elected by nurses (11/14)

Supervision - RN

- Less direct care work - More supervisory work - Is always accountable for assessment, diagnosis, planning and evaluation. - Also accountable for initial assessments and intermittent evaluations

National Regulation vs State Regulation

- National Council of State Boards of Nursing (NCSBN) - NCSBN is a not-for-profit organization whose members include the boards of nursing in the 50 states, the District of Columbia and four U.S. territories. There are 21 associate members. - NCSBN is the vehicle through which boards of nursing act and counsel together to provide regulatory excellence for public health, safety and welfare. - Administers the NCLEX-RN licensing exam State Boards of Nursing

Moral Distress

- Occurs when people are faced with decisions in which two ethical principles compete -Example: Balancing patient autonomy with family wishes - Moral distress is experienced when nurses cannot provide what they perceive to be the best for a given patient -Examples: Limited patient care resources (staffing), disagreements among family members about interventions for patients

What strategies can nurses and nurse leaders use to address issues with the Nurse Practice Act?

- Stay current and connected to the State Board of Nursing-follow web pages, bulletins, reports - The NC BON publishes quarterly bulletins mailed to all RNs in NC - Know who your elected representatives are! - 2015 Dr. Yolanda Vanriel, Nurse Educator at UNCG SoN elected to the NC BON - Who is your state senator and congressman? - Get involved...especially with issues of importance to your practice...make recommendations and suggest changes to Nurse Practice Act and legislation - Specialty groups are good examples of successful political activism i.e. APRNs

Nurse Manager: Supervision, Delegation, and Assignment -what is supervision? -who do nurse managers supervise?

- Supervision: the active process of directing, guiding and influencing the outcome of an individual's performance of an activity. - Nurse managers supervise all of the personnel who provide direct care in their area or unit and maintain 24-hour accountability. - May include nurses, UAPs, housekeepers - Nurses supervise various levels of personnel who provide direct care on their shift - May include LPNs, UAPs

Causes of Malpractice for Nurses: 2. Failure to use equipment in a reasonable manner

2. Failure to use equipment in a responsible manner, including failure to: - Follow manufacturer's recommendations for operating equipment. - Check equipment for safety prior to use. - Place or position equipment properly during treatment. - Learn how equipment functions.

Code of Ethics for Nurses: Steps 4, 5, and 6

4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care. 5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue to personal and professional growth. 6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality care and consistent with the values of the profession...

6 Elements of Malpractice

6 elements which must be present for malpractice conviction: 1. Duty owed the patient. 2. Breach of the duty owned. 3. Foreseeability. 4. Causation. 5. Injury. 6. Damages.

Delegation

"the process of transferring the authority and responsibility to another team member to complete a task, while retaining the accountability" - Consists of a delegator (i.e. RN) and a delegatee (i.e. LPN, UAP) AND - some kind of transfer of authority and responsibility to perform the work

Licensed Practical Nurse -what can they do?

- Assists with the implementation of defined plan of care - Performs procedures according to protocol - Differentiates normal from abnormal - Has ability of asepsis and dressing changes - Ability to administer medications - this will vary with State Practice Act - Cares for physiologically stable patients with predictable conditions.

-Utilitarianism (or teleological or consequentialist) Theory -Deontological Theory -Duty-Based Reasoning -Rights-Based Reasoning -Intuitionist Framework -Ethical Relativism -Ethical Universalism

-Utilitarianism (or teleological or consequentialist) Theory- encourages decision making based on what provides the greatest good for the greatest number of people. In doing so, the needs and wants of the individual are diminished. Suggest that the end can justify the means. -Deontological Ethical Theory- judges whether the action is right or wrong regardless of the consequences. Primarily, this theory uses both duty-based reasoning and rights-based reasoning as the basis for its philosophy -Duty-Based Reasoning- an ethical framework stating that some decisions must be made because there is a duty to do something or refrain from doing something (ex. Supervisor feels a duty to hire the most qualified person for the job, even if the personal cost is high) -Rights-Based Reasoning- based on the belief that some things are a person's just due (i.e., each individual has basic claims, or entitlements, with which there should be no interference). Rights are different from needs, wants, or desires - Intuitionist Framework- allows the decision maker to review each ethical problem or issue on a case-by-case basis, comparing the relative weights of goals, duties, and rights. This weighting is determined primarily by intuition- what the decision maker believes is right for that particular situation - Ethical Relativism- suggests that individuals make decisions based only on what seems right or reasonable according to their value system or culture -Ethical Universalism- holds that ethical principles are universal and constant and that ethical decision making should not vary as a result of individual circumstances or cultural differences

