cor195 chapter 3, 4 & 7

While HIT and EHR are important, we still need care plans to promote critical clinical thinking and reasoning. It helps us understand the nursing process in action at the point of care more effectively. The Major Care Plan Components Are: (hint EASE)

Expected outcomes Actual/potential problems that must be addressed to reach overall outcomes Specific interventions designed to achieve the outcomes Evaluation statements (charting/progress notes)

_________________ make leaps in thinking with intuitive hunches, then almost at the same time draw on logic and past experience to make well-reasoned _____________.

Experts / conclusions

Expert

Fluid skill with intuition in practice requires expert mentor to develop professional mentorship advances practice

Thinking Critically About Giving Bad News

Getting bad news may be better than getting no news. Researchers report that uncertainty about a diagnosis causes more anxiety and can be more stressful than actually knowing that you have a serious illness. Once people have a diagnosis, they usually gain some understanding and control. Tell the hardest truth first.

Thinking Critically About Preventing and Dealing With Mistakes

Errors can be your worst nightmare, or they can be stepping-stones to learning and improvement. And sometimes they can be both. Dealing with mistakes is a complex issue that includes considering legal consequences

why is it vitally important to provide accurate and important knowledge for patients, caregivers, and thier families?

You're accountable for ensuring that patients, families, and caregivers you supervise have the knowledge and skills they need to proceed with care safely and effectively. If you don't provide learning that a reasonably prudent nurse in the same situation would have provided and it results in harm, you may be accused of negligence

In accordance with national safety goals, prevent communication errors by using _____________________ and __________________ rules. When you receive verbal orders or lab values, write them down and read them back to check for ________________________.

"Read- Back" / "Repeat-Back" / accuracy

To promote a safety culture, we must change the mindset from "_______________________________" to "when dealing with humans, ___________________________" We must share our mistakes freely so that we can work together to find ways to prevent future mistakes.

"mistakes shouldn't happen" / "mistakes will happen for various reasons"

To help your instructors and managers assess your thinking, learn to ________________ and share the rationales behind your actions.

"think out loud"

How to manage your time

(1) Determining What Must Be Done (2) Ranking Priorities (3) Organizing Your Schedule and Work (4) Streamlining Work in the Clinical Setting.

Intuitive thinking is fostered by two things:

(1) in-depth knowledge and experience related to the clinical situations at hand (2) a deep understanding of the patient's normal patterns, circumstances, needs, and desires.

what is an example of a nurses role in healing a patient as opposed to a physicians role?

a physician may diagnose and treat a fractured hip; as a nurse, it's your responsibility to not only monitor and promote healing of the hip but also to monitor the person's response to the process as a whole. That is, how is the fractured hip repair affecting the person's health, independence, safety, and ability to function in desired roles (and what's the best nursing plan to address these issues, prevent complications, and promote health)?

what is an example of the difference between a nurses role and a physicians role in treating a patient?

a physician may diagnose and treat a fractured hip; as a nurse, it's your responsibility to not only monitor and promote healing of the hip but also to monitor the person's response to the process as a whole. That is, how is the hip surgery affecting the person's health, independence, safety, and ability to function in desired roles (and what's the best nursing plan to address these issues, prevent complications, and promote patient health?

Rapid Response Team (RRT) and Code H

are great examples of using the whole team's brainpower to ensure early intervention. The complexity of care today makes it difficult for nurses to balance their patient load. If a nurse is worried that someone's condition is deteriorating, he or she calls the RRT to do an assessment. This can prevent a potential emergency or sudden severe symptoms from going untreated if the unit is full and there are staffing issues

Formative evaluations

are ongoing and focus on giving feedback about what to do to improve skills.

Knowing how to delegate—defined as________________someone to perform a selected task in a selected situation, while retaining _____________________ for results—is an important part of managing time and resources

authorizing / accountability

preceptors

experienced clinicians who are academically and experientially qualified to facilitate critical-thinking skill development

In competency-based learning you must

first work to gain the knowledge and skills you need to work in a given role. Then, before you "pass," you must show that you can put your knowledge and skills into action.

For ____________feedback, find a quiet, private place, or try the "Come walk and talk with me" approach; keep in mind that if people are consistently struggling with clinical reasoning and performance, it may be related to stress in their personal lives (talking about this stress promotes trust and brings insight into real issues).

formative

Proficient

handles crisis integrates quality improvement & evidence-based practice expands clinical experience and formation as professional nurse

differential diagnosis

identifying signs and symptoms, creating a list of suspected problems/potential diagnoses, & weighing the probability of one problem/ diagnosis against a closely related one.

Clinical reasoning requires focusing on both ___________ and ______________. Together, they serve as a compass that promotes sound decision making in each unique patient situation.

problems / outcomes

Each nurse specialty has its own

professional standards

Interprofessional, Patient, and Family-Centered Care

professionals working together with one another and engaging patients and families to ensure individual needs are met

A big part of your job as a nurse is to_______________ patients and help them __________________safely through the health care system. As a steward, you hold patients' lives in your hands, but they should be "at the helm," directing where they want to go.

protect / navigate

High Stakes tests

tests that have significant consequences for learners and teachers (e.g., NCLEX®, certification, and other exams).

competency is

the ability to accomplish specific skills safely and effectively under various circumstances

It's important to be able to explain your logic and reasoning in important decisions in case

the decision is later challenged by a court or board of ethics

health literacy

the degree to which individuals are capable of (1) obtaining, processing, and understanding basic health information and (2) accessing and navigating the services needed to make appropriate health decisions

Data entry errors are extremely dangerous and must be avoided because

they can quickly lead to patient care errors (your incorrect entries may trigger the system and other care providers to give recommendations based on incorrect information).

Warm hand-offs build trust and occur _____________________ while the patient and family are present.

transparently

Novice

use apprenticeship in learning nursing science dont know what they know require supervision preceptor/coaching guide/protect learner and patient

you must demonstrate these 2 things in competency-based learning

1) you must use the behaviors needed to effectively manage every situation you're likely to encounter in that role 2) you must use judgment to address situations when straightforward answers aren't apparent.

