Prof Issues Exam 2

Pros/Cons of Whistle-Blowing: Cons

•Poses personal & professional risks •Casts doubt on motives •Job loss or employer retaliation •Tiring, anxiety-provoking, frustrating experience •Extra work •No legal protection for whistle-blowers

Principles of Communication in Collaborative Relationships

•Presence •Empathy •Respect •Genuineness

Pros/Cons of Whistle-Blowing: Pros

•Protects patients •Improves quality of care •Meets professional expectations & standards •Satisfies ethical duty •Brings problems into the open •Moral "rightness"

Culture and Non-Verbal Communication

•Proximity/Spacing •Touching •Gestures •Eye contact •Silence •Body Language

Clearly defined organization structure

•RN recognized as leader of health care team •Clear job descriptions defining roles and responsibilities, consistent with state nurse practice acts •Worker credentials on nametags

Verbal Communication

•Requires functional physiologic, cognitive mechanisms that produce, recognize, receive speech •Developmental age -verbal, cognitive ability •Cultural heritage -connotative meanings

Sender and Receiver Responsibilities Sender Should

•State one idea at a time, simply and clearly •Monitor tone and tempo •Explain when needed •Repeat if necessary •Encourage feedback

Guidelines for Whistle-Blowing

•Stay calm; think about risks before acting •Know your legal rights (state laws vary r/t whistle-blowing) •First, confirm (be certain!) there is really a problem •Seek validation from colleagues that there really is a problem (but don't let them sway your actions) •Follow chain of command when reporting concerns whenever possible •Present just the •Use the internal processes/mechanisms for your institution •Document the problem you've observed & detail ALL steps you've taken to rectify the situation •Do not expect to be thanked or vilified for your actions

Communication Styles

•Styles -assertive -aggressive -passive -passive-aggressive Goal: meaning of message is understood by both the sender and the receiver

Sources of Law

•United states constitution •Federal and state legislatures •Administrative agencies •Courts

Types of Communication

•Verbal •Non-Verbal •Intrapersonal •Interpersonal •Group -public speaking

Factors Affecting

•Vocabulary •Denotative vs. Connotative Meaning •Pacing of conversation •Intonation: tone, pitch, cadence, volume •Timing •Relevance of information •Credibility of the sender •Humor

Communication 101

•Words 7% •Vocal Tone 55% •Body Language 38%

RN must always be:

•accountable for care given •responsible for instructing UAP as to who needs what kind of care and when

Fragmentation: The opposite of Care Coordination

•characterized by weak connections among multiple component part •makes simple tasks difficult •makes difficult tasks impossible •signs: poor communication, repetition of services (tests), increased costs

What you need for alleviating results of fragmentation?

•good communication •relentless patient advocacy •good teamwork

Lower professional nursing staff on a equals?

•higher number of med errors •nosocomial infections and wound infections •higher fall rates •increased levels of restraint usage •higher medication errors in assisted living, school settings

UAP accountable for knowing:

•how to perform care properly, following institutional best-practice policies •when others need to be called in for tasks beyond limits of knowledge and training

Two Types

•internal •external

Motivation to use UAP

•maximize human resources •cost reduction

Educational Requirements of UAP's Varies

•minimum of 75 hours of theory and practice with successful completion of competency exam in both areas •most UAP training in facility with no formal certification: training is institution-specific and "often inadequate" •formal training at vocational schools and community colleges -focus on long-term care -certification to meet state requirements

Unlicensed Assistive Personnel (UAP)

•nurse aides •nurse extenders •healthcare aids •technicians •orderlies •assistants or attendants

Delegation Decision Tree

•right task •right circumstance •right person •right direction/monitoring/communication •right supervision/evaluation

Delegation definition ANA

"The transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome."