ANA Scope and Standards of Practice

ANA Tenets of Nursing Practice: 1. Caring and health are central of the practice of the RN 2. Nursing practice is individualized 3. RNs use the nursing process to plan and provide individualized care for HC consumers 4. Nurses coordinate care by establishing partnerships 5. A strong like exists between the professional work environment and the RN's ability to provide quality health care and achieve optimal outcomes

US Legal System- Sources of Law: -Constitution - Statutes - Administrative Agencies - Court Decisions

1. Constitution - a system of laws that govern a nation, society, corporation of other aggregate of individuals There is a US constitution that establishes the general organization of the federal government and each state has a state constitution. 2. Statutes - laws that govern. - The 51 Nurse Practice Acts (50 states plus District of Columbia) are examples of statutes - Define and limit the practice of nursing - State what constitutes authorized practice as well as what exceeds the scope of authority - Vary state to state but all must be consistent with provisions or statutes set at the federal level 3. Administrative Agencies - Are given authority to act by the legislative bodies - Create rules and regulations that enforce statutory laws - State Boards of Nursing are administrative agencies set up to implement and enforce the State Practice Act - Conduct hearings and investigations to ensure the law's enforcement 4. Court Decisions - Judicial or decisional laws are made by the courts to interpret legal issues that are in dispute - Different types of courts: Criminal- Crimes against an individual or society Example - nurse found guilty of intentionally administrating fata doses of drugs to patients Civil- One individual sues another to compensate for a perceived loss Example - malpractice cases

Elements of Liability

1. Duty to use due care (defined by the standard of care) - The care that should be given under the circumstances (what the reasonably prudent nurse would have done) 2. Failure to meet standard of care (breach of duty) - Not giving 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 (breach) and injury can be proved - Patient is harmed because proper care is not given 5. Injury - Actual harm results to the patient

Overcoming Barriers to Planning

1. Must have goals and objectives - An organization can be more effective if movement within it is directed at specific goals and objectives. - Novice leaders frequently omit setting goals or objectives 2. Flexibility - Plans are guides used to reach a goal so must be flexible 3. Key team members - Employee involvement increases employee commitment to the goal 4. Specific, simple, and realistic plans - Vague plans impossible to implement. - Unclear plans must be revisited and made clear 5. To plan, or not to plan? - Avoid over planning (details often best to leave to those who will implement the plan) - Avoid under planning (events won't simply fall into place) 6. Check points - Need these to correct and adjust for unexpected events - Don't forget final evaluation

Why do nurses need to know about laws?

1. Nurses must know their state's laws and use the nurse practice act for guidance and appropriate action. 2. Nurse leaders have same responsibility to apply legal principles to their practice but also responsible for monitoring the practice of employees under their supervision. 3. All nurses must remain current knowledge of state practice act and applicable laws because of the potential for liability.

5 Change Management Functions

1. Planning/Assessment 2. Organizing 3. Implementing 4. Evaluating 5. Seeking feedback

Stages of Change Model

1. Precontemplation- no current intention to change 2. Contemplation- individual considers making a change 3. Preparation- there is intent to make a change in the near future 4. Action- individual modifies his or her behavior 5. Maintenance- change is maintained and relapse is avoided

Four Modes of Planning: -Reactive Planning -Inactivism -Preactivism -Interactive/Proactive

1. Reactive Planning - planning after a problem exists -often a result of a crisis -can lead to hasty decisions and mistakes 2. Inactivism - seek the status quo, "as is" - Spend energy preventing change and promoting conformity - When change occurs it is usually slow and incremental 3. Preactivism - utilize technology to accelerate change and is future oriented - Usually unsatisfied with both the past and the present - Believe the future is always preferable to the past 4. Interactive/Proactive - consider the past, present and future and attempt to plan the future of their organization rather than react to it - Adaptability is key - This type of planning occurs in anticipation of changing needs or to promote growth within an organization

7 Common Sources of Malpractice for Formal Nurse Leaders

1. Supervision, delegation, and assignment (The nurse manager retains personal liability for the reasonable exercise of assignment, delegation and supervision activities.) 2. Duty to orient, educate and evaluate (Nurse managers and their representatives are responsible for the daily evaluation of whether nurses are performing safe and competent care.) 3. Failure to warn potential employers of staff incompetencies or impairment (Information about suspected addictions, violent behavior and incompetency is of vital importance to employers. State Boards of Nursing should also be notified.) 4. Staffing Issues (Maintaining adequate numbers of staff members in a time of advancing patient acuity and limited resources. Floating staff from one unit to another Using temporary staff (agency) to augment current staffing.) 5. Protection, reporting, consent (Protective and reporting laws ensure the safety or rights of specific classes of individuals.) 6. Policies and Procedures (Policies and procedures set standards for care for the institution and direct practice. Nurse managers must assure staff are knowledgeable.) 7. Employment Laws (Nurse managers must comply with Federal and State laws regarding employment.)