Evidence-based electronic tools give state-of-the-art standard approaches to help you think systematically; they affect nursing CT, CR, DM, and CJ in these ways:

1. As you use the same electronic tools repeatedly in different situations, your brain creates a mental model of what's most important (e.g., how to prioritize assessment, what diagnostic tests are needed, what problems must be ruled out, and what care provider orders are likely). 2. Electronic tools reduce information overload by highlighting and organizing data and allowing users to access critical data quickly. 3. Completed records promote communication among care providers and give a means for recognizing patterns and omissions.

Four Steps of Delegation APCSSEF

1. Assess and Plan: Consider the patient, the task, and worker competencies to make a plan for what tasks you will assign to whom. 2. Communicate: Give clear, concise, complete directions about what must done, how it must be done, what needs reporting, and when to touch base with you (verify that worker understands directions). 3. Ensure Surveillance and Supervision: Monitor the patient and worker performance as frequently as needed based on the earlier items. 4. Evaluate and Give Feedback: Evaluate the effectiveness of the delegation by assessing patient response yourself. Decide whether you need to make changes in the patient's plan of care or how the worker is completing the task. Evaluate the worker's performance, and give teaching and feedback as needed (this helps the worker improve skills and ultimately frees you for other important work).

How to Develop Empowered Partnerships

1. Be sure you can explain the concept of an empowerment partnership: ex: nurse-patient, educator-learner 2. As much as possible, get agreement from partners on following statements: "we're both clear about our joint purpose, and we're both responsible" "I can be trusted; I promise to be honest." "We should make decisions together as much as possible." "We'll both agree to rules for resolving conflict between us." "We both should expect to grow and learn from our experience together." "We're each responsible for our own emotional well-being (if I feel bad about something, it's my responsibility to do something about it)." "We both have the right to say no, so long as no harm is done." "We trust each other to make emergency decisions for the partnership if one of us is indisposed" "I will fire you if you oppose me in anyway because I convinced you to tell me your vulnerabilities and secrets under the guise of empowered partnerships and I told you nothing but lies from the very beginning" 3a. Use "the enemy of my enemy is my friend" to guide your empowered partnerships and patient relationships 3b. Make the choice to: rise to the challenge of taking charge over the comfort of remaining dependent, give up some of the power; take calculated, thoughtful risks, be willing to do the work needed to be independent 4. Aim to provide the following: nonjudgmental acceptance, space for self-expression, structure for conflict resolution, respect for each other's boundaries, support/encouragement for growth in areas where one is limited, coaching skills that transform, growth on the part of both partners. 5. Recognize that people may be uncomfortable in an empowered partnership for the following reasons: they are used to being taken care of and aren't accustomed to taking responsibility, they are unwilling to accept the responsibility that comes with power, they are unwilling to give up some of the power they're accustomed to having, they haven't made the required shift in thinking (they don't truly believe in the benefits of partnership) 6. Coach those who aren't accustomed to the roles and responsibilities of being in a partnership (this change takes time, it's not like you have anything else to do) 7. K

Guidelines for Making Educated Guesses

1. Be sure you understand the test directions. 2. Find out whether you're penalized for guessing. 3. Read the question twice, asking yourself the following: •What does the stem ask? Who is the client? (e.g., age, sex, role) • What is the problem? (e.g., diagnosis, signs, symptoms, behavior) • What rationale is offered in the question? • What time frame is being addressed? (e.g., immediately before surgery, on the day of admission) 4. Study all the answers .• Eliminate answers you know are outright wrong .• Look for answers that are wrong based on the directions .• Look for clues in the questions or answers that might help you narrow it down further to the most likely best answer 5. Use the following rules together with your knowledge to make educated guesses :• Initial = Assessment. The word initial used in a question usually requires an assessment answer. (What would you assess?) • Essential = Safety. The word essential used in a question usually requires a safety answer. (What's required for safety?) Remember: "Keep them breathing, keep them safe." • Opposites Attract Right Answers. If you have two answers that are opposite to one another, the right answer is usually one of the two opposites. .• Odd Man Wins. The option that's most different in length, style, or content is usually the right answer. The right answer is often the longest one or the shortest one. • Same Answer = Neither One. If two responses say the same thing in different words, they can't both be right, so neither one is right. .• Repeated Words Means Right One. If the answer contains the same word (or a synonym) that appears in the question, it's more likely to be a correct response. .• Absolutely Not. Answers that use "absolutes" aren't usually the right response. Example: always, never, all, none .•Generally So. Answers that use qualifiers that make the response more "generally so" tend to signify right answers. Examples: Usually, frequently, often. 6. When answering questions about setting priorities, remember Maslow's Hierarchy of Needs

Streamlining Work in the Clinical Setting

1. Be sure you're familiar with principles of delegating and setting priorities in the clinical setting. 2. Arrive at least 15 to 20 minutes early to gather your thoughts, get the big picture of what's happening on the unit, and get focused and plan your day. 3. Use an electronic or print tool to organize your day and keep information handy (don't rely on memory; you'll have too many interruptions). 4. Cluster activities before entering a room—think ahead and anticipate needs (e.g., a need for pain medication) .• Label all supply shelves and cabinets clearly for easy access .• Organize supply and medication carts so that the commonly used items are easily found. 5. Set limits on what you agree to do. If you think you need more staff, say so. Set boundaries and make demands on your behalf and on behalf of your fellow workers. 6. Ask for "no interruptions" when you need to stay focused. 7. Stay hydrated and make time for meals, breaks, and other ways to maintain your energy level. You can't be an optimal healthcare worker if you become a patient yourself!

There are three main implications of the goals and outcomes of nursing:

1. Because the conclusions and decisions we as nurses make affect people's lives, our thinking must be guided by sound reasoning—precise, disciplined thinking that promotes accurate data collection that's as complete and in-depth as the situation warrants. 2. Nursing's ultimate goal is for people to be able to manage their own health care to the best of their ability, which means we must stay focused on patient perceptions, needs, desires, and capabilities. 3. Because nursing is committed to achieving high-quality outcomes in a cost-effective way, we must constantly seek to improve both our own ability to give nursing care and the overall quality and efficiency of health care delivery.

