transitions exam 1

Functional care nursing model

(task model) -every provider is giving care based on the task that they can do -lines of responsibility and accountability is based on nurse manager Staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients. Lines of responsibility and accountability RN nurse manager assigns responsibility for completion of tasks to a group of health care workers RN is responsible for planning care and supervising workers RN retains accountability for the patient care provided Common use areas: operating room, long term care

Cause-and-effect diagram

- *can help determine potential sources of a problem* - Lists potential causes arranged by category to show their effect on a problem - Cause-and-effect diagrams are helpful when the major problem areas have been localized through the use of the Pareto chart.

flowchart

- Maps out what actually occurs in a work process - Includes steps and substeps, and who does the work - *helpful when dealing with processes that cross over multiple areas and caregivers* - understanding the process as a whole top-down flowchart simply lists the main steps and substeps of a process in a linear fashion deployment flowchart maps out the steps of a process under headings that designate the people or departments carrying out each step.

lack of access to health care

- Primarily reflects a lack of health insurance coverage - Primary groups with no insurance: 1. Working poor employed by small firms without insurance coverage 2. Part-time workers and unemployed people - Poor more likely to lack usual source of care, less likely to use preventive services, and more likely to be hospitalized for avoidable conditions Medicaid: Intended to improve access to health care for the poor - Underinsured and uninsured generate uncompensated care and "bad debt" for health care providers, who must then increase charges to paying customers (households and public and private insurers) in a process known as "cost shifting" - Uncompensated care and cost shifting: primary reasons for national health insurance plan • Concerns about the poor: 1. more likely to lack usual source of care 2. less likely to use preventive services 3. more likely to be hospitalized for avoidable conditions

managed care

- Primary commonality of managed care is to oversee the use of health services •Coverage may be denied (in contrast to the previous "if it might help, do it" approach) •Goal is to minimize payment for inappropriate or excessive health services - Rapid expansion of managed care in response to numerous factors •Overuse of medical care and resources •Effects of employers' health costs on business profits •International competitiveness

Communicate performance expectations (directing)

- Quality improvement, the goal, how to get there - ongoing process that begins in new-employee orientation and continues throughout the term of employment - directly observe, communicate expectations, determine barriers to meeting expectations

networking

- Research potential employers by networking at school, community sites, and student nurse organizations - Explore websites of health care facilities; many have jobs posted and provide online applications - Question faculty, other nurses, employees, former employees, and alumni of one's own school - Talk with nurses and other employees of potential institutions - Review employment sections of newspapers, job fairs, and the Internet - Listen to family members, neighbors, and friends who have been patients in facilities

health policy defined

- Set course of action taken by governments or health care organizations to obtain desired health outcome - Private health policy is made by health care organizations such as hospitals and managed care organizations - Public health policy refers to local, state, and federal legislation; regulation; and court rulings that govern the behavior of individuals and organizations in the provision of health care services

open systems

- The organization is affected by not only internal changes (short staffed) but also external environmental forces (pandemic is external) - External forces- asthma season, flu season, tornadoes

systems theory

- Views organization as a set of interdependent parts that together form a whole - suggests that anything that affects the functioning of one part of the organization will affect the other parts - To be successful, today's health care organizations must be able to continually adapt to internal and external changes. - provided nurses with a framework to view nursing services as a subsystem of the larger organization and to realize the interrelatedness and interdependence of all the parts of the organization Open system vs closed system As internal forces in one department (hospital administration) mandated changes that affected another area (RNs and patient care), internal forces (RNs) pushed for changes from the external environment (state nurses association and state government). The external environment may now force changes to the organization (hospital administration).

Chaos theory

- attempts to account for the complexity and randomness in organizations - Actually a degree of order obtainable by viewing complicated behaviors and situations as predictable. - Look for patterns. - Chaos theory says that variation is a normal part of managing health care systems. - Views complicated behaviors, situations, and variations as predictable; reflects cultural diversity, constantly fluctuating patient census (overabundance or none), and staffing shortages Examples: variations in hospital census during flu seasons or asthma triggered weather/seasons; Staff absences due to illness; caring for sick children, etc. Staffing patterns, hires during nursing graduation, etc.

Pay-for-performance

- method of reimbursing providers based on the quality of care provided with an emphasis on disease prevention and reducing complications Never events - Medicare no longer pays hospitals for the extra cost of treating preventable errors commonly referred to as "never events" - Purpose is to encourage hospitals to direct resources to preventing errors rather than being paid for them - Never events include hospital-acquired infections, injuries from falls, wrong site surgery, mismatched blood transfusions, and others

closed systems

- suggests system totally independent of outside influences (unrealistic for health care org)

Grassroots Political Strategies

-Registering to vote and voting in all elections -Joining a professional nursing organization -Working in candidates campaigns -Attending a "meet the candidates" town hall meeting -Visiting with policy makers or their staff -Communicating with policymakers by email, fax, & phone

leaders

1. Attempt to influence the beliefs, opinions, or behaviors of a person or group 2. Guide people and groups to accomplish common goals 3. May not have formal authority but are still able to influence others - Actual position (formal)

applicants rights

1. Be informed of available positions and minimum qualifications 2. Apply for available position for which he or she is qualified 3. Be seriously and fairly considered 4. Have an interview and be shown a job description 5. Be informed of the benefits package 6. See the nursing unit, and meet the manager if one is being seriously considered 7. Be made aware of the orientation program- how long, is there a residency program, how long is that 8. Be given an expected time when a decision will be made

managers

1. Coordinate people, time, and supplies to achieve desired outcomes in a defined area of responsibility - Are leaders with specific responsibilities to coordinating 2. Have an appointed management position and a formal line of authority and accountability - Chain of command 3. Task oriented 4. Obligation- duty that may have a consequence 5. willingness- accept position without hesitation 6. Intent- managers must be clear on why things are done 7. Ownership- power or control over something; they have accountability and power 8. Commitment- emotionally compelled to follow through on ones actions

1. planning (budgeting)

1. Decide goals to achieve for a specified period, and identify resources to achieve those goals 2. Predict revenues and expenses on the basis of goals and budget assumptions •Budget assumptions allow managers to answer various questions that will have an effect on the budget •What should nursing salaries be in the coming year to remain competitive with other health care organizations in the area? •How will new services that are being offered by other health care organizations in the area affect our organization? •Budgets are most often developed for a 1-year period on the basis of predicted quantities of services 2 part- gather info and plan •community assessment to determine needs of the zip codes; prevalence of HTN, school programs, immunizations •organization must assess unemployment and reimbursement programs, impact those areas have had on budget delivery •look at patient satisfaction scores (HCAHP) •organizations must examine data related to programs based on their missions and values Predictions based on past performances, needs of community, and overall expenses based on staffing and materials

1. Planning (management functions)

1. Decide in advance what to do; how, when, and where it is to be done; and who is to do it 2. All management functions based on planning (1) identify goals and objectives to be achieved; (2) identify resources needed (e.g., people, supplies, equipment); (3) determine action steps; and (4) establish a timeline for the action steps and goal achievement. - Effective planning requires the nurse to understand the organization's mission, philosophy, strategic plan, goals, and objectives.

3. Staffing

1. Determine the number and type of staff needed on the basis of goals and budget requirements. 2. Recruit, interview, select, and assign personnel according to job description and performance standards. 3. Get new employees off to a good start by offering excellent orientation, training, and socialization programs. 4. Implement an ongoing staff-development program to ensure that employees at all levels have opportunities to develop personally and professionally and to enhance their knowledge and skill levels. 5. Implement creative and flexible scheduling based on patient care needs, employee needs, and productivity requirements.

clinical pathways background

1. Developed to identify quality, cost-effective care plans to reduce the patient's length of stay in the hospital 2. Dictate the type and amount of care given and thus have financial implications for the health care facility

exploring career options

1. First you must, Know yourself - The choice of the first nursing position deserves study - Consult an instructor, a job counselor, or a trusted nursing mentor for objective input - Review general interests, abilities, and strengths - Consider physical and emotional stamina - Consider energy level and responsibilities to others - Consider long-term goals

2021 Hospital National Patient Safety Goals

1. Identify patients correctly • Use at least two patient identifiers when providing care, treatment, and services. • Eliminate transfusion errors related to patient misidentification. 2. Improve staff communication • Report critical results of tests and diagnostic procedures on a timely basis. 3. Improve the safety of using medications. • Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. • Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. • Maintain and communicate accurate patient medication information. 4. Use alarms safely • Improve the safety of clinical alarm systems. 5. Prevent infection • Comply with either the current Centers for Disease • Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. • Implement evidence-based practices to prevent health care-associated infections due to multidrug- resistant organisms in acute care hospitals/critical access hospitals. • Implement evidence-based practices to prevent central line-associated bloodstream infections. • Implement evidence-based practices for preventing surgical site infections. • Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections. 6. Identify patient safety risks • Identify patients at risk for suicide. 7. Prevent mistakes in surgery • Conduct a preprocedure verification process. • Mark the procedure site. • Procedure time-out is performed before the procedure.

leadership trait theory shortcomings

1. Neglected interaction between other elements of the leadership situation. 2. Failed to see that leadership traits CAN be developed