Three phases through which the change agent must proceed before a planned change becomes part of the system:

1. Unfreezing- occurs when the change agent convinces members of the group to change or when guilt, anxiety, or concern can be elicited. 2. Movement- the change agent identifies, plans, and implements appropriate strategies, ensuring that driving forces exceed restraining forces 3. Refreezing- the change agent assists in stabilizing the system change so that it becomes integrated into the status quo. If refreezing is incomplete, the change will be ineffective and the prechange behaviors will be resumed. Because change needs at least 3 to 6 months before it will be accepted as part of the system, the change agent must be sure that he or she will remain involved until the change is completed

Do First Things First -priorities

1st- 1st Priority-Life Threatening Conditions A=Airway B=Breathing C=Circulation 2nd- Potentially Life Threatening Conditions -Examples- anaphylaxis, shock, hemorrhage, child or elder abuse 3rd- Essential Safety Measures -Preventing adverse outcomes -Falls precautions -IV infiltrations 4th- Comfort, Healing & Teaching - Relief of symptoms: pain, nausea - Activities that promote healing: nutrition, ambulation, positioning, medication administration, teaching

Causes of Malpractice for Nurses: 3. Failure to communicate

3. Failure to communicate, including failure to: - Notify the physician or other healthcare provider in a timely manner when conditions warrant. - Listen to a client's complaint and act upon it. - Communicate effectively with a client. - Seek higher medical authorization for a treatment.

A patient is admitted with a cerebrovascular accident (CVA). The nurse notes the patient has difficulty swallowing and requires assistance with bathing, toileting and feeding. The delegation is appropriate if the RN delegates the tasks of bathing and toileting to which of the following staff members? a) The nursing assistant. b) The LPN/LVN. c) The RN. d) The physician's assistant.

A

The nurse delegates a task to the unlicensed assistive personnel (UAP). Which of the following includes appropriate techniques to use when delegating? Select all that apply. a) The nurse maintains eye contact. b) The nurse asks the UAP to report "any problems." c) The nurse states what, how, and when a task should be performed. d) The nurse does not require feedback from the UAP. e) The nurse states, "You should do..."when describing the task.

A & C

What is change? -characteristics

A natural social process of individuals, groups, organizations and society. -constant, inevitable, pervasive, unpredictable, varies in rate and intensity, influences individuals, technologies and systems at all levels of an organization

3. For clients coming to the ambulatory care GI clinic, which task would be most appropriate to assign to the LPN? a) Teach a client about self-care measures for hemorrhoids. b) Assist the physician in incision and drainage of a pilonidal cyst. c) Evaluate a client's response to sitz baths for an anorectal abcess. d) Describe the basic pathophysiology of an anal fistula to a client.

B Best answer is B. Assisting with procedures in stable clients with predictable outcomes is within the educational scope of the LPN. NOT A. Not C. Not D. Teaching the client about self-care or pathophysiology and evaluating the outcome of interventions are responsibilities on the RN.

4. You are working in an AIDS hospice facility that is also staffed with LPNs and UAPs. Which of the following actions is best to delegate to an LPN you are supervising? A. Assess patients' nutritional needs and individualize diet plans to improve nutrition. B. Collect data about the patients' response to medications used for pain and anorexia. C. Teach the UAPs about how to lower the risk for spreading infections. D. Assist patients with hygiene and activities of daily living as needed.

B Best answer is B. Collecting data used to evaluate the therapeutic and adverse effects of medications is included in LPN education and scope of practice. Not A. Not C. Assessment, planning and teaching are more complex skills that require RN education. Not D. Assistance with hygiene and ADLs should be delegated to the UAP.