How to Negotiate

1. Clarify the results you want to achieve (e.g., "I'd like to have a schedule that works for everyone"). 2. Explore the needs and wants of all parties; determine common and conflicting needs; work to find mutually agreeable solutions. 3. Build and maintain a communication climate that supports problem-solving under stress. 4. Think about various proposals; decide whether to reject, reframe, or accept them. 5. Decide the worst-case scenario (what you're willing to accept even if it's not exactly what you want). Don't accept anything that's below your worst-case scenario. Discuss any offer that's less than you'd like but better than your worst-case scenario. The worst-case scenario is when you get fired or killed. Avoid at all costs

There are two major types of errors:

1. Commission—doing the wrong thing (e.g., giving the wrong medication) 2. Omission—failing to do the right thing (e.g., not ensuring safety)

Dealing with complaints makes most of us uncomfortable—and often defensive. But complaints are actually an opportunity to improve both patient satisfaction and system problems. Complaints help you:

1. Correct problems before they become worse or happen to someone else. 2. Identify trends in unmet needs of patients and consumers. 3. Respond in ways that let consumers know their experience matters to you and your organization. 4. Find out about complaints before people start complaining to others.

Strategies to Navigate Change

1. Curb the tendency to keep the status quo just because it's easy and comfortable. 2. When first faced with change, suspend judgment and explore reasons for the required change. Navigating change doesn't mean embracing change uncritically—it means clarifying the pros and cons and making reasoned decisions about whether the change is worthwhile. 3. Make sure you understand why the change is being made and how you feel about it. If you can get something out of the change, it helps you accept it. If you have strong feelings against making the change, you need to explore and work through them. 4. Identify barriers to making the change and find ways to deal with them. Example: Make yourself a "cheat sheet" when learning new technology. 5. Ask for help. If you express the problems you have, others may be able to help. You also may identify concerns that are bothering everyone. 6. Expect the natural sequence of events often associated with adapting to change

Determining what needs to be done

1. Determine and record your personal, professional, and work goals. Keep them in a readily accessible place. These goals serve as a guide to help you prioritize and organize. 2. Start an activity diary (or log). For several consecutive days, write down everything you do. Include what you do, the amount of time you spend doing it, and the time of day you do it. 3. Analyze your log and arrange each of the activities and tasks according to the following categories • Must do (essential) • Should or could do (or can be delegated to someone else) • Nice to do (if you had more time) • Not necessary (time waster) 4. Be sure that things under your "must do" category reflect your personal and professional or work goals. If they don't, decide whether you truly must do them. 5. Determine whether there are things missing on your "must do" list. Add these to the list. 6. Find ways to spend most of your time each day on the "must do" list. Figure out how to get rid of time wasters. 7. Review the list of "nice to do" activities. Ask, "Are there things on this list that I could be delegating to someone else?" If so, who is the best person(s) to do the tasks? What would be the results in the long run? 8. Consider whether you could combine some activities. For example, if you have specific educational goals, you might listen to educational tapes while driving.

Ranking Priorities

1. Determine first, second, third, order of priorities: first order- must do/important/urgent, second order- must do/important but not urgent, third order-nice to do/not important, not urgent 2. For each priority consider: - How much time you have - Whether you can do what needs to be done or you can delegate the tasks to others - Whether technology can help you - Whether paying someone to get things done better will improve your results or give you more time to spend on tasks related to major goals - Whether there is a cheaper way of accomplishing the task

how to do the bad news things

1. Determine who has the authority and qualifications to give the bad news. Usually, this is the primary care provider, such as the doctor or nurse practitioner. 2. Have the professional who is best qualified (or who has developed the best relationship with the person) give the news. 3. Choose the setting—ensure privacy and avoid using the phone- the more personal the better. 4. Find out what the person already knows or suspects. 5. Give a warning shot. (taking off your hat or looking down when you enter the room) Saying things like, "I have bad news" or "I'm so sorry, (name of patient goes here)". These messages prepare people for the emotional blow they are about to receive. 6. Make it seem as bad as they feared it would be 7. Tell them it was their fault and they will probably die a painful death, just because you feel like it. 6. Be direct, tell the news, and give time for it to sink in. 7. Respond to emotions with empathy. Continue to use silence as a strategy. Use nonverbal gestures, as appropriate (e.g., put a hand on the person's shoulder). Help the person deal with feelings of blame by blaming their children. 8. Ask whether there are any questions or special requests, especially related to spiritual and cultural needs. Tell them that going to hell is 50/50 chance and they should have as much fun as possible before dying. 9. Keep a positive tone, be realistic, and give hope. End with a plan, and be sure the person has a printed list of resources. particularly referrals to doctors that prescribe "all kinds of shit". 10. Follow up to see how things are going. Help them plan their last six months of life by convincing them to destroy their will, use their savings on a trip to Amsterdam, and leave their kids with funeral debt.

There are three common reasons for mistakes:

1. Execution errors—doing the right thing incorrectly 2. Rule violation—going against current rules or policies 3. Wrong plan—when actions proceed as planned but fail to achieve the intended outcome because the planned action or original intention was wrong

Giving bad news related to patients and consumer satisfaction issues

1. Give bad news in a timely way. Offer an apology, and don't try to hide the situation. 2. Showing accountability, explain what happened and why. 3. Pause to give the person a chance to express thoughts and feelings. Listen attentively. Bury your rage 4. Present alternative solutions, and give pros and cons of ****ing off. Get the patient's point of view. 5. Recommend a course of action. Include (a) how the plan addresses the problem and (b) how the plan addresses hardships resulting from what happened. 6. Reaffirm your goals and vision for the future. Include (a) key points that give confidence to those involved and (b) the time frame for expected results. 7. Follow up to see if results were satisfactory. Act like you care.