Management functions

1. Planning 2. Organizing 3. Staffing 4. Directing 5. Controlling -functions are interrelated; different phases of the process occur simultaneously, and the processes should be circular, with the manager always working toward improving quality, patient safety, and staff and customer satisfaction

Delete "If Only" fromYour Vocabulary

1. Regret is a luxury and a great time waster 2. Time is wasted rehashing mistakes 3. Admit mistakes, learn from them, accept responsibility, and move on 4. Replace "if only" with "next time"

"Building Stronger Brains" 13 Funded ACEs Projects in Tennessee

1. The Infant Court Project - Davidson County 2. ACE Health Care Provider Educational Program- Baptist Memphis Hospital for Women 3. Belmont University's Educating Trauma-Informed Professionals - Nashville 4. Trauma-Informed Care Boys & Girls Club-Johnson City 5. Medical Collaboration and Nurturing Parent's Program - Northeast TN 6. Discover Together - Tracy City, Grundy County in Middle Tennessee 7. Trauma-Informed Practices - Nashville Public Schools 8. ACEs Initiative Program - Murfreesboro City Schools 9. Head Start Trauma SMART - South Central Human Resource Agency (3 in Middle TN) 10. ACEs On-Line Learning for Early Childhood Workforce - TN State University 11. Protecting Children from ACEs and Trauma - UTHSC - Memphis 12. Community Resilience: Educate, Act, Train, Inspire, Value Empower - United Way of Greater Chattanooga 13. Mitigating ACEs in Pediatric Primary Care - Vanderbilt University Medical Center

Psychological Obstacles to Productive Work Habits

1. Unclear goals and priorities: lack clarity about purpose and expected work outcomes 2. Conquistador of chaos: constantly overburdened with tasks, events, urgent requests, and last-minute cancellations 3. Fear of downtime: feel guilty with "timeouts" or time off 4. Need to be a caretaker: need to be a caretaker is unbalanced 5. Fear of failure: avoid making the effort because you may fail 6. Fear of success: sometime in life you've received the message that you do not deserve success 7. Fear of disrupting the status quo: not pursuing your goals for fear of the reactions of those around you 8. Fear of completion: afraid of completing projects for various reasons 9. Need for perfection: demand extremely high standards for every single task 10. Fear of losing creativity: feel that creating an organized time management structure harms creative tendencies Carefully consider how these obstacles may affect your personal ability to develop productive, energetic work habits

strategies to work with informal leaders

1. Understand their source of power 2. Involve them in decision making and change implementation processes 3. Clearly communicate goals and work expectations 4. Do not ignore attempts to undermine teamwork and change processes • Identify the informal leaders in the work team and develop an understanding of their source of power. • Involve the informal leaders and other staff members in decision-making and change-implementation processes. • Clearly communicate the goals and work expectations to all staff members • Do not ignore an informal leader's attempt to undermine teamwork and change processes. Coaching and counseling the person and setting clear expectations may be required.

Activities for Continued Success

1. When feeling overwhelmed, always stop and plan activities 2. Keep focused on priorities, and act accordingly 3. Avoid favorite forms of procrastination 4. Maintain a positive attitude about established goals, or revise them so they coincide with your values 5. Do something for yourself every day 6. Continue to work on overcoming your fears 7. Resist doing the easy but unimportant tasks

applicants task

1. assess the climate of the work environment - is a tone of respect and pride used by the organization? - In the hallways, do people acknowledge each other? - Read in-house publications available to you - Do people acknowledge each other? 2. ask for a tour - Ask to meet the immediate supervisor - Pay attention to pace, staff interactions, and morale - Is the manager accessible to the staff? - How do people seem to be getting along? - Note bulletin boards and public displays of staff recognition - Opportunities for the applicant to meet with the staff may be offered 3. follow up Send a thank-you letter to the recruiter after the interview - Demonstrates courtesy - Reminder of the applicant's interest in receiving a timely response Avoid impulse decisions - Do not feel pressured to accept a position while still unsure - Offer to telephone the recruiter with an answer within an agreed-on time - Compare other job offer 4. weigh options - Does the position match the nurse's qualifications? - What are the actual responsibilities of the job? - Does the position lead the nurse in the direction of projected career goals? - How will the work be compensated?

7 steps of EBP

1. cultivating a spirit of inquiry 2. asking a clinical question in picot format- population, intervention, concept group (comparison), outcome, time 3. searching and collecting most relevant and best evidence from reliable resources- systematic reviews, pre appraised lit, peer reviewed journal 4. critically evaluate the evidence, validity, reliability, applicability- then synthesize the evidence 5. integrating the best evidence with ones clinical expertise and patients preferences and values, making a practice decision regarding whether a change should be made or not 6. evaluating outcomes of practice decisions or change based on the evidence; outcomes should be measured for positive or negative outcomes of the change 7. disseminating the evidence based practice decision or change through presentations, publications so others can benefit from the process

employers tasks

1. determine qualifications 2. Validate applications: work history and references will be checked to ensure accuracy 3. Preemployment physical examination 4. Preemployment skills testing: may include a pharmacology test and clinical skills test 5. Commitment

ANA 6 core components of nurse staffing

1. quality of care 2. cost effective care 3. RN expertise 4. settings 5. collaborative and interdisciplinary partnerships 6. healthcare systems

3 areas for effective leadership

1. technical skills 2. human skills 3. conceptual skills Advancing from staff level management (direct patient care and mentoring new nurses) to higher management levels requires the nurse to build more conceptual skills such as: 1. support mission, vision, and goals of the organization; 2. accept complexities of health care systems (ongoing change is inevitable); 3. improve patient safety and quality in midst of reducing costs (cost-effective care); 4. understand and meet the needs of external customers (patients, families, physicians, referring facilities, stakeholders, community partners, academic partners).

fee-for-service

A method of reimbursing health care providers (i.e., physicians, hospitals) in which professional services are rendered and charges are billed based on each individual service provided - May also be known as "retrospective payment system" - May encourage overuse of health care services because the more services rendered or procedures performed, the more revenue received by providers Lack of cost consciousness contributed to increased costs: Patients not aware of costs Providers had little incentive to be concerned about costs Providers received more income for using more services Providers incurred no financial risk for using additional resources

fee for service cont.

A method of reimbursing health care providers (i.e., physicians, hospitals) in which professional services are rendered and charges are billed based on each individual service provided May also be known as "retrospective payment system" May encourage overuse of health care services because the more services rendered or procedures performed, the more revenue received by providers

building stronger brains cont.

ACEs Initiative Program - will promote prevention of ACEs by educating school staff, parents, and community partners regarding childhood trauma and the impact of ACEs on children's physical and social development. As a protective factor against ACEs, this program will enhance social connections within the family and greater community. These programs and services help mitigate the effects of ACEs by providing small group intervention for students who are identified at-risk and link the students to available school-based and community services. Parents will received parent training and support. Head Start Trauma - The goal of the project is to implement a trauma-informed system of interaction in the classroom that transcends into the home. The expected outcome is that children will develop coping skills that allow them to achieve greater mental wellness, a necessity to being successful in the school setting. ACEs On-Line Learning - Division of Research and Sponsored Programs will develop module training. This module will be a comprehensive, sustainable, accessible, dynamic professional development tool for the state's early childhood workforce to support Building Strong Brains. Protecting Children from ACEs and Trauma - will incorporate a wraparound approach with trauma-focused interventions to address the needs of children and families that have been impacted by trauma and other adverse experiences in childhood. Will utilize existing community organizations to provide the services and build community awareness and understanding of the impact of adverse childhood experiences (ACEs) on child development, work with local groups to address childhood adversity and build on the foundation of existing ACEs and childhood exposure to violence initiatives currently being implemented. Community Resilience - based in evidence, experience, and a theory of change specific to thoroughly understanding early childhood education, ACES, and reform. Specifically, the program will address abuse and neglect beyond physical abuse to emotional abuse as part of engaging people in conversations, motivating them to act, and helping them overcome roadblocks. Key actions include a community summit, professional education and training, awareness through social media and neighborhood based engagement, and measuring our work. Mitigating ACEs - The goal of Mitigating ACEs in Pediatric Primary Care is to affect policy and practice related to Adverse Childhood Experiences (ACEs) screening and intervention in pediatric primary care. This research project will include, first, developing and testing a new ACEs screening tool that is brief, has a pediatric perspective, builds on parents' strengths, and measures parenting-related ACEs that can be treated. The new ACEs screening tool, the Parenting and Family Stressors Assessment (PAFSA), will measure parenting-related ACEs (e.g. corporal punishment, threatening, humiliation) and family stressors (e.g. divorce, incarceration, mental illness).

1. A nurse is very interested in hospice care and is considering a position that has become open in that department. The nurse's spouse and family are not in favor of the move. The nurse withdraws the application based on the obstacle of: A.fear of failure B.fear of success C.fear of disrupting the status quo D.fear of completion

ANS: C Rationale: C is correct because fear of disrupting the status quo prevents one from pursing goals because of worrying about the reactions of others such as family and friends. A is incorrect because fear of failure is an obstacle that is based on concern that one will not be able to meet personal goals or successfully complete an important project or task. B is incorrect because fear of success is the planted idea that one does not deserve to succeed. D is incorrect because fear of completion is a concern that a fun creative project may not be offered again.