External

reporting concerns outside organization •this is more standard understanding of true whistle blowing, especially if media is involved)

Internal

reporting concerns via chain of command

Connotative

represents the various social overtones, cultural implications, or emotional meanings associated with a sign

Genuineness

state of being real, honest, sincere

Minimizing Malpractice Risk Continued

•Maintain client confidentiality •Provide education and counseling •Delegate, assign, and supervise properly •Accept appropriate assignments •Participate in continuing education •Observe professional boundaries •Observe mandatory reporting regulations •Be aware of legal safeguards for nurses

Personal Risks Associated with Whistle-Blowing

•Negative reactions from coworkers •Loss of job •Employer retaliation •Legal retaliation •Treatment as traitor •Professional reprisals (threats) •Reprimands •Referral to psychiatrist •Pressure to resign

Professional Communication Routes

•Nurse to Nurse •Nurse to/from interdisciplinary team member (physician, PT, OT, Resp) •Nurse to/from Manager •Nurse to/from Patient-Therapeutic Communication

Minimizing Malpractice Risk

•Observe mandatory standards of care •Use nursing process; follow professional standards •Avoid medication and treatment errors •Report and document accurately •Obtain informed consent •Attend to client safety

Common Malpractice Claims

•Failure to assess and diagnose •Failure to plan •Failure to implement a plan of care •Failure to evaluate

Negligence

•Failure to perform as a reasonable, prudent person would •Failure to follow standards of practice •No intent to harm is present

LNA Requirements

•Federal Law=must keep a state registry •NH has MNA or LNA •Scope of practice of LNA •2 part testing for licensure: written and performance based

Whistle Blowing=avoiding "Groupthink"

"Groupthink definition: inappropriate conformity to group norms, attitudes, and opinions •cones with significant personal, professional risks •tendency is to ignore problem until crisis occurs or problem becomes public •reality: professionals torn between what they believe they should do, what they actually do=MORAL/ETHICAL DILEMMA

SUMMARY of ANA Pearls: for RNs working with UAPs

1. Recognize & use the legal authority vested in RNs to delegate non-professional tasks to trained UAPs 2. Understand & practice the supervisory role expected of RNs regarding the delegation of tasks to UAPs 3. Understand employer rules, regulations, policies & procedures pertaining to the use of UAPs 4. Know the skill set(s) that UAPs possess, which should be documented & easily accessible at the institution employing the UAP 5. Exercise decision-making authority regarding whether to delegate nursing tasks to UAPs, using professional nursing judgments in planning patient care

Creating a Safe Work Environment

A. Clearly defined organization structure B. uniform training, orientation programs for UAP C. Adequate program development in leadership and delegation skills for RNs prior to supervision of UAPs

Which of the following would be appropriate for a nurse to delegate to a UAP? A. Vital sign measurements B. Care planning C. Patient assessment D. Patient teaching

A. Vital Sign Measurements

Whistle-Blowing

Act of going outside organization for public's best interest when organization unresponsive to reporting danger thought organization's proper channels

Presence

All energy is focused on interpersonal interaction •presence precedes -genuineness -empathy

Activities NEVER to be delegated to UAP/LNA(NAP)

All parts of the nursing process (ADPIE) •pt assessment •nursing diagnosis •care planning •pt teaching •health education •outcomes evaluation RN ultimately responsible for ensuring pt's receive appropriate high-quality care

In which of the following circumstances might the nurse advocate to defer obtaining informed consent for care and treatment of a patient? A. The patient is brought to the emergency department in cardiac arrest and no family is present. B. An unconscious client scheduled to receive a central intravenous catheter is admitted to the unit with no family present. C. The surgeon requests that the patient be sent to the surgical suite before the consent form is signed. D. The patient is confused and agitated and cannot understand or sign the consent form.

B. An unconscious client scheduled to receive a central intravenous catheter is admitted to the unit with no family present.

Why is nursing care coordination imperative?

Better Patient Outcomes Such As: •Reductions in emergency department visits •Noticeable decreases in medication costs •Reduced inpatient charges •Reduced overall charges •Average savings per patient •Significant increases in survival with fewer readmissions •Lower total annual Medicare costs for those beneficiaries participating in pilot projects compared to control groups •Increased patient confidence in self-managing care •Improved quality of care •Increased safety of older adults during transition from an acute care setting to the home •Improved clinical outcomes and reduced costs •Improved patient satisfaction overall

Which action associated with the use of restraints can be delegated to the LNA? A. Assessment of patient's safety needs B. Evaluation of patient's response to treatment C. Range of motion after the release of the restraint D. Selecting the appropriate type of restraint

C. Range of motion after the release of the restraint

UAP Shortage

Current nationwide shortage of well-trained UAP due to high turnover rate for nursing assistants because of: •Low pay •Physical and emotional job demands •Negative messages from managers, supervisors, coworkers •Lack of employer-paid benefits, health insurance coverage •Limited career paths •Less-than-ideal working conditions; high turnover rate leaving others short-handed •Outdated federal regulations for minimum standards for staffing in nursing homes

