nurse as leader exam 2

capacity staatistic

# of beds or blocks of time available for providing services

percentage of occupancy

# of occupied beds for reporting period

volume statistic

# of units of service reporting period

delegation to LPN

- Auscultate/Listen - Check(s) - Reinforce/remind - Administer (PO,SubQ,IM -- NO high alert meds, plasma, blood products - Observe - Collect (data, specimens) - Monitor - Set up (basic equipment) - Review/Teach-- Usually standard practices (hand washing/hygiene) or med administration (ie. eye drops) -- RN mostly teaches/educated and LPNs Reinforce - Wound care/Suction/Urinary Cath/Blood glucose readings * get CHRONIC, STABLE pts with predictable outcomes (a popular one is COPD!) * pts who are 24hr post-op * NO: d/c planning, admission assessments (including admission VS) and IVs. * YES: can give narcs, have patients 72hr after MI, have patients with CVA, SCI, on vents or with low coma scale AFTER ONE WEEK. * can do sterile procedures * give meds (but nothing IV) * nursing process under the direction of the RN * can work with contagious patients (think of patient assignments! these can all be delegated to the LPN) Avoid These Assignments for New/Float/LPN/Traveling -New onset/sudden/acute -New admission -Transfer -Newly diagnosed -Discharge -Require education/teaching (beyond basic skills -- tend to be complex and specific to patients on that particular unit) - Unstable (ie. High risk of sudden respiratory failure, or requires frequent assessments and changes in therapy(like electrolyte imbalances)

why decisions go wrong

1. No framework used 2. Flawed data 3. Bias - filtering out data you don't want to hear, assumptions 4. Want to avoid conflict or change 5. Ignorance 6. Using what's available ("availability heuristics") "rule of thumb", "good enough" 7. Overconfidence in decision-making, problem-solving powers - jump to conclusions 8. Haste - shut off data collection before you have all the needed information

staffing key points

1. Patient need 2. RN nurse experience 3. Practice environment: ranging from supervisory support to continuing education 4. Staffing guidelines

long term care

>30 days

consolidated systems

A group of healthcare organizations that are united based on common characteristics of ownership, regional location, or mutual performance objectives for the purpose of optimizing utilization of their resources in achieving their missions.

Roles of nurse manager

Accountable for quality/safety indicator performance in responsibility areas Communicates performance priorities and targets to staff Meets regularly with staff to monitor progress/help with improvement work Uses data to measure effectiveness of improvement Works with staff to develop and implement action plans for improvement of measures that do not meet target Provides time for unit staff to participate in quality improvement measures Observes staff directly and coaches as needed Consults quality management team/risk management team as appropriate Writes and submits to senior leaders periodic action plan including performance measures and plans for improvement Shares information and benchmarks with other units and departments to improve organization's performance

accreditation organization

Accreditation: depends on type of organization/services provided a. Acute care: Joint Commission, American Osteopathic Association, DNV GL - have "deeming authority" through CMS

overt behaviors

Aggressive behaviors such as shouting or threatening harm Being accused of making errors made by someone else Nonverbal info Eye rolling Physical harm

at-will employment

An employer's common law right to terminate employment

subtle behaviors

Being excluded from activities Being gossiped about Having opinions ignored Assigned unreasonable unpleasant or impossible tasks, targets, or deadlines Being humiliated at work Having key areas of responsibility removed or replaced with trivial or unpleasant tasks Having all decisions challenged Being manipulated into taking on roles or tasks that were not in the nurse's best interest

covert behaviors

Being sabotaged Having info or resources withheld that affects performance Moving the goal post in a person's work without informing them Giving confusing or inaccurate information Being told tasks were urgent when they were not Not responding when a response is called for

build on the change

Change is ongoing, create a culture where continuous improvement is a norm Kotter's model

create vision for change

Change may involve lots of small alterations, but these must always be connected to a larger, inspiring vision kotter's model

informed decision making

Consumers have access to relevant and accurate information to make rational decisions

form powerful coalition

Develop a core group of change advocates who will help build momentum and support individuals through the change experience Kotter's model