2. A nurse is faced with choosing between returning to school for an advanced practice degree or accepting a position that is much coveted as a research assistant with a cardiology group. Time is spent at a local park contemplating how to best focus energy and vision for the future. The nurse is using which type of energy management? A.Physical B.Mental C.Spiritual Emotional

ANS: C Rationale: C is correct because reflection on what is important and identifying one's vision or purpose for the future represent an important aspect of spiritual energy. A is incorrect because physical energy is a balance of diet, sleep, exercise, and planned breaks at work to increase productivity. B is incorrect because mental energy is the ability to maintain sustained concentration for task completion. D is incorrect because emotional energy is the building of self-confidence, self-control, self-regulation, and social skills.

human skills (effective leadership)

Ability and judgment to work with people in an effective leadership role 1. Maintain honesty and integrity in work and relationships— trust is essential for effective leadership. 2. Create a teaching and learning environment—earn a reputation for exceptional teaching and mentoring. 3. Develop and role model a commitment to excellence. 4. Create an open, nonthreatening environment—share information, keep staff informed, and encourage them to discuss issues. 5. Become a proactive problem solver—knowing how to solve problems is more important than knowing all the answers. 6. Maintain a confident, positive outlook—identify areas in which you are weak, and seek help to learn and grow.

conceptual skills (effective leadership)

Ability to understand the complexities of the overall organization and to recognize how one's own area of management fits into the overall organization 1. Make a commitment to support the mission, vision, and goals of the organization. 2. Accept the realities of complex health care systems, which are under pressure to improve patient safety and quality while reducing costs. 3. Understand the needs of external customers (patients, families, physicians, referring facilities) and internal customers (staff, administrators, and other departments).

health care organization

Any business, company, institution, or facility (e.g., hospital, home health agency, ambulatory care clinic, health insurance company, nursing home) engaged in providing health care services or products.

Applicant's Tasks: Job Decision Making

Assessment tool for decision making: Standards of nursing practice are evident and integral to patient care Nurse-patient ratio is adequate and is adjusted for patient acuity Orientation is structured, individualized, and adequate for new graduates Opportunities for horizontal transfer and advancement exist Salary is competitive and reasonable Benefits are competitive Continuing education is available A nurse administrator is responsible for delivery of nursing services

3. implementing (time management)

Attacking priorities and use "extra" time by eating while reading something enjoyable or easy. AVOID procrastination. Figure out why you are procrastinating. Delegate or ask for help. Control interruptions by not answering calls or texts unless it is an urgent matter. and learn how to say "NO". Use technology in a beneficial way to help keep you organized. Build in small rewards to yourself like "earn TV or music time" or take a beverage break.

power and authority

Authority: legitimate right to direct others through an authorized position in an organization Power: ability to motivate people to get things done with or without the formal right granted by the organization - Informal structure

portfolio

By creating a professional portfolio, a professional may showcase personal and professional development, practice excellence, and clinical leadership. Portfolio compilation gives one an opportunity to assess abilities, identify learning goals, and devise a plan for further personal and professional development Broader showcase than a resume- papers, projects, letters of rec, activities - Show what you are developing - Resume is part of a portfolio - Hard copy or electronic - Allows nurse to showcase credentials - Concrete examples of professional competence

Emerging roles: CNL (clinical nurse leader) and DNP (doctor of nursing practice)

CNL - nurse generalist use quality improvement in evaluating individual and aggregate client care; masters level DNP - provide leadership for EBP in nursing and translate EBP nursing research in their own practice. They are expected to disseminate and integrate new knowledge.

IOM's Six Aims to Guide Improvements

Care must be: (quality care) 1. Safe: avoiding injuries to patients caused by the care that is intended to help them 2. Timely: reducing waits and sometimes harmful delays for those who receive and give care 3. Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit 4. Efficient: avoiding waste of equipment, supplies, ideas, and energy 5. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status 6. Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

Priority Policies for Reducing Toxic Stress & ACEs

Child healthcare coverage and screenings - Newborn screenings for substance abuse exposure; infant and toddler disability screenings Preconception and prenatal health care - Trends in births covered by Medicaid and CHIP; teen pregnancy rates and infant mortality rates Childhood nutrition- Breastfeeding rates for six months Breastfeeding laws and public decency, Obese rates for low-income 4 year olds, food insecurity and food deserts Health, safe homes, neighborhoods and communities- Child maltreatment rates, foster care and trauma-informed care practices Safe, stable and nurturing relationships - Limited exposure to health hazards in the home, asthma and health homes, cigarette tax, smoke-free laws for restaurants and public workplaces, hours minimum wage to afford one bedroom unit. Increasing economic opportunities for families - Minimum wage levels, consumer protection from predatory payday loans, family and medical paid leave. Affordable, quality child care - Focus on ages 0-4; Head Start child care development grants, tax provisions for child care, Family of three with an income at 100% poverty and one child Early childhood education - Enrollment criteria, funding and quality ratings for early childhood education programs.

Technical skills (effective leadership)

Clinical expertise and nursing knowledge • Keep your own clinical skills and knowledge current. • Act as a willing expert resource and teacher for clinical problems. • Use sound clinical judgment and critical thinking.

nursing case management model

Collaborative approach to: 1. provide and coordinate health care services 2. identify and facilitate options and services for meeting health needs 3. decrease fragmentation and duplication of care 4. enhance quality, cost-effective clinical outcomes Nurse case manager "manages" a "case load" of patients from preadmission (onset of illness) to discharge (resolution of illness) RN case manager assumes a planning and evaluative role and usually is not responsible for direct care duties Case management is generally reserved for the chronically ill; the seriously ill or injured; and long-term, high-cost cases

thought process

Content: suicidal, homicidal, guilt, worthlessness, hopelessness, obsessions, ruminations, phobias, paranoia, hallucinations, delusions Process: coherence, logical, perseveration, flight of ideas, blocking, tangential, attention (distractible, concentration)

management

Coordination of resources, such as time, people, and supplies, to achieve outcomes; involves problem-solving and decision-making processes.

fixed costs

Costs that do not vary with the quantity of output produced do not change as unit-of-service volume changes administrative salaries

BSN researcher

Critically appraise research, identify different types of research methodology, being able to reconcile best ways to find research evidence and to evaluate that evidence -may work alongside any other doctorate/masters prepared -likely to find issues in clinical care that need to be examined further, and to keep on top of best practices and when there might need to be a change

Diagnostic Related Groups (DRGs)

DRGs: 1. Common method of reimbursement for health care services based on a predetermined fixed price-per-case or diagnosis 2. Patient is assigned to a diagnostic grouping based on primary diagnosis at hospital admission 3. Payment to the hospital is set based on this DRG, regardless of length of hospital stay or procedures/tests preformed 3. If hospital costs exceed the DRG payment, hospital incurs a loss; if costs are less than the DRG amount, hospital makes a profit 4. Hospitals face a strong financial incentive to reduce length of stay and minimize procedures performed

4. Directing

Directing involves issuing assignments and instructions that allow workers to clearly understand what is expected, in addition to guiding and coaching workers to achieve planned goals • Clearly communicate performance expectations. • Create a motivating climate and team spirit. • Model expected behaviors. • Facilitate feedback and manage conflict

Pre-employment physical exam (employers task)

Done at the employer's expense Ensures protection for patients Ensures that the person can carry out the necessary physical responsibilities of the job Even after a job offer is made, start dates might be contingent on final screenings, reference checks, and résumé verification

2. organizing

Establish formal structure to define the lines of authority, communication, and decision making The formal organizational structure helps establish the roles and responsibilities of each level of management - involves developing policies and procedures to help outline how work will be done and establishing position qualifications and job descriptions to define who will do the work • Using resources (e.g., staff, supplies, time) wisely. • Assigning duties and responsibilities appropriately. • Coordinating activities with other departments. • Effectively communicating with subordinates and superiors to ensure a smooth workflow. Example: The organizational chart - shows lines of communication and authority. All organizations should have these charts and readily available to staff. Organizing at the unit level: how to use resources (staffing, supplies); Nursing Care Delivery Models; assigning duties and responsibilities.

informal leadership

Exercised by the person who has no official authority to act but is able to influence others in the work group - may or may not be a professional nurse, may have considerable power in the work group and can influence the group's attitude and significantly affect the efficiency and effectiveness of workflow, goal setting, and problem solving. - may be positive if the informal leader's purpose is congruent with that of the nursing unit and organizational goals

process improvement tools

Flowchart Pareto chart Cause and effect diagram Run chart

Energy Management

Four Sources of Energy Required to Perform Our Best Physical - Requires attention to proper eating, adequate sleep, rest, exercise, and hydration in order to pay attention to mental, spiritual, and emotional capacities Mental- Being optimistic while working toward optimal solutions to problems. Ability to maintain sustained concentration to focus on a task. Mental preparation to visualize success. Positive self-talk. Spiritual- Take time to think about what's important in your life. What direction do you see yourself taking in life? Taking time to grow patience and looking at issues/challenges objectively Emotional- Physical, mental, and spiritual energies to manage emotions to improve: self-confidence, self-control, self-regulation, social skills, interpersonal effectiveness, empathy, patience, openness, trust to enjoy life.