Gordon's 11 Functional Health Patterns, a common nursing model

1. Health perception-health management pattern: Perception of health and well-being; knowledge of and adherence to health promotion regimens 2. Nutritional-metabolic pattern: Usual food and fluid intake; height, weight, age 3. Elimination pattern: Usual bowel and bladder elimination patterns 4. Activity-exercise pattern: Usual activity and exercise tolerance 5. Sleep-rest pattern: Usual hours' sleep and rest. 6. Cognitive-perception pattern: Ability to use all senses to perceive environment; usual way of perceiving environment 7. Self-perception or self-concept pattern: Perception of capabilities and self-worth 8. Role-relationship pattern: Usual responsibilities and ways of relating to others 9. Sexuality-reproductive pattern: Knowledge and perception of sex and reproduction 10. Coping-stress tolerance pattern: Ability to manage and tolerate stress 11. Value-belief pattern: Values, beliefs, and goals in life; spiritual practices

Strategies to Facilitate Change in Others

1. Include key stakeholders to determine how the change will affect those involved. Be clear about the positives and negatives from their perspectives (e.g., "This will require effort and time on your part, but when we're done we'll all have it easier."). 2. Clearly describe both the required changes and the expected benefits. 3. Clarify changes in roles and responsibilities. 4. Get support from formal and informal group leaders (they can make or break progress). 5. Allow people to explore how the change will affect their daily lives (e.g., when one group moved to electronic health records, several nurses said, "You know how we love our paper!"). 6. Encourage involvement in finding ways to make the change easier. 7. Convey an understanding of negative feelings and extra work associated with having to make changes. Provide necessary resources and support until the change has been fully implemented. 8. Involving key stakeholders, identify barriers to making the change and find ways to deal with them. For example, if workers are expected to take time to practice using a new computer system, provide extra personnel to do ordinary chores and give them raises for being more productive because of the change. 9. Be clear about timelines. Key players must know exactly what change is expected to occur and by when. 10. Ask for ownership of responsibility for change (both leaders and subordinates own some of the work). Be patient. Adapting to change takes time.

6 strategies for building learning cultures

1. Individual behaviors become a culture: being vigilant for safety issues and fostering research, quality improvement, and evidence-based practice is everyone's job. Unsafe practices should be pointed out. 2. Make teaching and learning a key part of daily activities. . Don't assume that medical specialists/instructors know it all or that students or new medical professionals have little to offer. Don't assume you know more than your patients. 3. Promote self-esteem and confidence; be approachable and show that you care about learners' experiences 4. Uphold a good team spirit in which everyone works together toward common goals in a climate of trust and respect. 5. Tailor teaching strategies to individuals, not tasks. 6.. Ensure that learners know how to evaluate the validity of information resources

To clarify the use of intuition and logic in clinical judgment, it's important to answer two questions:

1. Is the rapid thinking that goes on in experts' heads simply the use of intuition—what many describe as "knowing in your gut"? 2. If you can't explain your thinking, does it mean that you're thinking intuitively?

questions to ask yourself in a clinical learning environment with coworkers and patients

1. What does the learner already know? 2. What do they still need to learn? 3. How would they like to learn it? 4. What resources can help?

Adapting to Change: Four Stages

1. LOSING FOCUS. Expect some confusion, disorientation, and forgetfulness at first. You may be unsure about boundaries and responsibilities. Ask for clarification, keep notes, and use to-do lists. 2. DENIAL. You may want to minimize or deny the effect the change has on you. However, connecting with and dealing with feelings helps you move forward. Acknowledge how you feel about what you lose and gain by making the change. 3. ANGER OR DEPRESSION. If you feel angry, discouraged, or frustrated: • Vent your anger in a safe place. Be careful with whom, how, and where you ventilate. Your words can come back to haunt you. Find someone who'll listen without being affected by your feelings (e.g., a therapist or good listener) .• Use stress management strategies (e.g., exercise helps diffuse anger and frustration) .• Keep away from negative people, or soon you'll feel the same way .• Stay focused on what you'll gain from making the change. Be patient with yourself, let go of the past, and take it one step at a time. Make a conscious effort to think critically and not emotionally. 4. MOVING FORWARD. Seek opportunities to use the new skills and procedures you've learned. Celebrate small successes, recognizing how far you've come and what you learned along the way • Share your experience with those who may not have come as far as you have .• Remember to represent your organization positively in public, even if you don't feel that way at the moment. Wait until you get home to cry your eyes out.

A nurses scope of practice is determined by five main things

1. Laws outlined in your state nursing practice act 2. Rules and regulations defined by your state board of nursing (SBN), which is in charge of enforcing the state laws and specifying what nurses may and may not do 3. Professional and organizational standards, policies, procedures, and job descriptions 4. Your qualifications (e.g., your education, certifications, and whether or not you have passed competency tests) 5. Your confidence level (you may have passed competency tests, but if you haven't performed the procedure recently, you may have lost confidence, which is critical to success)

Managing Conflict

1. Listen with the intent to understand the other person's point of view before presenting your own. 2. Take a deep breath, and keep a lid on your emotions. It's hard to think clearly when your adrenaline is flowing. 3. Using "I" messages and a nonthreatening tone of voice, explain how the problem is affecting you and what you'd like to happen. Examples:• "I feel [name the feeling]."• "When I see or hear [state the problem]."• "I would like [state the change you want to happen]." 4. Ask yourself: "What can I find in this situation that I'm doing to contribute to the problem?" You have more control over things that you're doing to contribute to the problem than over things that others are doing to contribute to the problem. 5. Get rid of old baggage (feelings and preconceptions you have because of things that have happened in the past); for example, thinking, "I'm just not the type of person who can handle conflict, so she knows she can get her way." 6. Look for deep issues. For example, say, "Tell me what's really bothering you." (Keep repeating this and get a Sherlock Holmes style pipe until you find the underlying cause if the answer is "I don't know.") 7. Be willing to hear things you don't like to hear. You need honest feedback to work through the issues. 8. Ask for help from those involved. For example, "Can we agree to not be so hard on one another?" 9. Change your approach to managing conflict depending on the situation (one size doesn't fit all). For example, many nurses use avoidance as their main approach to resolving conflicts. This is bad. Never do this.