Commonalities in Negligence and Malpractice

Both concern actions that are a result of: - omission (failure to do something that the reasonably prudent person or nurse would do) - and commission (acting in a way that causes injury to the patient). Both also concern nonintentional actions - injury occurs but the individual who caused the harm never intended to hurt the patient. THIS IS THE MOST IMPORTANT DETERMINANT OF MALPRACTICE AND NEGLIGENCE

2. In planning the post-operative care for a morbidly obese client, how can the expertise of the LPN best be applied? a) Obtain an oversized blood pressure cuff and a large-size bed. b) Set up a reinforced trapeze bar. c) Assist in the planning of bathing, turning and ambulation. d) Design alternatives for routine tasks such as daily weights.

C Best answer is C. The LPN can assist in planning but the RN should take ultimate responsibility for planning or designing. Not A. Obtaining equipment should be assigned to the UAP. Not B. Not D. Obtaining specialized equipment should be assigned to physical therapy.

Care for which of these clients is most appropriate to assign to the LPN under the supervision of the RN? a) A client with oral cancer who is scheduled in the morning for glossectomy. b) An obese client returned from surgery following a vertical banded gastroplasty. c) A client with anorexia nervosa with muscle weakness and decreased urine output. d) A client with intractable nausea and vomiting related to chemotherapy.

D Best answer is D. Nausea and vomiting are common after chemotherapy. Administration of antiemetics and fluid monitoring can be done by a LPN. Not A. because the RN will need to do pre-operative teaching for the glossectomy patient. Not B. because the client returning from surgery needs extensive assessment. Not C. because the client with anorexia is showing signs of hypokalemia and is at risk for cardiac arrythmias

Ethical Decision Making Framework

Ethical decision making involves asking questions about the following: Who should make the choice? What are the options or courses of action? What are the available options? What are the consequence of options (good and bad)? What rules and values should direct these choices? What are the desired goals or outcomes?

What is the appropriate response to an unlicensed personnel who doesn't carry out the assigned tasks? Is it the responsibility of the nurse to carry it out since the nurse is fully responsible?

First the RN should ask or follow up with the UAP about the task assigned. There should be communication between the parties and if at the end of the day the task has not been completed, The UAP is responsible, but the RN remains accountable

Whistle Blowing - Healthcare Provider is terminated for:

Healthcare Provider is terminated for: - Speaking out against unsafe practices - Reporting violations of federal law - Filing lawsuits against employers Termination is viewed as retaliation against the employee by the employer

If you have a highly experienced LPN, is it acceptable to delegate the care of a patient that may not be the most stable? If an RN delegates to the care of a patient the LPN can take care of (within the scope), will the RN be accountable or responsible for the LPN's patient? Who will be responsible for the patient?

No, RN should only delegate patient to LPN that is stable and predictable. Pieces of care can be delegated. The RN is accountable for appropriate delegation. The RN is accountable for the decicion to delegate, the tasks and activities and responsible for ensuring that the nursing care is performed correctly in accordance with a standard of practice, scope of care and facility policy. Because the task is in the scope of the LPN's role, she/he would be responsible

Lewin's Stages of Change

STAGE 1 - UNFREEZING The awareness of an opportunity, need or problem for which some action is necessary Requires mental readiness May occur naturally or may result from a deliberate activity as a first step in planning a change EXAMPLE: Natural change: staff decide system of shift-to-shift hand-off is not working. They want a better system of communication. Deliberate change: nurse manager introduces concept of hourly rounding to better meet patient needs STEPS IN UNFREEZING Gather data Accurately diagnose the problem. Decide if change is needed. Make others aware of the need for change Should not proceed to stage 2 until the need for change is perceived by the group STAGE 2 - MOVEMENT-ALSO CALLED EXPERIENCING THE CHANGE Change agent identifies, plans and implements appropriate strategies. Workers incorporate the new change/solution into their work and interpersonal processes. STEPS IN MOVEMENT/EXPERIENCING Develop a plan. Set goals and objectives. Identify areas of support and resistance. Include everyone who will be affected by the change in its planning. Set target dates. Develop appropriate strategies. Implement the change. STAGE 3-REFREEZING Occurs when the participants in the change accept and use the new attitude or behavior Change is integrated into the new way of thinking or doing Acceptance is assumed when most staff members integrate the change into their work processes. STEPS IN REFREEZING Support others so that the change continues.