Federal health policy

Funding for health and disease prevention and research; supplemental funding for education for health professionals; payment of health care services through Veterans Affairs Administration and Indian Health care services; Shaping nursing practice: such as the Sheppard-Towner Act (1921) that provided states with matching funds to establish prenatal and child health centers staffed by public health nurses. Goal was to reduce maternal and infant mortality rates through teaching women about personal hygiene and infant care. Another example is the Hill-Burton Act 1950- funding to construct hospitals in local communities. •Funds health-related research •Funds education for health professionals, including nurses and physicians •Pays for health care through Medicare, Medicaid, SCHIP, and the Veterans Administration health care system •Plays a monumental role in shaping nursing practice •Passage of the Patient Protection and Affordable Care Act (PPACA) (2010)

goals and objectives

Goals: measurable, observable, and realistic Objectives: specific and detail how a goal will be accomplished with an established target date.

appearance

Grooming, facial expression, tremors, dress, skin condition, identifying characteristics (e.g. tattoos, piercings), scars, age, body build, position, alertness, affect Psychomotor:gait, pacing, crying, threatening, withdrawn, angry, suspicious, attention to events, eye contact, agitation, tremor, grimace

management theory

How managers and supervisors relate to their organization; based on behaviors of managers Today's health care system requires democratic (or participative) management - Depending on the situation, the nurse manager may need to use different types of management styles - involves the staff in patient safety, quality improvement, patient-centered care, and cost reductions 1. authoritarian 2. democratic 3. Laissez-faire

National Database of Nursing Quality Indicators (NDNQI)

Indicators that strongly affect clinical outcomes and are measured -clinical indicator can be measured to show the degree to which care is or is not implemented as it should be (points to areas where quality is an issue) Two major purposes: 1. Provide comparative data to health care organizations to support quality improvement activities 2. Acquire national data for better understanding of link between nurse staffing and patient outcomes - workload monitoring system; average hour of numbers needed to care for each pt on the unit-staffing and how workload is distributed

External Time and Energy Distractions

Interruptions Socializing or visitors Meetings Excessive paperwork Understaffing Lack of information Ineffective communication Lack of feedback Travel Inadequate policies and procedures Incompetent or uncooperative coworkers Poor filing systems Personnel or coworkers with problems Lack of teamwork Duplicating efforts Confusing lines of authority, responsibility, and communication Bureaucratic red tape Junk mail Waiting, meeting delays

disadvantage of fee for service

Lack of cost consciousness contributed to increased costs: Patients not aware of costs Providers had little incentive to be concerned about costs Providers received more income for using more services Providers incurred no financial risk for using additional resources

leadership vs. management

Leadership: ability to guide or influence others - In positive ways Management: coordination of resources (time, people, supplies) to achieve outcomes

Manager responsibilities

Managers plan and organize what is to be done, who is to do it, and how it is to be done. • An appointed management position within the organization with responsibilities to perform administrative tasks, such as planning staffing, performing employee performance reviews, controlling use of supplies and time, and meeting budget and productivity goals • A formal line of authority and accountability to ensure that safe and effective patient care is delivered in a manner that meets the organization's goals and standards

run chart

Measuring data over time to evaluate patterns in process variation - time plots, are graphs of data points as they occur over time A control chart is a more sophisticated run chart that helps to distinguish between "common" cause and "special" cause

local health policy

Meets needs of residents. Examples: free or reduced-rate immunizations offered to all children in the community. Funds to employ RNs as school nurses in public schools; Tobacco free public areas. •Cities or counties offer a variety of health care services to meet the needs of their residents •Examples include free or reduced-rate immunizations, tobacco-free public buildings, safe drinking water, enforcement of seat belt and child restraint laws, and provision of an emergency medical system

determine qualifications (employers task)

Meets the minimum requirements for the position? Suitable for contributing to the mission of the health care delivery system? Any evidence that the nurse is impaired in terms of providing safe nursing care? (background check) •Incompetence or unprofessional conduct •Unreliability in attendance •Chemical dependency •Criminal activity

mission and philosophy

Mission: the foundation of planning for any organization, describes the purpose of the organization and the reason it exists. - Most health care organizations exist to provide high-quality patient care, but emphasis may be placed on different concepts, such as research, teaching, preventive care, spiritual care, and community service philosophy: set of values and beliefs that guides the actions of the organization and thus serves as the basis of all planning

create a motivating climate (directing)

Motivation is the inner drive that compels a person to act in a certain way 1. Positive encouragement and support from the nurse manager are essential to create a motivating work climate (sincere 'thank you') - For positive reinforcement to be effective, it must: •be specific, with praise given for a particular task •occur as close as possible to the time of the achievement •be spontaneous and unpredictable •be given for a genuine accomplishment •Praise in public

Total Patient Care Model

Nurse is responsible for planning, organizing, and performing all patient care during the assigned shift Oldest method of organizing patient care, sometimes referred to as case nursing Nursing student typically performs total patient care for assigned patients Common in Critical Care Units and Post-anesthesia Units -now 12 hour shifts oldest model pro=consistency of care

cognition

Orientation (time, place, person) State of consciousness: lethargic, drowsy, hyper-vigilant Mood: depressed, euphoric, labile Memory: impaired (past/present) intact Concentration: poor/good Judgement: impaired/good Insight: none/limited/goodThoughts

2. organizing (time management)

Personal organization is an important component of time management. Avoid the stacked desk syndrome and remove everything from the work surface that does not relate to the project at hand. Place the cell phone out of sight but within reach. FOR PATIENT CARE: Eliminate clutter from the patient's room so that care can be more efficient. Concentrate on one activity until it is accomplished. Handle a piece of paper one time: use it, file it, or trash it. EMAIL: check 2-3 times a day and handle pressing issues.

Behavior

Physical: pacing, crying, threatening, withdrawn, angry, suspicious, attention to events, eye contact, agitation, tremor, grimace Speech: loud, quiet, slow, rapid, over-talkative, pressured, mute, slurred, incoherent, stuttering, long pauses, mute Self-care: sleep insufficient or excessive, appetite poor or excessive

3 Key Areas for Time Management

Planning Organizing Implementing

role modeling (directing)

Positive role modeling simply means that the nurse performs the job in such a way that he or she demonstrates ideal performance as a professional nurse, with the hope that others will follow the example

state health policy

Powerful influence on health and safety of each state's residents. Examples: safe meat supply through livestock inspections; ensuring safe food storage, preparation, and serving in restaurants. May include paying for some individual health care services: State Children's Health Insurance Program (CHIP) to provide insurance coverage to uninsured children who do not quality for the Medicaid program. State funding for public mental health and substance abuse services, long-term care services for older adults and disabled persons, and health care of prisoners. •Governs nursing through nurse practice act •Provides "invisible services" through regulatory activities •Maintaining a safe meat supply through livestock inspections •Ensuring safe food storage and preparation in restaurants •Ensuring that health care facilities provide safe, quality care •Pays for health care services through various programs: •Medicaid and State Children's Health Insurance Program (SCHIP), which are partly funded by federal funds •Other indigent care programs, which vary from state to state •A key piece of the health care reform legislation is the opportunity for states to develop State Health Insurance Exchanges (SHIEs)—a set of state regulated and standardized health care plans from which individuals may purchase health insurance eligible for federal subsidies

formal leadership

Practiced by the nurse who is appointed to an approved position and is given authority by the organization to act - nurse manager, supervisor, director

Internal Time and Energy Distractions

Procrastination Inadequate planning Ineffective delegation Failure to set goals and priorities A cluttered desk or mind Personal disorganization Inability to say no Lack of self-discipline Responding to crises Haste Indecisiveness An "open door" policy -Open door policy in theory is designed to build a culture of trust, improve communication and collaboration. This is a helpful way for leaders to welcome employees to stop by and share ideas or concerns. However, if this is not used properly, it can turn into ineffective problem solving, grip session, story-telling time, and time waste for the leader and employee. Shifting priorities without sound rationale Leaving tasks unfinished Not setting time limits Daydreaming Attempting too much at once Overinvolvement in routine details Making numerous errors Surfing the Internet Not listening

organizational theory

Provides a framework for understanding complex organizations 1. Systems theory 2. Chaos theory

Primary nursing model

RN "primary" nurse assumes 24-hour responsibility for planning, directing, and evaluating the patient's care from admission through discharge Provides total patient care while on duty While off duty, care is provided by an associate nurse, who follows the care plan established by the primary nurse Lines of responsibility and accountability RN primary nurse has 24-hour responsibility and accountability for patient care Associate nurses are responsible for following the plan of care RN primary nurse is responsible for maintaining clear communication among all members of the health care team Common use areas: home health, hospice, long-term care

Team leader nursing model

RN functions as a team leader and coordinates care for a small group of patients (3-6 patients) -must know patients acuity -strong communication and collaboration skills -good at delegation and decision making Lines of responsibility and accountability RN team leader is responsible for the following: 1. Planning care 2. Assigning duties 3. Directing, supervising, and assisting team members 4. Giving direct care RN retains accountability for all patient care RN team leader is responsible for encouraging a cooperative environment and maintaining clear communication Common use areas: effective, efficient method of patient care delivery that has been used in most inpatient and outpatient health care settings

transformational leadership benefits

Reduces staff turnover- saves money and maintains unit morale Enhances nurse satisfaction because transformational leader is empowering, listening, engaging- positive work environment Improves patient outcomes change: - data analysis from the past to see where we are now (managers) transformation: - creation process, starting something brand new; process is not in place yet; not in reference to the past but to where we are trying to go - future point in mind, visional - acknowledges the past but focuses on what we can do better

using nursing research

Research use: Research findings basis for making decisions & developing interventions

national institute of nursing research (NINR)