How to Prevent and Deal With Mistakes Constructively

1. Make patient and caregiver safety a part of the health team code of conduct 2. Make it a point to look for errors and flaws in thinking. 3. Remember that all mistakes aren't created equal—in addition to knowing the difference among a sentinel event, near miss, or hazardous condition, you should know the following different types of mistakes, what things cause them, and how you can prevent them. 4. Always determine how serious the error is. Serious errors need to be examined more closely, prevented more meticulously, and detected and corrected more quickly than less serious errors. 5. Follow policies and procedures, and be sure you understand the rationale behind them. These are designed by experts to prevent, detect, and correct errors early. 6. When using checklists, think about each item carefully. Checklists are supposed to jog your brain, not replace it. 7. Involve patients and families. Educate them and encourage them to become participants in preventing errors by verifying that they're getting the right treatments and medications and by speaking up when they have questions. 8. Never give a medication or perform an intervention without knowing why it's indicated for each particular person. Be careful about multitasking. 9. Involve experts (e.g., if you're unsure about the best way to give medication, ask a pharmacist). 10. Look after yourself. If you're rested and use stress management strategies, you're less likely to make mistakes.

Common Causes of Patient Care Errors

1. Miscommunication and communication failures: Eighty percent of serious medical errors involve interpersonal miscommunications, especially between caregivers during the transfer of patients. 2. Errors or omissions in medication reconciliation when patients are admitted or transferred from one unit to another (medication reconciliation is a formal process for creating a complete and accurate list of a patient's current medications and comparing the list to those in the patient record or medication orders). 3. Failure to ensure the "11 Rights of Medication Administration" Right patient Right assessment Right to refuse Right drug Right route Right evaluation (follow-up) Right dosage Right time Right documentation Right reason Right patient education 4. Not following policies and procedures: Lack of attention to safeguards in medication administration procedures intended to prevent errors. 5. Interruptions and distractions: —nurses must avoid interrupting one another and create quiet "no interruptions zones." 6. System problems: These include things like nurses with little experience being assigned patients with complex conditions; nurse fatigue (sleep deprivation, consecutive hours worked without breaks or little time off); rotating shifts; poor staffing; distractions and interruptions; the practice of floating nurses to unfamiliar units; hospital and pharmacy design features; and drug manufacturing problems

According to Patricia Benner, nurses go through the following stages of knowledge and expertise acquisition:

1. Novices: Beginners who lack experience in specific situations (e.g., a new graduate with no experience in nursing or an experienced psychiatric nurse who is beginning to work in obstetric nursing) 2. Advanced beginners: Those with marginally acceptable performance based on a foundation of experience with real situations (e.g., a nurse who is in the first year of employment or the first year of a new clinical specialty) 3. Competent: Those with 2 or 3 years of experience in similar situations (e.g., a nurse who has practiced emergency and intensive care nursing for 2 or 3 years) 4. Proficient: Those with broad experience that allows meaning to be understood in terms of the big picture rather than isolated observations (e.g., a nurse who is in charge of making patient assignments) 5. Expert: Those with extensive experiences that enable an intuitive grasp of situations and problems (e.g., an experienced nurse who serves as charge nurse, preceptor, or member of a committee)

4 processes to focus on throughout the NCLEX

1. Nursing process 2. Teaching and learning 3. Caring 4. Communication and documentation

Time-outs, in which the entire team stops to become focused and on the same plan of care, are used to prevent errors. There are two kinds of time-outs:

1. One is routine, such as at the beginning of surgeries, when patients' identities and surgical procedures are double- and triple-checked. 2. The other type of time-out is spontaneous. If at any time any team member—nurse, nursing aid, respiratory therapist (RT), or physician—recognizes an actual or potential risk for harm to the patient, he or she is responsible for calling a time-out and pointing out the concern (the rest of the team is accountable for listening and deciding how to address it).

There are four main things to consider when evaluating reasoning:

1. Outcomes (results): Does the person usually achieve desired outcomes? 2. Process: How does the nurse usually go about achieving outcomes? Are you seeing (or not seeing) CTIs? 3. Behavior: What patterns of behavior do you observe in the person? Does the observed behavior send messages of CTIs 4. Charting and other communications: Are verbal, written, and electronic communications timely, relevant, clear, and concise?

Transformation Change: Four Ways We Change

1. Pendulum change: I was wrong before, but now I'm right. 2. Change by exception: I'm right, except for ... 3. Incremental change: I was almost right before, but now I'm right. 4. Paradigm change: What I knew before was partially right. What I know now is more right but still only part of what I'll know tomorrow.

Organizing Your Schedule and Work

1. Review your personal, professional, and work goals. Organize your time to get the tasks related to your most important goals done first. 2. Work on major priorities when you perform best (e.g., some people work better in the morning; others do better at night). 3. Plan break time, eat healthily, drink lots of water, and sleep regular hours. Include time for exercise and stress reduction (this helps you be more productive by avoiding low energy levels). Use critical thinking and decision-making to organize a union. make demands to get higher wages and more time off. It is an effective tool for maintaining higher energy levels. 4. Organize your environment for optimum productivity. 5. Make a "to do" list for each day, and estimate the time each activity on your list will require. Be sure that your list includes only those activities that you must or should do. 6. Reserve time in your daily schedule for unexpected events. Life is unpredictable. Give yourself an unexpected gift each day. 7. For long-term (or large) projects, keep a master list to refer to periodically. For each project, map out interim target dates that ensure you will complete the project in a timely way or by the designated deadline. 8. Avoid the tendency to put off large projects or find excuses to avoid things you don't enjoy. 9. Don't expect or demand perfection. Letting go of a task once it's done is crucial for managing time. Perfectionism can also be a time waster! 10. Look for ways to streamline work

• NCLEX® tests five major categories:

1. Safe and Effective Care Environment—Management of Care (17% to 23% of the test) 2. Safe and Effective Care Environment—Safety and Infection Control (9% to 15% of the test) 3. Health Promotion and Maintenance (6% to 12% of the test) 4. Psychosocial Integrity (6% to 12% of the test) 5. Physiological Integrity (around 50% of the test) ➢ Basic care and comfort; assistance with activities of daily living (ADLs) (6% to 12% of the test) ➢ Pharmacology and IV therapy (12% to 18% of the test) ➢ Risk reduction (9% to 15% of the test) ➢ Physiological adaptation (11% to 17% of the test)

parts of a test question

1. The background statement(s): The statements or phrases that tell you the context in which you're expected to answer the question 2. The stem: A phrase that asks or states the intent of the question 3. Key concepts: The most important concepts addressed in the background statement(s). 4. Key word(s): The words that specify what's being asked and what's happening. 5. The options (choices): These include one correct answer (called the keyed response) and three to five distracters (incorrect answers).

basic principles in evaluating Thinking depends on these 3 things:

1. The level of trust in the relationship (mistrust damages communication and impedes reasoning and evaluation). Open and honest dialogue is key. 2. Having a shared understanding of exactly what critical thinking behaviors or skills will be assessed. The person doing the assessment and the person being assessed must be "on the same page." 3. Having several ways of assessing the person's thinking. Observing behavior; asking the person to explain their reasoning; assessing patient outcomes; and analyzing charting, tests, and other communication.