Delegation to UAP

Do Not Delegate: Assessment Teaching Medication Evaluation Unstable Patients

effective staffing

Evaluating what you do - how effective is it? a. NDNQI - nurse quality indicators b. readmissions, never events c. patient satisfaction, staff satisfaction 2. Organizational factors that affect effective staffing

roles of follower/staff (direct care nurse)

Follows policies, procedures, protocols to ensure quality, safe patient care Remains current in the literature on quality and safety specific to nursing Promotes evidence-based practice standards Communicates with and educates peers immediately if they are observed not following quality and safety standards Reports quality and safety issues to supervisor/manager Invests in the process by continually asking self "What makes this indicator important to measure?" "What has been done to improve it?" "What can I do to improve it?" Participates actively in the quality improvement activities Provides insight as a direct care provider Generates ideas for unit quality improvement efforts Serves as a role model for other direct care providers

Bureaucracy characteristics

Formality Low autonomy Hierarchy of authority Rule dominated environment Division of labor Specialization Centralized decision making High control

create urgency

Generate open dialogue about external and internal realities affecting the need to change kotter's model

anticipated scheduling variables

Hours of operation Shift rotations Weekend rotations Approved benefit time (vacations and holidays) Approved leaves of absence/short-term disability Approved seminar, orientation, and continuing education time Scheduled meetings for the schedule period Current filled positions and current staffing vacancies Number of part-time employments

collective action

How groups form and organize to pursue their goals or objectives, including how to get individuals and groups to participate and to cooperate. The term has many applications in the various social sciences such as political science, sociology, and economics.

QI steps

Identify needs most important to the consumer of healthcare services Assemble team to review consumer needs and services Collect data to measure status of these services Establish measurable outcomes and quality indicators Select and implement a plan to meet the outcomes Collect data to evaluate the implementation of the plan and the achievement of outcome

negative impacts of workplace violence on workplace

Immediate and often long term disruption to interpersonal relationships, the organization of work and the overall working environment Deterioration in quality of service provided Direct costs of legal liabilities Indirect cost of reduced efficiency and productivity Difficulty in recruiting or retaining qualified personnel Loss in company image and reduction in number of clients Unemployment and retraining costs for victims who lose or leave jobs because of violence Disability costs if the working capacities of the victims are impaired by psychological or physical violence at work The need for expensive and security measures

remove obstacles

Keep alert for barriers in structure and processes that limit the ability to change; remove them when you find them Kotter's model

roles of senior leader

Leads culture transformation Sets priorities for house-wide activities, staffing effectiveness, and patient health outcomes Builds infrastructure, provides resources, removes barriers to improve Defines procedures for immediate response to errors involving care, treatment, or services and contains risk Assesses management and staff knowledge of quality management process regularly, and provides education as needed Implements/monitors systems for internal/external reporting of information Defines and provides support system for staff who have been involved in a sentinel event Empowers nursing leaders and direct care providers to implement and evaluate improvement efforts Removes barriers and ensures resources are adequate Rewards high-performing teams

communicate the change vision

People tend to pay attention to what is reinforced, so communicating regularly and consistently is paramount to sustaining the effort. kotter's model

QA vs QI

QA: discovery and correction of errors QI: prevention of errors

Anchor the changes in culture

Recognize when the change is working, report on the difference it is making, and honor the people who helped make it happen Kotter's model

create short-term wins

Success motivates future successes, so create short-term targets and celebrate accomplishing them Kotter's model

5 rights of delegation

Task: is it appropriate? Circumstance: are the environment and equipment available? Person: is person able and willing to? direction/communication: is the task clear and does delegatee understand? Supervision: will delegatee provide feedback r/t task and will delegator monitor appropriately

organizational theory

The study of how organizations function and how they affect and are affected by the environment in which they operate

negative impacts of workplace violence on individual

The suffering and humiliation resulting from violence, which usually lead to lack of motivation, loss of confidence, and reduced self-esteems If situation persists, consequences such as physical illness, psychological disorders, or tobacco, alcohol and drug abuse often observed Potential of workplace violence leading to nurses leaving the workforce

unions in nursing

a form of a trade or labor union which is an organization that advocates for the interest of the nurses that comprise the group. advocates for nurses

shared governance

a method that aims to distribute decision making among a group of people no leader