Symptom science—promoting personalized health strategies to manage illnesses across diverse populations and settings over the lifespan Wellness—promoting health and preventing illness by identifying factors that promote lifelong health and prevent illness Self-management—improving quality of life for individuals with chronic illness in home settings End of life and palliative care—the science of compassion to prevent and manage symptoms of advanced illness, pain management, and decision making support

building stronger brains

The Infant Court Project will bring an evidenced based infant court team model to Tennessee to address the unique needs of infants, toddlers, and their families with court involvement. The Association of Infant Mental Health in Tennessee (AIMHiTN) will develop and implement the first specialized infant and toddler court docket in the state. Focus on unique needs of children in state custody between birth and age 3. ACE Health Care Provider Program - educate physicians and other health care providers on adverse childhood experiences and social determinants of health, and arm them with the information and tools they need to address ACEs in their practices. Educating physicians, and engaging them to ask the ACE questions of their patient families and referring patient families to Universal Parenting Places (UPPs) will impact parenting behavior in such a way as to prevent childhood adversities. The program will secure inclusion of ACE risk questionnaires in initial medical assessments at physician offices, including local primary care physicians, pediatricians and obstetricians Belmont's program - will directly address the need to improve professional practices and promote cross-fertilization among professions that touch children and families during sensitive periods of development and beyond. 1) to develop an evidence-based, cross-disciplinary, trauma-informed care curriculum for undergraduate nursing, public health and social work students and 2) to identify and address knowledge and training needs among recent graduates and practicing professionals in these disciplines. Trauma Informed Care Boys & Girls Club is designed to determine whether implementing trauma-informed care (TIC) at the Boys & Girls Club will reduce the effects of toxic stress in at-risk children and their caregivers. Three facets" Agency-wide TIC training for all paid and volunteer staff; Create a quite room to be a safe space to de-escalate situations in which someone is upset or angry; Parent/guardian training for Positive Parenting program. Medical Collaboration and Nurturing Parent's Program - to support high risk mothers and infants born with Neonatal Abstinence Syndrome (NAS) in collaboration with the medical community. The program will expose parents to positive parenting guidelines, and information and access to services which address substance use and mental health needs, creating a positive impact and increasing protective factors for their children prior to giving birth and continuing thereafter. Discover Together - collection of programs designed to provide families with positive adaptive skills that help them thrive in the face of isolation and poverty. Focusing on social connectedness and narrative skills, programming includes: a summer camp for children ages 6-12; a family Co-op for children 0-5 and their caregivers; and an after-school learning lab that offers a visual narrative module. Trauma-Informed Practices - puts an emphasis on social-emotional support through its schools, beginning work on developing social emotional learning six competencies in all district initiatives. The new program called Trauma Informed Practices (TIPS) will work to incorporate extensive professional development (PD) to promote awareness of the impacts of adverse childhood experiences on neurobiological development and school success, and integrate evidence-informed, trauma-sensitive practices with existing school practices.

leadership

The act of guiding or influencing people to achieve desired outcomes; occurs any time a person attempts to influence the beliefs, opinions, or behaviors of an individual or group -an effective nurse leader is able to inspire others on the health care team to make patient-centered care an important aspect of all care activities. - relationship; building strong relationships between leaders and followers (transformational leadership) - committed to excellence - passion about their work - strategic goals and focus - trustworthy and accessible- integrity; doing what you say you will do - empathy and caring - commitment to coaching and developing staff

productivity

The amount of output or work produced (e.g., home visits made) by a specific amount of input or resources (e.g., nursing hours worked). method of measuring and tracking the amount of labor costs as compared with the amount of work produced and is a factor in staffing decisions.

authority

The legitimate right to direct others, given to a person by the employer through an official position, such as manager or administrator.

1. planning (time management)

The most important step in time management. Important to engage in planning before beginning any task, project, or the day's activities. Decide what should be done first based on top priorities starting with urgency and time-sensitive tasks or projects. Make a schedule with the "to-do's" list.

health care financing shift

To control rapidly rising health care costs, Medicare moved from a retrospective (fee-for-service) payment system to a prospective payment system (PPS) based on diagnosis-related groups (DRGs) in 1983. This shift was critical for hospitals because Medicare is the largest single payer of hospital charges. Under DRGs, each Medicare patient is assigned to a diagnostic grouping on the basis of his or her primary diagnosis at hospital admission

4 spheres of political action in nursing

Workplace: addresses issues affecting jobs and patient care Government: Addresses laws, rules, and regulations governing nursing practice Community: Addresses issues affecting community health Organizations: addresses issues which shape nursing practice

mandatory measures

address acute myocardial infarction, heart failure, pneumonia, perinatal care, and surgical care improvement project

mental status assessment

appearance, behavior, cognition, thought process

information power

based on a person's possession of information that is needed by others - Similar to expert power, but based on holding any form of knowledge that others need

connection power

based on a person's relationship or affiliation with other people who are perceived as being powerful - "Who you know". Power based on a person's affiliation with others who are perceived as being powerful.

legitimate power

based on an official position in the organization. Through legitimate power, the manager has the right to influence staff members, and staff members have an obligation to accept that influence power comes from the official position in which others are obligated to comply. Example: manager position

expert power

based on knowledge, skills, and information. For example, nurses who have expertise in areas such as physical assessment or technical skills or who keep up with current information on important topics will gain respect from others - "Knowledge is Power" - based on knowledge, skills, and information expertise

Leadership Trait Theory

based on the assumption that leaders were born with certain leadership characteristics. Traits found to be associated with leadership include intelligence, alertness, dependability, energy, drive, enthusiasm, ambition, decisiveness, self-confidence, cooperativeness, and technical mastery

reward power

comes from the ability to reward others for complying and may include such rewards as salary, desired assignments, and acknowledgment of accomplishments - ability to reward people for compliance: money, desired scheduling or assignments, acknowledgement of accomplishments privately & publically

referent power

comes from the followers' identification with the leader. The admired and respected nurse is able to influence other nurses because of their desire to emulate him or her - ability to influence others due to respect and admiration from others who want to emulate the leader's actions. Role Model

establishing performance standards (controlling)

describe a model of excellence for work activities and serve as the basis of comparison between actual and desired work performance • Written organizational policies and procedures • Standards for the practice of professional nursing developed by the ANA and published in Nursing: Scope and Standards of Practice (ANA, 2015a) • Standards for professional nursing specialty practices, such as Home Health Nursing: Scope and Standards of Practice (ANA, 2014) and Genetics/Genomics Nursing: Scope and Standards of Practice (ANA, 2016). • Evidence-based practice guidelines

Clinical nurse researcher (CNR)

doctorally prepared with clinical and research experience. Specializes in research methodologies and statistics. (may have PHD, DNP) Focuses on the conduct or facilitation of research (point of care) Works with staff to identify research questions Designs studies Disseminates findings to staff, administrators, and legislators

Transitional Care RN (newer model)

facilitate effective transitions for chronically ill patients to ensure good communication across settings and providers, appropriate follow-up, clear understanding of prescribed medications, assistance with referrals, and encouraging patients and families to take an active role in their health care

discretionary measures

include children's asthma care, stroke, immunizations, hospital outpatient department, and hospital-based inpatient psychiatric services

strategic planning

long-range planning, extending 2 to 5 years into the future. It results from an in-depth analysis of (1) the business, community, regulatory, and political environment outside the organization; (2) customer and patient needs; (3) technology changes; and (4) strengths, problems, and weaknesses internal to the organization • Identify strategies to respond to changes in customer needs, technology, health care legislation, the business environment, and the community. • Dedicate resources to important services and new programs. • Eliminate duplication, waste, and underused services. • Establish a timeline for goal achievement.

private health policy

made by health care organizations such as hospitals and managed care organizations. Example: Hospital's plan to report errors in patient care

Clinical nurse specialist (CNS)

master's degree-prepared nurse who is an expert clinician with additional responsibility for education and research; assesses agency's readiness for research utilization (synthesizing, disseminating, and using research generated knowledge) to make an impact on or change in the existing nursing practice BUT smaller focus than EBP; works with staff to identify clinical problems; helps staff find, implement, and evaluate findings relevant to current practice. Advanced practice nurses bring specialized knowledge to practice setting 3 spheres of influence: 1) facilitate quality outcomes for individual patients & patient populations; 2) support and mentor nurses through education and leadership; and 3) spearhead innovative changes that advance the healthcare system in meeting needs of patients, families, populations, and communities.