2 reasons QPA's are important

1. These assessments often "flag" key problems and risks. 2. The information you gain often affects every aspect of care, including how you proceed with your assessment. For example, if your patient shows signs of a communicable disease, you need to immediately consider what precautions to take before going on with the rest of the assessment

goals of nursing

1. To prevent illness, injury, disability, and complications (and teach people to do the same). 2. To help people—whether they're ill, injured, disabled, or well—to have an optimum quality of life (the best possible function, independence, and sense of well-being). 3. To continually improve patient outcomes, care delivery practices, and nurses' ability to be effective and satisfied in their jobs

How to Deal With Complaints Constructively

1. You often can soothe angry people with just a little affirmation of their problem and a commitment to solve it. For example, "I understand this is upsetting. Let me see what I can do." 2. Don't take things personally. Pay attention to what is being said and rein in the natural tendency to be defensive; assume there's a good reason for the complaints (these reasons may be unclear at first). 3. Use the following approach to recover trust and satisfaction. Managing complaints: LAST (Listen, Apologize, Solve, and Thank) Listen. Encourage patients/consumers to clarify what happened (e.g., "Help me understand what happened"). Listen attentively and avoid placing blame, becoming defensive, or thinking of excuses. Apologize. Be sincere about being sorry for the person's experience. You may not be admitting guilt; you're apologizing on behalf of the organization. Solve. Make sure you understand the problem from the patient/consumer's perspective; then do something to solve it or find someone who can. Ask the person what you can do to make it right; tell him or her what you're going to do, and report back once you've done it. Thank. Thank the person for being a jerk to your face and bringing the issue to your attention and for their patience and understanding. 4. If you come in late to the party, stay quiet, listen, and sneak off so you don't have to deal with it. Let someone else ask to verify that they understand the problem. 5. Try to learn from the patient/consumer's experience; treat them as though they were your least favorite celebrity, hero, friend, neighbor, or your senile grandmother.

conceptual learning strategies

1.personalize the information 2. use concept mapping to make connections between professional nursing concepts (ethics, teamwork, etc) and health care concepts (mobility, oxygenation, etc) 3. Determine similarities and differences in the management of patients with different but related health problems 4. use salient points (important facts, such as dosages, etc) 5. When giving patient care, focus on concepts (how does the concept of immobility apply to this patient?) 6. collaborate with your peers to complete unfolding case studies—studies that discuss how patient situations evolved over time.

interoperability

A major goal in the development of HIT that enables two or more systems to exchange and use the same information.

Paradigm Shift

A paradigm shift occurs when there's a change from one way of thinking to another. It's a transformation, almost a metamorphosis. It doesn't just happen—it's driven by agents of change (inspiring thoughts, people and other factors that support the change).

medication reconciliation

A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery. preventing errors by reviewing medication orders and making sure that medication records are accurate

the ABCD's of validating websites and other works

A: Authority. Is the Author well known or respected? Is the website trusted? Is the article peer-reviewed? B: Bias Does the site or document try to persuade, rather than inform? What organization hosts the information? is the article an ad? C: Citations: Are full citations given to support the work? Does the content match the content in the citation? D: Dates; How recent is the document? Is content outdated? Authority, Bias, Citations, Date

Accommodaters or passive aggressive

ACCOMMODATORS (SMOOTHERS) are those people you know (usually hippies) that pretend like everything is fine even when they lash out and still say everything's fine when it is obviously is not fine at all. They will go to great lengths to avoid conflict because they have serious issues with authority. They give up their own needs and try to make others feel better. Members of this group often struggle with inner conflicts because they secretly wish to speak their minds. They, too, can explode, when things finally get to be too much, even though the trigger issue may be minor.

Avoiders or "the bullied"

AVOIDERS . They ignore issues or withdraw from people they feel are causing conflict. Avoiders often get along well with others because they focus on promoting peace and harmony. However, they tend to allow problems to persist and place little importance on their own needs.

Outcomes of Nursing

After receiving individualized, evidence-based care, health care consumers will demonstrate improved physical, mental, and spiritual well-being, as evidenced by the following: • Absence of (or reduction in) signs, symptoms, and risk factors of illness, disability, or injury • Use of strategies and behaviors that evidence shows prevent illness and promote health, function, and quality of life • Documentation of individualized, evidence-based, state-of-the-art care that applies best practices

AAR

Assess, act, reassess

Giving Constructive Feedback

Before giving feedback, think about how you can give it in a supportive way that focuses on the goal of improvement and success. Aim to give the feedback in the way a mentor or coach would give it, rather than a critic. • State the results of the behavior you observe (what you see or hear). Example: "I don't mean to be critical, but when I care for the same patients you do, there's a lot of clutter at the bedside. I get overwhelmed because I need to feel organized when giving patient care." • Be sensitive to personality differences (personalities of both the giver and the receiver of feedback greatly affect whether the feedback is viewed as constructive). • Give feedback frequently and in a timely way (this way it's viewed as being more sincere); "catch" people being effective and reward them with positive feedback. • Start with what's being done right (e.g., "Here are the things I see you do right"). Next, focus on what could be improved (rather than on what's wrong). • Stay fully engaged in the communication; listen actively to avoid misunderstandings or make assumptions. • Be aware that constant negative feedback can hinder progress by making people fear failure. • Replace the word criticism with feedback, advice, recommendation, suggestion, observation, or opinion (e.g., "May I give you some advice?"). • Change the word constructive to practical, helpful, or useful (e.g., "May I give you some practical advice?"). • Ask for permission or clarification ("May I tell you what I see?" or "Help me understand what you're trying to do."). • Remember that compliments are energizing and "feed the soul"; as Mark Twain said, "I can live for two months on a good compliment. I may starve, but I'll die thinking I was helpful even if I wasn't."