Delegation Process

STEP 1: Assess the patient and UAP - Consider safety, critical thinking, stability and time. SAFETY - If patient is unsafe, delegation may be inappropriate - CRITICAL THINKING - Refers to intensity and complexity of decisions made Example - simple teaching such as hand washing can be done by UAP but complex teaching such as diabetic care cannot - STABILITY - The more stable a patient is the more likely a UAP can provide care - TIME - Length and intensity of intervention STEP 2: Communication - State exactly what is being delegated and what the expected outcome is - Convey recognition of the authority to perform what is expected - Identify priorities - Acknowledge monitoring activities you may be doing - Specify: discuss time limits, deadlines, expectations - Specify what deviations to report and when STEP 3: Supervision & Monitoring/Feedback Loop - UAP performs tasks (responsibility) and RN monitors care and outcomes (accountability) - RN should seek information and UAP should report information - Two-way follow through - When RN-UAP are unfamiliar with one another feedback will be more frequent STEP 4: Evaluation and Feedback - Evaluate the effectiveness of the delegation - Provide feedback to the UAP regarding performance of tasks - Evaluate the nursing care outcomes - Evaluate the effectiveness of the nursing plan of care and modify as needed - Must ask specific, focused questions: - Was the work completed? - How did the patient respond? - What changes were noted?

Nurse State Practice Act -why have one? -where does it come from? -what is its purpose?

State Nurse Practice Act: 1. Defines categories of nurses - Licensed practical nurses (LPNs) - Registered nurses (RNs) - Advanced practice nurses. 2. Defines functions for each category of nurses. 3. Sets educational and exam requirements 4. Provides for licensure. 5. Establishes a State Board of Nursing (guided by NCNSB - National Council of State Boards of Nursing) 1. Nurses must know their state's laws and use the nurse practice act for guidance and appropriate action. 2. Nurse leaders have same responsibility to apply legal principles to their practice but also responsible for monitoring the practice of employees under their supervision. 3. All nurses must remain current knowledge of state practice act and applicable laws because of the potential for liability.

Good Samaritan Laws

Statutes (laws) that help protect and provide immunity to nurses and other health professionals for acts that might otherwise result in negligence. -If a nurse provides emergency care and intervention away from his or her workplace, the laws protect him or her from allegations of negligence. - Laws vary from state to state. - The nurse must act in good faith and receive no compensation fro services provided. - The nurse must understand that gross negligence and criminal wrongdoing are not protected by this law.

Decision Tree for Delegation to UAP

Step 1- Assess the patient and UAP - Safety, Critical Thinking, Stability, Time Step 2 - Communication - Clear expectations, Priorities, Be specific Step 3 - Supervision and Monitoring - Two way follow through, frequency varies Step 4 - Evaluation and Feedback - Evaluate effectiveness/modify Feedback/focused questions

What is the best way to approach a UAP who is performing a delegated task, but using an incorrect technique?

Stop the UAP in a firm but polite manner - how you stop them will depend on what is it they are doing i.e. if they break sterile technique the RN might hand them a pair of fresh sterile gloves and ask them to put them on. If they seem to need more guidance or do not understand what they did wrong, RN should intervene and say "here's what you need to do, let me show you." and guide the UAP through the task using proper technique Once outside the room the RN should explain to the UAP what was wrong with what they did and educate them. Tell them next time you can do it and I will observe

Informed Consent -Nurses role as a witness

The client's right to voluntarily consent or refuse treatment, based on understandable information about risks, benefits, and alternatives to treatment. -The physician performing the treatment or procedure is responsible for obtaining informed consent. - A registered nurse may be asked to witness the client's signature on consent which includes: -Consent was voluntary -The client's signature was authentic -The client has the capacity to understand the information given

A RN delegates a task to an UAP that the UAP has performed competently many times. However, this time the UAP does not complete the task correctly resulting in complications with the patient. Even though the RN delegated a task that is within the UAP's scope of practice and the UAP has competently performed the task many times, will the RN still be held fully responsible for the outcome?

The nurse is not fully responsible because the UAP has previously demonstrated competency in the task and successfully completed it before. RN is responsible for correcting the mistake providing education to the UAP about why it was wrong and the nurse also must follow up with error reporting as needed.

Causes of Malpractice for Nurses: 1. Failure to follow standards of care

Usually involve the nurse's responsibility for maintaining s standard of safe and competent nursing care. 1. Failure to follow standards of care, including failure to: - Perform a complete admission assessment or design plan of care. - Adhere to standardized protocols or institutional policies or procedures. - Follow a physician's verbal or written orders.

-Veracity -Justice -Paternalism

VERACITY...Truth telling Nurse managers must give all of the facts when assisting employees with decisions JUSTICE...principle of treating all persons equally and fairly Nurse managers use this with determining policies i.e. time off, floating, etc. PATERNALISM...allows one person to make partial decisions fro another and is often seen as negative or undesirable. Nurse managers use this principle when counseling employees about career options

How do you obtain trust in fellow co-workers so that you feel comfortable delegating tasks to them? Give an example of how you would approach working with a new UAP for the first time.