evaluating employee performance (controlling)

occurs through the formal annual evaluation process and through frequent feedback and coaching provided to employees - Consistent, ongoing feedback and coaching about job performance clarify expectations, improve the quality of work, and allow the manager to correct problems before they become serious (don't wait for annual) - Result of routine performance evaluations should be mutual goal setting designed to meet the employees' training, educational, and work improvement needs

operational planning

short-range planning that encompasses the day-to- day activities of the organization • Number, acuity, type, and location of patients to be cared for. • Qualifications and competencies of nursing and other health care staff. • Type and amount of supplies and other physical resources available. • Allocation of resources (e.g., staff, supplies, time) to meet budgetary goals. Examples nurse-patient ratios; nurse satisfaction

coercive power

the opposite of reward power, is based on fear of punishment for failure to comply. Sources of coercive power include withholding of pay increases, undesired assignments, verbal and written warnings, and termination opposite of reward power; based on fear of punishment for failure to comply: threats to or actual withheld/delayed pay increases; unwarranted verbal and written warnings and possibly termination. BULLYING

5. controlling

to ensure that employees accomplish goals while maintaining a high quality of performance • Establish performance or outcome standards. • Determine action plans to improve performance. • Evaluate employee performance through performance appraisals and feedback. Determine an action plan to improve performance - Look at practice standards

full cost

total of all costs associated with a unit-of-service and includes direct and indirect costs

Direct costs

traced directly to production of the unit-of-service - supplies

pareto chart

type of bar graph, with the height of bars reflecting the frequency with which events occur or the effect events have on a process problem. The bars are arranged in descending order so that the most commonly occurring problems are readily visible. identify key aspects of a process or indicator to focus on

variable costs

vary directly with changes in volume of units of service immunization costs, clinics, medications and supplies; supplies for PPE, masks, supplies maintained

HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems

• Communication with nurses • Communication with doctors • Responsiveness of hospital staff • Communication about medicines • Cleanliness and quietness of hospital environment • Discharge information • Overall rating of hospital

authoritarian (management theory)

• Determines policy and makes all decisions • Ignores subordinates' ideas and suggestions • Dictates the work with much control • Gives little feedback or recognition for work • Makes fast decisions • Successful with employees with little education or training - Makes all decisions with no staff input and uses the position to accomplish goals Situation example: Emergency Situation

Laissez-faire (management theory)

• Does not provide guidance or direction • Unable or unwilling to make decisions • Does not provide feedback • Initiates little change • Communicates by memos or e-mail • May work well with professional people - Provides little direction or guidance and will forgo decision making

democratic (management theory)

• Encourages staff participation in decision making • Involves staff in planning and developing new ideas and programs • Believes in the best in people • Communicates effectively, and provides regular feedback • Builds responsibility in people • Works well with competent, highly motivated people "Participative Management" - Encourages staff involvement in goal setting, problem solving, and decision making Situation example: Structuring weekend call/rotation in home health settings.

Transactional Leader

• Focus on day-to-day operations and are comfortable with the status quo • Reward staff for desired work ("I'll do X in exchange for you doing Y.") • Monitor work performance and correct as needed or • Wait until problems occur, and then deal with them 1. Correct performance as needed 2. Do not think far in advance 3. Deal with the situation when it's presented to them

transformational leader

• Identify and clearly communicate vision and direction • Empower the work group to accomplish goals and achieve the vision • Impart meaning and challenge to work • Are admired and emulated • Provide mentoring to individual staff members based on need 1. Help answer why and so what; why we're doing something 2. Common in magnet status 3. achieve higher levels of staff satisfaction and greater work group effectiveness

Sources of work satisfaction

• Leaders who inspire vision and have a passion for excellence in nursing • Empowerment and trust to make decisions and support for decisions that are made • Positive environment with opportunities to learn from mistakes • Transparent sharing of unit clinical and operational data • Fairness of the work schedule and salary • Meaningful connections with leaders and ongoing feedback about performance • Sincere thanks and positive recognition • Leaders who role-model professionalism through dress and communication • Guidance, mentorship, and opportunities for professional development and advancement • Opportunity to be involved in change processes and problem solving • Respectful relationships among staff and physicians, peers, administrators, and other departments

4. evaluating performance (budgeting)

• Manager's evaluation and may include a staff bonus structure • Determine a manager's overall success in achieving goals • Manager's effectiveness managing overtime costs & supply use • Performance evaluations can motivate managers to control budgets • Manager maintains budget accountability, but lack of staff ownership & involvement leads to budget problems 1. Nurse managers frequently evaluated on basis of their effectiveness in managing nursing overtime costs and supply use—both reflected in the nursing unit's budget 2. Performance evaluations based on budget results can motivate managers to effectively control budgets 3. Even though the manager maintains ultimate accountability for the unit's budgetary performance, lack of staff ownership of and involvement in the unit's operation usually leads to problems for the manager

Why are ACEs significant?

• Nearly 64% of adults have at least one ACEs •ACEs cause adult onset of chronic disease such as cancer, heart disease, mental illnesses such as depression and substance abuse •More ACEs you have, the greater risk for chronic disease and being victim of violence •ACEs of 4 or more are likely to be smokers leading to chronic bronchitis and asthma (children). •ACEs responsible for big chunk of workplace absenteeism and costs in health care, emergency response, and mental health and criminal justice. •ACEs occur in response to toxic stress

Sources of Dissatisfaction

• Supervisors who are uninvolved and unsupportive • Tolerance for bullying and incivility • Poor communication and unclear expectations • Vague, inconsistent rules and regulations • No thanks or recognition • Not being informed about changes or involved in the change process • No commitment to professional development • No help from managers during crisis • Inadequate feedback about performance • Excessive workload negatively affecting quality and increasing stress for the nurse

Nursing research

• Systematic inquiry or study conducted to generate new knowledge or to refine existing knowledge to support nursing care processes • Results: 1. provide foundation for practice decisions and behaviors 2. create strong scientific base for nursing 3. provide support for quality & cost-effectiveness interventions 4. Application of results demonstrates professional accountability Results provide support for the quality and cost-effectiveness of interventions Application of results demonstrates professional accountability to insurers and health care consumers Generate knowledge in areas that indirectly affect nursing care process -generate new knowledge; or refining existing knowledge -to provide a foundation for practice decisions and behaviors -research guides a lot of evidence based practice

quality improvement

• Systematic, data-guided approach to improve processes or outcomes • Evolved from Total Quality Management (TQM) and Continuous Quality Improvement (CQI) • Critical to clearly define: 1. Patient outcome for improvement* 2. Outcome measurement 3. Data collection strategies pre/post interventions 4. Planned intervention(s) QI projects normally are site specific and results are NOT intended to provide generalizable knowledge or best evidence. (different from nursing research)

Evidence-based Practice

• Translating best evidence and applying it to clinical decision-making. • Best evidence from research hierarchy and clinical expertise. • Critical appraisal of evidence to ensure credibility and clinical significance: 1. What were the study's results? (What is the evidence?) 2. How valid are the results? (trustworthiness & credibility) 3. Will results be helpful in caring for patients? (Translation)

Service unit or unit-of-service

• basic measure of the product or service being produced • *Provides the basis for allocating expenses and revenues* Examples: "Patient days" are common for inpatient facilities "Patient visits" or visits by categories (short, intermediate, long) are common for ambulatory clinics and home health agencies unit of service- the basic measure of the product or service being provided; unit of service would be patient days, based on hospital census at midnight to calculate patient load -50 pts in hospital for 1 day= 50 pt days -pt visits or by categories (short, intermediate, long)

patient centered care

•"Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions" •Nurses, physicians, and other health professionals partner with patients and families to ensure that health care decisions respect patients' wants, needs, and preferences •Philosophy of care - Not a nursing care delivery model but a philosophy of care - Should be incorporated as an essential component of any nursing care delivery model

"Building Strong Brains" ACEs Initiative in TN

•A national model to promote culture change in early childhood •Preventing and mitigating ACEs and their impact •Goals: -Increase potential every child born in TN has opportunity to lead a productive healthy life. -Raise public awareness about ACEs. -Impact public policy in TN to support prevention of ACEs and reduce community conditions that contribute to them. -Support local projects for precise measurement of impact of ACEs and toxic stress in children -Seek sustainable funding to ensure long-term commitment to reduce impact of ACEs - Embrace responsive governance statewide planning groups with the Governor to advance child welfare & realign juvenile justice system

insight on ACEs

•ACE score by category, not by number of events •ACE score increases, ↑smoking, ↑alcohol use, and ↑injection use especially ACEs 6 (4,600% greater ACE score). •Depression is a normal response to adverse events, rather than a disease or illness r/t neurochemical imbalances or genetics. •Important to study ACEs? Plays out the health of adults •Pathways -Coping mechanisms -Complex CNS hypersensitivities -Epigenetics effect

staffing

•Activities required to ensure an adequate number and mix of health care team members to meet patient needs and provide safe, quality care •Considerations are: - patient needs - nursing characteristics - organizational needs and the practice environment

team leader nursing model pro/con

•Advantages •High-quality, comprehensive care can be provided with a relatively high proportion of ancillary staff •Each member participates in decision making, problem solving •Each member contributes his/her own special expertise or skills •Disadvantages •Continuity of care may suffer with daily team assignments •Team leader may not have the leadership skills required to effectively direct the team •Insufficient time for care planning and communication leads to unclear goals and fragmented care