On admission to Hospital A, the patient indicates that he would like information about making a living will. The nurse informs the patient that the hospital does not have a process in place to facilitate this. Hospital A is not in compliance with the A. Health Insurance Portability and Accountability Act B. EMTALA C. Americans with Disabilities Act D. Patient Self-Determination Act

D. Patient Self-Determination Act

SBAR: Background

Give other information pertinent to the situation-not the patient's entire history since admission, but circumstances leading up to the situation (ex. medications, lab results, current symptoms)

Maximize Human Resources

•Free professional nurses from tasks and assignments not requiring independent thinking and professional judgment using the nursing process •Examples: Bed making, vital signs, feeding, I/O, weight, height

The nurse is expected to:

Demonstrate responsibility and accountability for practice and decisions. Indicators: •exhibits ethical behaviors •establishes and maintains therapeutic boundaries •limited practice to current knowledge, skills and abilities •clarifies expectations of the role •intervene when unsafe nursing practice occurs •practices within the legal authority granted by the jurisdiction •implements professional development activities based on assessed needs

Denotative

Denotation represents the explicit or referential meaning of a sign. Denotation refers to the literal meaning of a word, the 'dictionary definition.'

T/F: The RN is responsible for instructing UAP in how to properly perform the assigned care.

False

T/F: There are no legal consequences for nurses who do not follow the ANA Standards of Professional Performance as these are not laws.

False

Malpractice

Four elements necessary to collect damages •Existence of a duty •Breach of the duty •Causation •Damages

Lack of coordination =

Fragmentation

Accountability-Patient Report

Guidelines for clear and complete reporting •Organize the report before beginning •Give client room #, name, age, diagnosis, and physician •Provide brief account of patient condition -include new or changed orders •Mention PRN's given •Refer to VS, temp change, IV fluids, and I/O •Use standardized process

SBAR: Situation

In 10 seconds, identify yourself and the pt. and describe the present situation that prompted you to call. State: •your name •your unit •the patient's name and room number •the problem

The nurse is expected to: demonstrate responsibility and accountability for practice and decisions

Indicators: •Exhibits ethical behaviors •Assures client welfare prevails •Establishes and maintains therapeutic boundaries •Limits practice to current knowledge, skills and abilities •Clarifies expectations of the role •Intervenes when unsafe nursing practice occurs •Practices within the legal authority granted by the jurisdiction •Implements professional development activities based on assessed needs

Nursing Assistive Personal (NAP)

LNA

Care coordination is indispensable to ____ nursing care

Quality

Other Guidelines for Nursing Practice

•Institutional polices and procedures •Nursing Codes of Ethics •Patient Care Partnership -(Formerly Bill of Rights) •ANA Bill of Rights for Nurses

State Laws Guiding Nursing Practice

Mandatory Reporting Laws •nurses are mandatory reporters in state of NH •communicable disease •abuse Good Samaritan Laws •differ by state Nurse Practice Acts •credentialing •licensing •discipline

Teamwork and Effective Communication

Teamwork and effective communication •Effective communication: is a marker of safe and highly reliable care •Use of effective communication by leaders=role modeling •Administrative structures should support and require effective communication and teamwork •Ability to manage/confront conflicts arising out of poor communication

Standards of Practice

Standard of Care •What a reasonable and prudent nurse would do in a given situation based on: -Nurse Practice Acts (mandatory standard) -Professional Organizations (voluntary) *joint commission *ANA *Other specialty organizations

SBAR: Assessment

State the problem and what you think is causing it. This is an inference rather than traditional data collection

SBAR: Recommendation

State what you think will correct the problem, or what you need from the physician

Communication: NOF Competency

The Nurse of the Future will interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes.