systems theory

a system comprises 4 elements: structure, technology, people, and environment Viewed as inputs, throughputs, and outputs Closed system: self-contained Open system: interacting with internal and external forces

regulatory organizations

a. Federal: CMS, Dept Health & Human Services b. State: licensing, regulation, safety c. Local: specific business licenses, safety regulations d. Voluntary/Industry: American Hospital Association

internal factors affecting decision making

a. Internal: things personal to the decision maker such as emotions, values, biases, experience, knowledge, attitudes towards risk (taking/avoiding) b. external: things outside the individual - the circumstances, environment, time available, resources -effective nurse leaders "create a work environment that welcomes considered risk taking and encourages employees to share and discuss new and innovative ideas -risk taking affected by self-esteem, self-confidence, peers, confidence in making decisions c. Research Perspective, p. 261: 5 principle factors that influence decision making

clinical judgement model

a. noticing: picking up on patterns in patient behavior, outcomes, etc. b. interpreting: recognizing from the "noticing" that you need to make a decision/respond c. responding: deciding the best option d. reflecting: evaluating what happens

negative impacts of workplace violence on community

access to quality health services are threatened

leaders in change

acknowledge thoughts and feelings align with purpose and values create agency with genuine choices adjust your attitude

critical thinking

active skillful process, uses concepts, higher thought process, not regurgitating facts, used in decision making and problem solving

shared (governance) decision making

all working together to make a decision

bureaucracy

an administrative concept imbedded in how organizations are structured

assignment vs delegation

assignment: accepting the care within the scope of practice of the nurse delegation: a specific task is requested and to be completed and overseen by the licensed person

example of typical unit activity productivity report

assume that a 20-bed med-surg unit (capacity statistic) accrued 566 patient days in June (volume statistic). 98 of these patients were discharged during the month. Average Daily Census on this Unit: 18.9 (566 patient days / 30 days) Percentage of Occupancy for June: 95% (19 patients / 20 beds) Average Length of Stay for June: 5.8 (566 patient days / 98 patient discharges)

average length of stay

average # of days that a patient remained in an occupied bed

average daily census

average # of patients cared for per day for the reporting period

Bureaucracy drawbacks

can lead to frustration and delays due to low autonomy on the front line

power coercive

change agent strategies include application of power/authority to effect change, resistance is handled by authority measures

rational-empirical

change agent that assumes resistance to change is from lack of knowledge and resistance will lessen with factual information ex: evidenced based

normative re-educative

change agents used social expertise to influence others, peer pressure and attitudes

good change agent attributes

commitment to a better way (excited about designing a better future) courage to challenge power bases and norms (closest to the work) Go beyond role, take initiative, think outside the box (assurance of change happening) Persona (self-motivated, generate enthusiasm) Caring (commitment to patients about their welfare) Humility (about the change, not about "me") Sense of Humor (self-support through challenges)

change agent characteristics

committed to best way of doing things courageous take initiative and think out the box motivated caring humble sense of humor

Accountable Care (ACO)

coordinates care among different types of facilities and providers, focus is usually Medicare pts but not always -teaching status: academic teaching facilities - part of a university or affiliated w/ a university - ex.: University of TN Medical Center; St. Thomas -accreditation status

Kotter's 8 step model (change agent)

create urgency form powerful coalition create a vision for change communicate the change vision remove obstacles create short-term wins build on the change anchor changes in culture

quality control process

criterion or standard is determined info is collected to determine whether standards have been met educational or corrective action taken to meet criteria benchmarking is process of measuring products, practices, and services against best performing organizations

quality management

customer satisfaction, innovation, employee involvement most effective in a flat, democratic organization improves systems and processes, does not place blame

DECIDE (for problem solving)

define establish consider identify develop evaluate

indirect intervention

delegate influence

total quality management

edwards deming all staff committed to customer satisfaction

planned change

first order change type change that results from a well thought out and deliberate effort to make something happen

quality improvement

focuses on outcomes leaders, managers, and followers must be committed

Fishbone diagram

gather data; objective & subjective analyze the data develop solutions: be open-minded, pull out and examine your assumptions select a solution implement the solution evaluate the result

decision making

goal directed process uses systematic process choosing among options not always a problem ex: buying a new appliance or vehicle

root cause analysis

goal: learn from mistakes and to minimize blame •Most fundamental reason for failure or inefficiency of a process, in any work setting, is referred to as a "root cause" action: the product of a a root cause analysis joint commission plays a role