Total patient care model pro/con

•Advantages •RN maintains a high degree of practice autonomy •Lines of responsibility and accountability are clear •Patient receives holistic, unfragmented care •Communication at shift change is simple and direct •Disadvantage •Number of RNs required is very costly •Some tasks could be accomplished by a caregiver with less training and at a lower cost •Nursing shortage will affect RN availability

functional care nursing model pro/con

•Advantages of patient care •Provided economically and efficiently •Minimum number of RNs required for patient care •Tasks completed quickly; little confusion about responsibilities •Disadvantages of patient care •May be fragmented; possibility of overlooking priority patient needs •Patient may feel confused because of many different care providers •Caregivers may feel unchallenged when performing repetitive functions

clinical pathway vs. clinical practice

•Clinical pathways define key processes and patient goals in the day-to-day management of care •Clinical practice guidelines guide broader decision making and focus on decisions made in performing a procedure or service

Health policy development

•Complex, dynamic process •Involves numerous individuals •Involves Executive, Legislative & Judicial branches of the government

contribute

•Contribute to reduced complications, reduced length of stay, and improved quality

2. coordinating and communicating (budgeting)

•Coordinating and communicating are essential functions of budgeting •Many different groups within an organization come together to discuss the resources necessary to accomplish the goals of a business unit •Provide opportunity for individuals from various parts of the organization (e.g., finance, nursing) to discuss concerns and resolve issues critical when funding new programs and services -negotiating and revising budgets about how costs are allocated

Primary commonality of managed care is to oversee the use of health services

•Coverage may be denied (in contrast to the previous "if it might help, do it" approach) •Goal is to minimize payment for inappropriate or excessive health services

clinical pathways

•Delineates a predetermined written plan of care for a particular health problem •Specifies desired outcomes and the interdisciplinary intervention required within a specified period for a particular diagnosis or health problem •Written to address common medical diagnoses such as heart failure and pneumonia, common nursing care needs such as immobility, and medical complications such as weaning from mechanical ventilation

Nursing care delivery model

•Detail how task assignments, responsibility, and authority are structured to accomplish patient care •Describe which health care worker is going to perform what tasks, who is responsible, and who has the authority to make decisions •Basic premise is that the number and type of caregivers are closely matched to patient care needs in a cost-effective manner

variance (3. monitoring progress)

•Difference between planned budget and actual results •A variance is favorable when the results are better than expected •A variance is unfavorable when the results are worse than expected •preferred results compared to the actual performance •budget amount was greater than the amount spend (favorable) •negative- budget was less than the amount spent •respond with plan to modify expenses •shifts in variances may not be avoidable or always bad

primary nursing model advantages

•Direct patient care provided by a small number of nurses allows for high-quality, holistic patient care •Patient able to establish a rapport with the primary nurse, and patient satisfaction is enhanced •Job satisfaction high because nurses are able to practice with a high degree of autonomy and feel challenged and rewarded

Summary Health Policy: Nurses' Role

•Educate politicians and know your data! •Politicians tend to actively support children's needs. •Use our voice, even if it is only one. •Consult with children and parents about their needs. •Other countries take parents and children to parliament to tell legislators what is needed. •Policy formation is slow and takes time to consult thoroughly and know with whom to consult. Nurses must understand how policy informs practice and how our practice informs policy

engage in

•Engage in robust evidence-based practice programs that will lead to increased quality and lower costs

ensure

•Ensure appropriate discharge instructions and proper follow-up to reduce costly readmissions patient teaching*, discharge instructions to follow through and heal

incremental budgeting pro/con

•Extremely efficient and effective when applied to a well-run department that supports organizational goals •Primary weakness: does not take into account significant changes that may need to be made within a department •Perpetuates current operating assumptions, whether they are correct or incorrect •Problematic when departments are not well run or require significant change to support organizational goals •Does not address past mistakes that have been incorporated into the budgeting process disadvantages: - that activities will continue the same way - little incentive to reduce cost- spend or lose the money next year

capital budget

•Funds allocated for construction projects and major equipment •Main requirement for a purchase/acquisition to be considered part of the capital budget: - Useful life expectancy of longer than 1 year - Cost more than a minimum dollar amount established by the organization, usually from $500 to $2000 •Capital: funds used to purchase long-term investments •Capital assets are treated differently from the operating budget expense because of their multiyear value •Capital purchases are often considered investments and are carefully scrutinized during the budgeting process •Planning capital budget requests will test the nurse manager's long-range planning skills •The unit or department need for capital purchases must be weighed against financial implications when a request is made for a portion of the organization's annual capital budget •Capital expenditures necessary for ensuring patient safety should be addressed with urgency

Public insurance: Medicare and Medicaid

•Government is the biggest influence in the health insurance market, generating 50% of hospital revenues and 25% of physician incomes Medicare: •Largest health insurance program in the United States •Entitlement program based on age or disability criteria rather than on need •Part A covers inpatient hospital services, skilled nursing facilities (SNFs), and home health benefits •Part B covers physician services •Part D provides a prescription medication benefit

Influences on the Type of Nursing Care Delivery Model Used

•Health Care Setting •Acute care •Long-term care •Ambulatory care •Home care and hospice •Organizational structure and resources •Management structure •Staffing resources •Supply resources •Physical layout of the facility •Patient needs •Acute •Long-term/chronic •Staff availability, skills, and competencies

Health policy and ACEs

•Health Policy to impact support of non-pharmaceutical treatments at affordable costs. •Law and policy to advocate how we work with children "Children are our future, yet they are also our present" •Law and policy across governments globally •Policy and funding (examine state budgets) •Policy determines: •Our practice •Resources available •Who is part of the team •Relative values •Reflection of how politicians view the needs of others

Managed care

•Health maintenance organizations (HMOs) •Preferred provider organizations (PPOs) •Point-of-service plan (POS) •The insurance company, a peer review organization, or another review mechanism evaluates patient's medical options and brings cost consciousness to bear on medical decision making

managed care examples

•Health maintenance organizations (HMOs) •Preferred provider organizations (PPOs) •Point-of-service plan (POS) •The insurance company, a peer review organization, or another review mechanism evaluates patient's medical options and brings cost consciousness to bear on medical decision making

Value-based purchasing (VBP)

•Hospital reimbursement for VBP based on: 1. Patient experience of care: based on the hospital's scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), standardized patient satisfaction survey 2. Clinical processes of care: examples include discharge instructions for heart failure patients, fibrinolytic therapy received with 30 minutes of hospital arrival for a patient with acute myocardial infarction

identify

•Identify the most cost-effective medical-surgical supplies that can replace more expensive products bargain brand vs name brand; materials management department

primary nursing model disadvantages

•Implementation may be difficult because primary nurse is required to practice with a high degree of responsibility and autonomy •Inadequately prepared primary nurse may not be able to make the necessary clinical decisions or to communicate effectively with the health care team •RN may not be willing to accept 24-hour responsibility as required •Number of RNs required for this method of care may not be cost-effective and may be difficult to recruit and train

medicaid

•Joint federal-state program to provide health insurance coverage for impoverished families •Covers primarily disabled persons, low-income households with children, and those in nursing homes who qualify on the basis of low income •Primary payer of long-term care nationwide •For most states, Medicaid represents the fastest growing component in the state budget

private insurance

•Largest percent of coverage for health care •Cost of health insurance to employees passed on by the employer to the consumer •Everyone pays part of the country's health care cost in every purchase made •Individuals also pay a portion of their health care directly through payments for insurance premiums, deductibles, and copayments •With managed care products such as HMOs and PPOs, the premium the consumer pays for coverage has continued to rise

Legislative and Health Policy Development

•Legislative process fundamental to movement from public problem to viable program. •Analysis of issues for potential policy development •Steps in the legislative process: -Introduction and action -Complex process legislation to become a law

productivity metric (labor budget)

•Low productivity (high nursing hours worked/low patient care provided) not desirable; it means higher staff salaries combined with lower revenues for patient care services •High productivity (high patient care provided with low nursing hours) means that the staff may be overworked and not be able to provide safe and quality patient care daily and annual planning basis workload calculations to determine workload productivity- working hours per patient in a day ratio of nursing staff to total number of patients (monthly or weekly basis) - want in the middle productivity - low means higher staff salaries with lower revenues for patient care - high may mean the staff is overworked and it may not be safe

National Hospital Quality Measures

•Measures are being used along with patient satisfaction scores and other select clinical measures "pay for performance" •Goal is to move health care payments away from simply paying for the provision of services to paying based on the quality process and outcomes associated with those services •Mandatory measures •Discretionary measures

Nurse Involvement: Examples of ANA's Policy Issues

•Medicare and Medicaid reform •APRN direct reimbursement •Safe workplaces •Safe patient handling •Patients' rights •Whistle-blower protection •Access to health care •Comprehensive health care reform

HMO (Health Maintenance Organization)

•Member (covered individual) pays a premium •There is a a fixed copayment •Member must select a primary care physician approved by the HMO •Member must be referred for treatments, specialists, and services by the primary care physician •Services outside of "network" must be preapproved for payment •Plan may refuse to pay for services not recommended by primary care physician •Plan encourages use of preventive care

PPO (Preferred Provider Organization)