You obtain trust by: Observing them perform skills Working with them and seeing them consistently demonstrate good practices and work ethic over time What do you do when working with a new UAP for the first time? Take time to talk with UAP before you begin your assignment Have UAP explain their routine and what they are capable of and NOT capable Share your expectations Start with frequent check-ins i.e. hourly and then adjust as needed Frequent feedback

Res Judicata

means a "thing or matter settled by judgement." It applies only when a competent court has decided a legal dispute and when no further appeals are possible. This doctrine keeps the same parties in the original lawsuit from retrying the same issues that were involved in the first lawsuit

Criminal Law vs Civil Law vs Administrative Law -Preponderance of the Evidence

• Criminal- individual faces charges generally filed by the state or federal attorney general for crimes committed against an individual or society. Presumed innocent until proven guilty. Ex. Nurse intentionally administer fatal doses of drugs • Civil- one individual sues another for money to compensate for a perceived loss -Preponderance of the Evidence- burden of proof required to be found guilty in a civil case. The judge or jury must believe that it was more likely than not that the accused individual was responsible for the injuries of the complainant. • Administrative- an individual is sued by a state or federal governmental agency assigned the responsibility of implementing governmental programs. State Boards of Nursing are one such governmental agency

Ethical Frameworks

• Ethical Frameworks- guide individuals in solving ethical dilemmas. These Frameworks do not solve the ethical problem but assist the manager in clarifying personal values and beliefs. Four most common frameworks: -Utilitarianism (or teleological or consequentialist) Theory -Deontological Theory -Duty-Based Reasoning -Rights-Based Reasoning -Intuitionist Framework -Ethical Relativism -Ethical Universalism

Informed Consent -Implied Consent -Express Consent

• Informed Consent- can only be given after the patient has received a complete explanation of the procedure and indicates that they understand the risks and benefits related to it - Implied Consent- in an emergency, the physician can invoke this and states in the progressive notes of the medical record that the patient is unable to sign but that treatment is immediately needed and is in the patient's best interest. Usually has to be validated by another physician - Express Consent- nurse witnesses patient sign a standard consent form and ensures that the patient has received information

Moral Indifference Moral Uncertainty or Moral Conflict Moral Distress Moral Outrage Moral or Ethical Dilemma

• Moral Indifference- occurs when an individual questions why morality in practice is even necessary • Moral Uncertainty or Moral Conflict- occurs when an individual is unsure which moral principles or values apply and may even include uncertainty as to what the moral problem is • Moral Distress- occurs when the individual knows the right thing to do but organizational constraints make it difficult to take the right course of action • Moral Outrage- occurs when an individual witnesses the immoral act of another but feels powerless to stop it • Moral or Ethical Dilemma- described as being forced to choose between two or more undesirable alternatives

-Plaintiff -Defendant -Negligence -Reasonable and Prudent -Malpractice

• Plaintiff- the injured party • Defendant- the professional who is alleged to have caused the injury • Negligence- the omission to do something that a reasonable person, guided by the considerations that ordinarily regulate human affairs, would do- or as doing something that a reasonable and prudent person would not do • Reasonable and Prudent- means the average judgement, foresight, intelligence, and skill that would be expected of a person with similar training and experience • Malpractice- the failure of a person with professional training to act in a reasonable and prudent manner- also called professional negligence

- Rational-Empirical Strategies -Normative-Reeducative Strategies -Power-Coercive Strategies

• Rational- Empirical Strategies- gives current research as evidence to support the change. Used when there is little anticipated resistance to the change or when the change is perceived as reasonable • Normative-Reeducative Strategies- use group norms and peer pressure to socialize and influence people so that change will occur. • Power-Coercive Strategies- features the application of power by legitimate authority, economic sanctions, or political clout of the change agent

Stare Decisis -pitfalls?

• Stare Decisis- means to let the decision stand. Precedents as a guide for decision making. This doctrine gives nurses insight into ways that the court has previously fixed liability in given situations. Two Pitfalls: - The previous case must be within the jurisdiction of the court hearing the current case. Ex. Can't go off of a Florida ruling in Texas - The court hearing the current case can depart from the precedent and set a landmark decision. Landmark decisions generally occur because societal needs have changed, technology has become more advanced, or following the precedent would further harm an already injured person