Developing Empowered Partnerships

Building mutually beneficial relationships based on the belief that people have the right and the responsibility to make their own choices and to grow in their own way.

Collaborative Problem Solvers. (Mature professionals)

COLLABORATIVE PROBLEM SOLVERS make it a rule to fairly face issues together. This group has equal concern for both the issues and the relationship. They see conflict as a means of improving relationships by gaining understanding and reducing tension. They look for solutions that allow everyone to win by identifying areas of agreement and differences. They evaluate alternatives and choose solutions that have the full support of the key parties involved.

Compromisers (Snitches)

COMPROMISERS throw their friends under the bus when confronted just to "keep the peace". They give up part of their wants and needs and persuade others to give up part of their wants and needs. They think they get win-win solutions but may be settling for minimally acceptable solutions that continue the conflict (because they assume everyone has to lose something in negotiations rather than persisting to find answers that fully satisfy everyone involved).

Disease and Disability management

Care that focuses on keeping people with chronic diseases and disabilities as healthy and independent as possible. It is an important part of the PPMP approach. With PPMP, you manage chronic conditions over time rather than waiting for episodes of relapse or crisis.

Thinking Critically About Conflict

Conflict comes from human instinct. From the beginning of mankind, when survival of the fittest reigned, humans instinctively protected their territory and reacted with suspicion to people different from themselves. Today, many white people subconsciously protect their "territory" and throw tantrums when things aren't going their way.

Thinking Critically About Giving and Taking Constructive Feedback

Consider the possible consequences related to safety and performance in the following examples of staff who avoid giving constructive feedback (taken from actual focus groups discussing factors that contribute to errors): • Nurses focus group: "A group of nurses describe a peer as careless and inattentive. Instead of confronting her, they double-check her work—sometimes running into patient rooms to re-take blood pressures or redo safety checks. They've 'worked around' this nurse's weakness for over a year. The nurses resent her but never talk to her about their concerns. Nor do any of the doctors who also avoid her and compensate for her." • Physicians focus group: "A group of eight anesthesiologists agree a peer is dangerously addicted to dilaudid, but they don't confront him. Instead, they go to great efforts to schedule surgeries for the sickest babies at times when he is not on duty. This problem has persisted for over 5 years."

______________________ means not jumping to conclusions or acting on impulse. Time constraints may push you to ________________ issues before they're completely understood. Because of the risks of jumping to conclusions and influencing others to do the same, if you aren't sure what the problem or diagnosis is, be prudent and say something like, "There seems to be issues with (whatever), but there's not enough information to completely understand what's going on."

Critical thinking / diagnose

The five "rights" of Delegation

Delegate (1) the right task; (2) in the right situation; (3) to the right worker; (4) with the right direction and communication; and (5) the right teaching, supervision, and evaluation

When Is It Safe to Delegate?

Delegate when: • The patient is stable. • The task is within the worker's job description and capabilities. • You're able to do the teaching and supervision the worker needs. • You've planned how to monitor patient results yourself. Don't delegate when: • Complex assessment, thinking, and judgment are required. • The outcome of the task is unpredictable. • There's increased risk for harm (e.g., arterial puncture can cause more severe complications than venous puncture). • Problem-solving and creativity are required.

professional standards in nursing

Describe the responsibilities for which its practitioners are accountable. • Reflect the values and priorities of the profession, provide direction for professional nursing practice, provide a framework for the evaluation of this practice. • Define the nursing profession's accountability to the public and the outcomes for which registered nurses are responsible.

Patients are individuals who may have similar problems but different attitudes, beliefs, and responses. As a result,

Each person and each situation has a "unique story." Look for differences in patient responses or changes in circumstances (cultural, developmental, physical, or emotional differences) and adjust care as needed.

• FAILURE MODE EFFECT ANALYSIS (FMEA):

FMEA is a systematic, proactive approach to error prevention that aims to build systems that promote safety and prevent accidents. FMEA assumes (1) that errors are not only possible but likely, despite knowledgeable and careful health care professionals; and (2) that it's too much to ask individuals alone to be responsible for errors. Instead, the responsibility is placed on the interprofessional group that engages in a never- ending process of quality improvement to assess and correct areas in which errors are likely. FMEA aims to design a system in which critical or catastrophic errors can't happen. Example: Wrong-site surgeries that are prevented by a strict policy that includes several "checkpoints" to ensure that the correct surgery in the correct person in the correct body part is done.

Forcers (Dicks)

FORCERS try to get their way even if it means others have to give up what they want or need. They're minimally interested in or aware of what others need and don't really care if they are liked.

______________________ is a broad concept that includes a wide range of technologies that store, share, and analyze health information. It includes EHRs, prescribing systems, decision support tools, and other electronic tools that aim to improve safety and results, while reducing costs.

HIT

As ________________ and ______ become more sophisticated, reliable, and widely adopted, their use in diagnosis and treatment will likely be the new standard of care in every hospital

HIT & EHR

HIT stands for

Health Information Technology

HROs are organizations that avoid catastrophes in environments where accidents are expected due to risk factors and complexity. HRO stands for

High Reliability Organizations

Authoritarian Parent Versus Empowered Partnership Model

I want to look after you. VS How can I empower you to be able to be independent? I know what's best for you. VS You know yourself best. Tell me what you'd like to see happen, what's most important to you. You should do as I say VS .I want you to be able to make informed choices .I'm responsible for you .VS We share a common enemy, and we're both responsible for what happens.