Bureaucracy assertions

high control and clear labor division promote efficiency and productivity

participatory management

implies that others are allowed to participate in decision making over which someone has control

performance improvement

individual, process, or system improvement

autocratic decision making

leaders make the decision alone without necessarily involving employees in the decision-making process

restraining forces of change

low energy level limited financial resources unreliable transportation time with family already limited reaching the goal

4 M's

manpower methods machines materials

nurse sensitive indicators

measurements of client care that are impacted by nursing interventions Nursing hours per patient day Patient falls with and without injury Injury level Pediatric pain assessment, intervention, reassessment (AIR) cycle Pediatric PIV infusion rates Pressure ulcers prevalence Hospital acquired Unit acquired Community acquired Psych physical/sexual assault rate Restraint prevalence RN education RN satisfaction surveys Job satisfaction scales or short form Practice environment scale (PES) Skill mix: percent of total nursing hours supplied to agency stagg Voluntary nurse turnover Healthcare associated infection UTI, CLABSI, VAP

collective bargaining

negotiation of wages and other conditions of employment by an organized body of employees.

continuous quality improvement

ongoing process of improvement in all aspects

driving forces of change

opportunity for advancement status, social gratification enhanced self esteem family supportive of efforts pay increase

change agents

person skilled in theory and implementation of planned change individual named as change agent and is responsible for communicating with stakeholders from beginning to end of change movement must be clear who the individual person named as change agent is; naming a group of individuals as change agent leads to role confusion typically change agent is a key stakeholder

quality assurance

programs to monitor used to ensure standard of care focuses on clinical aspects of care

change

regardless of type, it brings feelings of achievement, pride, loss, and stress

unplanned change

second order change type accidental change, change by drift, sudden change, forced change planned change theories don't work well but can provide useful tidbits -looks chaotic, but organizing below surface -change is constant -complexity theory: change is emergent, influenced by all individuals and subsystems

managers in change

single most important factor for how people accept the change it is critical that they do not view change as a threat without change, the organization may stagnate and die

purposeful inaction

stand back, watch, evaluate; use influence appropriately not the same as "laissez faire" (where you should act but choose not to)

acute care

stay <30 days

SWOT (decision making)

strengths weaknesses opportunities threats

complexity theory

the study of how order and pattern arise from very complicated, apparently chaotic systems how things connect and affect each other

choas theory

the universe is chaotic and requires organization to be self-organizing and adaptive to survive Viewed as unpredictable and random events Constant change resulting in little long-term stability

risk management

using strategies to reduce the amount of risk (the degree of likelihood that a person will become ill upon exposure to a toxin or pathogen). patients, staff, finances, managerial, facility safety and management

VUCA environment

volatile uncertain complex ambiguous

unfreezing

•Announce proposed change/include as many stakeholders as possible. Use EBP and encourage exchange of ideas. Encourage stakeholders to volunteer/participate lewin first phase of change

structure audit

•Assumes relationship exists between quality of care and structure or organization. Structural standards, often set by licensing/accrediting bodies, ensure a safe environment. •Example: Call lights in place, or if patients can reach their water pitchers, staffing patterns changing with patient census

process audit

•How nursing care is provided/Critical pathways & standardized clinical guidelines •Process audit task oriented and focused on whether practice standards are fulfilled. •Assumes relationship exists between process used by nurse and quality of care provided

Begin

•Movement: Begin implementation activities, cmte formation, address driving/restraining forces, evaluate process ongoing, prepare budget for resources needed to implement, plan ongoing methods for continual improvement lewin second phase of change

refreezing

•New process is implemented, evaluated multiple times, the new norm. Continue to address problems/process changes lewin 3rd phase of change

outcome audit

•Reflect end result of care/how patients status changes as result of intervention •Nursing Sensitive Indicators-Fall rates, nosocomial infection, pressure sores, physical restraint, and patient satisfaction scores