Delegation

Transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation

T/F: RN is legally liable if negligent in supervision of UAP at time of negligent act

True: RN must have awareness of UAP's job description, knowledge base, demonstrated skills

Purpose of whistle blowing

advocating for others who may be harmed

Interpersonal

refers to relationships or actions that take place between two or more people while

Intrapersonal

refers to things that go on exclusively within one person

Presence

being there, or gift of self produces deep personal connection for participants

Effective inter professional teams leads to?

better patient outcomes

Examples of Roles LPN

care for stable patients with predictable outcomes, works under supervision of the RN

Empathy

communicating understanding of how others feel, what or why they feel the way they do

Examples of Roles Physicians

experts in physiology, disease, pathways, and treatment

Respect

feeling or showing deferential regard or esteem

Examples of Roles OT and PT

focus on improving functional capacity

Examples of Roles Pharmacist

medication experts

Poor communication and lack of respect leads to?

poor patient outcomes

Examples of Roles Nurse Practitioner

possess advanced nursing skills including diagnosis, treatment and prescribing

Examples of Roles Social Workers

trained in family dynamics

Examples of Roles: Nurses

treat client from a disease management perspective but also from holistic perspective: psychosocial, spiritual, family

Delegation Dos and Don'ts Do's

•Know your state nurse practice act •Know agency policy •Know the training and background of people to whom you delegate tasks •Decide which tasks can be safely delegated •Consider specific needs of each client

Handoff Communication

•Legal Issue •Continuity of Care Issue •Patient Safety Issue

UAP/LNA Scope of Practice

•Like nursing, no universally nationally accepted scope of practice exists •In NH: LNA must work under "supervision of RN" •Scope of practice focuses on: -helping pt's maintain "functional ability" -documentation -upholding pt rights -skills that are delegated to them

Sender and Receiver Responsibilities Receiver Should

•Listen carefully, concentrate •Evaluate-think and process info •Provide feedback •Interpret the message •Verify interpretation of the message

Techniques to Improve Communication

•Be assertive •Listen •Use "I" statements

The Four Agreements

•Be impeccable with your word •Don't take anything personally •Don't make assumptions •Always do your best

Federal Laws Guiding Nursing Practice

•Bill of Rights •Emergency Medical Treatment and Active Labor Act (EMTALA) •Americans With Disabilities Act •Patient Self-Determination Act •Health Insurance Portability and •Accountability Act (HIPAA)

Communication Challenges: Situations that require a conversation

•Broken Rules: shortcuts, not following procedures •Mistakes: poor clinical judgment, inadequate assessments •Lack of support: refusing to help or share info •Incompetence: lack of knowledge and skills •Poor teamwork: cliques, upstaging •Disrespect: condescending, dismissive tone •Micromanagement: misuse of authority

Whistle Blowing in Nursing

•Complaints of unsafe staffing •Inappropriate use of UAP's •RNs asked to participate in illegal/unethical activites including fraud •Primary reason for not raising a concern: nothing would be done •Whistle-blowing rarely first solution; need to follow chain of command

Cost Reduction

•Conflicting research results about to actual cost-effectiveness •Consideration of lower-paid UAPs vs. higher paid RNs: research has shown that more number of RNs decreases cost related to decreased length of stay •Pt. outcomes in terms of money: poorer outcomes and longer stays in hospital=higher costs per pt.

Delegation Dos and Don'ts: Dont's

•Delegate components of nursing process to UAP •Assume the person you are delegating to knows how to perform the task •Delegate medication administration unless person is appropriately licensed to administer that med

Healthcare Team

•Doctors •Physician Assistants •Nurses •Pharmacists •Dentists •Technologists and Technicians •Social Worker •Therapists and rehabilitation specialists (PT, Speech, OT, Respiratory) •Emotional, Social and Spiritual Support providers (hospital chaplain) •Administrative and Support Staff •Community Health Workers and Patient navigators

Adequate program development in leadership and delegation skills for RNs prior to supervision of UAPs

•Educational programs for new graduates •Continuing education for practicing RNs

Tips on being assertive

•Ensure congruence between verbal and nonverbal messages •Guide the direction of the discussion •Use "I" statements •Focus on the issues •Do not invite negative responses •Avoid self-effacing statements •Maintain eye contact, as culturally appropriate •Speak clearly and firmly •Project a clear tone of voice •Communicate self-confidently •Maintain professional composure •Communicate in a positive manner •Refrain from sarcasm

Laws

•Established to protect society •Nursing practice guided by legal principles •Purpose of laws -Protect clients/society -Define scope of nursing practice -Identify minimum level of care to be provided

Factors Affecting Nonverbal Communication

•Facial expression: communicates feelings behind a message •Posture and gait: clue to attitude, self-concept •Personal appearance: clue to socioeconomic status, culture, feelings •Distance: indicates extent of familiarity •Gestures: emphasize and clarify spoken word; can have different meanings •Touch: can be misinterpreted