•Member (covered individual) pays a premium for a fixed percentage of expense covered •Plan includes deductible and copayment •Member may select physician, but pays less for physicians and facilities on the plan's preferred list •Plan may or may not pay for preventive care

fee-for-service plan

•Member (covered individual) pays a premium for a fixed percentage of expenses covered •Plan includes deductible and copayment •Allows member to choose physician and specialists without restraint •May cover only usual or reasonable and customary charges for treatment and services, with member responsible for charges above that payment •Plan may or may not pay for preventive care - contributed to increased costs •The more tests or procedures performed, the greater the physician's earnings because earnings tied to procedures •Economic incentives to provide as much care as possible •Patients insulated from costs because insurance was paying the bill

patient centered care methods

•Methods to engage patients, families, and significant others as partners in care •Include them in developing care plans and discharge plans •Include them in change-of-shift or handoff reports •Provide them with the information and education needed to make informed decisions •Establish "family advisory councils" to engage patients and families in decision making

modular nursing model

•Modification of team nursing •Patient unit divided into modules; same team of caregivers assigned consistently to same geographic location •Each location or module has RN as team leader •Goal is to increase the involvement of the RN in planning and coordinating care •Designated modules should contain all the supplies needed by the staff to maximize efficiency

incremental budgeting

•Most commonly used budgeting method, primarily because it is relatively simple to apply to most circumstances •Forward trend of current or recent performance with adjustments for future growth or decline in revenues or expenses •Primary strength is its simplicity •It is relatively easy to take current revenues or expenses and assume a small inflationary or growth factor •Compatible with most corporate organizational practices (*based on actual costs from previous budget year with adjustment increases for salaries and supplying*) advantages- stable, change is very gradual, managers can operate units on consistent basis and easier to coordinate budgets

newer models of case management

•Newer models are emerging because of health care reform and the need to move patients to less costly home and community care settings -transitional care RN - patient navigators

Federal policy that shaped nursing practice

•Nurse practice acts and registration of nurses (implemented in most states by 1910) •Sheppard-Towner Act (1921) •Hill-Burton Act (1950) •Medicare program (1965) •Renal disease program (1972) •Diagnosis-related groups (DRGs) (1983)

National Database of Nursing Quality Indicators (NDNQI) examples

•Nursing hours per patient-day •Staff mix (RNs, LPNs/LVNs, UAP) •Hospital-acquired pressure ulcers •Patient falls/injury resulting from falls •Nurse staff satisfaction/RN survey •RN education and certification •Nurse turnover •Nosocomial infections

POS (point of service)

•Offered by HMO or FFS •Allows use of providers outside the plan's preferred list or network, but requires higher premiums and copayments for services

Rapid expansion of managed care in response to numerous factors

•Overuse of medical care and resources •Effects of employers' health costs on business profits •International competitiveness

essential components of clinical pathways

•Physical assessment guidelines •Laboratory and diagnostic tests •Medications and procedures •Safety and self-care activities •Nutrition •Patient and family education needs •Discharge planning •May address triggers—potential or actual variations in the patient's response to the planned interventions

Themes that have driven health care financing

•Physician was primarily responsible for decision making - Physicians controlled access to health care services - Tests or procedures were provided if physician determined that any marginal benefit might be obtained •Objective was to provide the best care to everyone •Sophistication and cost of medical technology rapidly increased

QI Method: PDSA

•Plan - Plan the change & analyze current data; predict results. •Do - Do it: execute the plan. •Study - Study (analyze) new data and check the results •Act - Act: take action to sustain the gains. Unlike EBP; QI typically does not require extensive literature reviews and rigorous critical appraisal. Therefore, nurses may be much more involved in QI projects than EBP or research studies.

The Four Budgeting Basics

•Planning •Coordinating and communicating •Monitoring progress •Evaluating performance

prevent

•Prevent hospital-acquired conditions, such as injuries from falls and hospital-acquired infections

evaluate

•Proactively evaluate staffing patterns and care delivery models along with delegating non-nursing tasks to ancillary personnel keys to enhancing healthcare value; based on how well the processes are impacting pt safety, outcome, and costs

Policy: The IOM Future of Nursing Report

•Report calling attention to the essentiality of nursing in reforming the health care system •Four major recommendations: 1. Nurses should practice to the full extent of their education and training 2. Nurses should achieve higher levels of education and training through an improved education system 3. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care 4. Effective workforce planning and policymaking require better data collection and information infrastructure

Operational Budget

•Represents revenues and expenses for an operational unit, such as product line, unit, department, overall organization •Expenses in the operational budget are those necessary to operate on a daily basis 1. Salaries 2. Utilities 3. Equipment maintenance 4. Patient care supplies •Revenues in the operational budget are those paid to the organization from: 1. health insurance companies 2. Medicare and Medicaid 3. patients' out-of-pocket payments 4. other government programs or grants

Research, EBP, & QI

•Research applies a methodology (quantitative or qualitative) to develop new knowledge. •EBP seeks and applies the best clinical evidence (often from research) toward making patient-care decisions. •QI uses systematic processes to improve site specific patient outcomes.

staffing and patient needs

•Research validates contribution of RNs to improved patient outcomes and prevention of premature mortality •Primary considerations for staffing a nursing unit - Number of patients - Intensity of care required - Staff experience and preparation - Geography of the environment - Available technology •Patient classification systems - Categorize patients according to care needs (acuity level) - Higher acuity levels mean that nursing care needs are more intense

Staffing and Staff Satisfaction

•Satisfied nurses generally provide higher quality, more cost-effective care •24 hours/day, 365 days/year staffing needs make meeting the nurse's personal needs difficult •Creative staffing options are available to meet varied needs of staff members •Methods to gain staff input about staffing and to enhance autonomy are the key to staff satisfaction

level of staff preparation and experience

•Staff members must have the educational preparation, skill, and experience necessary to meet patient care needs •Ideally, clinical support from experienced RNs should be available to support RNs and other staff members with less experience •Concerns about inadequate numbers of appropriately skilled and experienced staff should be addressed with the next level managers

zero based budgeting pro/con

•Strengths and weaknesses essentially mirror the incremental approach: 1. Does not build on previous/incorrect assumptions 2. Complexity of the process yields a number of beneficial results 3. Encourages clinical and financial personnel to work closely together in developing a budget because neither group will have all of the information necessary to complete the task 4. Approach is extremely time-consuming and resource intensive 5. Requires that a common frame of reference be shared by all participants to be truly effective 6. A well-run organization that is not undergoing significant change may find this approach to be far more resource intensive relative to the marginal improvement it would yield

labor budget

•Subset of the operational budget •Purpose: provide detailed documentation of salaries, wages, and benefits with respect to operational unit •Factors that affect the labor budget: salary rates, overtime, benefits (e.g., paid time off, health insurance), staff development and training, and employee turnover •Largest expense item in an operational budget for a health care organization—typically 55-65% of total expenses •Used to provide managers with a productivity metric - Productivity metric necessary to give managers a measurement of number of hours worked in comparison with amount of patient care provided

nursing case management model cont.

•Supplemental form of nursing care that does not replace the nursing care delivery model already in place to provide direct patient care •RN case manager assumes a planning and evaluative role and usually is not responsible for direct care duties •Case management is generally reserved for the chronically ill; the seriously ill or injured; and long-term, high-cost cases

Fee-for-service payment and economic incentives contributed to increased costs

•The more tests or procedures performed, the greater the physician's earnings because earnings tied to procedures •Economic incentives to provide as much care as possible •Patients insulated from costs because insurance was paying the bill

Nursing Care Delivery Models

•Total patient care •Functional nursing •Team nursing •Primary nursing •Variations of these classics have been adopted to improve quality and cost-effectiveness of patient care

zero based budgeting

•Used far less frequently than incremental budgeting •Builds a budget from the assumption of no volume and no resources allocated; it is developed as though the budget were being prepared for the first time •Each budget cycle begins with a critical review of budget assumptions and proposed revenues and expenditures (difficult to follow because there is nothing to base it on)

3. monitoring progress (budgeting)

•Vital function of the budget •Nurse manager will be most involved with monitoring on a daily basis • *Through comparison of actual performance against expected, or budgeted, performance, an organization measures the effectiveness of its budget* - monthly monitoring may help see where the unit is at with the budget (within limits, over budget) - decrease in census, increase in staffing, increase in patient acuity (over budget) - pt census (24 hr period over midnight) •Variance

Health Policy and ACEs in the United States

•Washington State first to enact legislation at preventing ACEs •House Bill 1965 (June 2011) •House Bill 1965: Primary Prevention of Child Maltreatment and Community Engagement to Improve Public Health •Primary Prevention: fund for EBP home visiting programs; Trust Fund to prevent and reduce maternal depression; Philanthropic agencies - "Thrive by Five"(maximize quality child care & learning opportunities) •Community Engagement: engage residents in reviewing data and taking action to reduce population rates of child-abuse, neglect, youth violence and substance use, teen pregnancy, teen suicide, school dropouts, and domestic violence.

patient navigators (newer model)

•help people "navigate" the complex health care system (physicians, clinics, hospitals, outpatient centers, insurance and payment systems, patient-support organizations, etc.)

Indirect costs or overhead

•incurred as a result of the organization's operating expenses but not directly related to providing the unit-of-service salaries for security/housekeeping, adjunct services that are necessary

public health policy

•refers to local, state, and federal legislation; regulation; and court rulings that govern the behavior of individuals and organizations in the provision of health care services. - also refers to resource allocation related to coverage and reimbursement for health services Example: Mandatory licensure to practice professional nursing