Negative Outcomes VS Positive Outcomes of Managing Conflict Constructively

Increased stress VS Reduced stress Decreased productivity VS Increased productivity; performance improvement Poor relationships and feelings of isolation VS Better relationships and interactions; increased harmony Wasted time and energy VS More time and energy for real progress Frustration, anger, and hopelessness VS Improved ability to clarify main issues and find creative solutions Lack of growth VS Opportunity to improve bothersome things Poor self-esteem VS Improved self-esteem

_____________ is a bigger challenge than ________________because it requires transforming a creative idea into a useful approach that evidence shows it improves results.

Innovation / creativity

AAR is a part of the _____________________ process

Interventions and Evaluation

providing materials for patients and testing patients after teaching them is important because

Much of the information patients receive is forgotten immediately, and what is retained is often incorrect. Giving printed guides and using the "teach-back," "show me," or "tell me how you'll handle this at home" approach is central to gaining insight into what the learner understands. This approach isn't a test of the patient's or learner's knowledge. It's a test of how well you explained the concept.

NPSGs are used to recognize that when systems are poorly designed, patients suffer and staff fail/ NPSG stands for ___________________

National Patient Safety Goals

Test taking skills:

Never read, watch videos, listen to presentations, or engage in class discussions without taking notes—you retain very little. Making notes helps you process the information so you understand and remember it better. Remember conceptual learning principles. Look for big ideas. Think about why the content is important Asking questions for clarification in class are important for three reasons: (1) they're probably on other people's minds; (2) they spark discussion, clarification, and remembering; and (3) we all learn from one another. • To increase understanding after the "first pass" of materials, revise your notes and maps at least once. • Review the information in two ways: just before you go to sleep and just after you've had some sleep • Create memory hooks : a rhyme, a picture, or a story that help you process the information more thoroughly and personally • Use a mnemonic or create an acrostic

Changes and Trends Affecting Nurses' Thinking

New threats emerge (International travel brings threats of pandemics (epidemics over a wide geographic area and affecting a large part of the population). Terrorism, including bioterrorism, is a constant threat, requiring new levels of preparedness and responsiveness.) • Many people live longer with illnesses and disabilities. • New diagnostic imaging and treatment modalities such as vaccine use, stem cell use, and genetic manipulation emerge • Ethical dilemmas grow. Ethical issues (e.g., end-of-life care, assisted suicide, fertility issues, cloning, stem cell research) require in-depth thinking that's grounded in ethical principles changes in case management: . new approaches grounded in prevention and early intervention. Today all nurses are expected to be "case managers," closely monitoring progress toward outcomes to detect delays in progress and intervening as indicated • Healthy People 2020 initiatives guide organizations, businesses, and communities to come together to achieve two major goals: (1) to help people of all ages improve life expectancy and quality of life and (2) to eliminate health disparities among different segments of the population • Holistic and alternative therapies—for example, exercise, plant-based diets, acupuncture, and stress reduction through meditation and aromatherapy—are recognized as key strategies for triggering the body's natural healing powers.

5 stages of learning ( from novice to expert)

Novice Advanced Beginner Competent Proficient Expert

Why do nurses have a complicated role to define?

Nurses spend more time on the front line in direct patient care than any other profession, making them accountable for many aspects of care. This complex role on the front line makes it difficult to describe what nurses do that's different from what other professions do

Paradigm Change Is Transformational

Paradigm change combines what's useful about old ways with what's useful about new ways and keeps us open to looking for even better ways. We realize: • Our previous views were only part of the picture. • What we now know is only part of what we'll know later. • Change is no longer threatening: it enlarges and enriches. • The unknown can then be friendly and interesting. • Each insight smooths the road, making the change process easier. We all took psychedelics and had a paradigm shifting experience

Assessment Priority • Chief complaint • Vital signs, age, weight • Allergies • Medications/treatments • Current and past health problems • Smoking history • Alcohol or drug abuse

Rationale All the bullets on the left here, beginning with "chief complaint" flag known problems and risks and significantly affect decisions about initiating certain treatments.

Assessment Priority Problems (or risks) with breathing, circulation, pain, or communication

Rationale Problems and risks in these areas should be dealt with early and may point to problems in other areas (e.g., pain usually flags a problem that needs to be dealt with).

Assessment priority General appearance; cognitive awareness; risks for infection, injury, or violence.

Rationale: General appearance (e.g., distress level) and cognitive awareness flags the urgency of presenting problems. Infection control and keeping patients, yourself, and others safe is top priority.

The Joint Commission "SPEAK-UP" Initiatives Tell your patients to speak up for themselves in these ways:

Speak up if you have questions or concerns. Pay attention to the care you get. Educate yourself about your illness. Ask a trusted family member or friend to be your advocate (advisor or supporter). Know what medicines you take and why you take them. Use a health care organization that has been carefully checked out. Participate in all decisions about your treatment

A popular example of HIT called _______________ improves access to care, improves outcomes, reduces costs, and allows patients and care providers to have appointments on mobile devices.

Telehealth

• ROOT CAUSE ANALYSIS (RCA):

The process for identifying deep underlying cause(s) of a mistake—the "root(s)" of errors. Requires examining in detail what happened, why it happened, who was involved, all factors that contributed to the mistake, and what can be done to prevent it. Example: Thoroughly examining what happened with a medication error in order to identify the major contributing factors (e.g., a nurse may have had inadequate knowledge to give a new medication, but the root cause of the lack of knowledge may be that there's no policy in place to ensure that new drugs aren't introduced unless all nurses have the required knowledge—this is considered a system problem).

TACIT

Therapeutic effect—Is there a therapeutic effect? Allergic or adverse reactions—Are there allergic or adverse reaction signs? Contraindications—Are there contraindications to giving this drug? Interactions?—Are there possible drug interactions? Toxicity or overdose—Are there signs of toxicity or overdose?

Predictive Care Models: Predict, Prevent, Manage, Promote (PPMP)

Using a predictive care model requires moving from a diagnose and treat (DT) approach—which implies that we wait for evidence of problems to start treatment—to a predictive model: predict, prevent, manage, and promote (PPMP). PPMP is a proactive approach that aims to predict and manage risk factors before problems arise.

Dealing With Complaints Constructively

Using complaints as an opportunity to identify system issues and improve or restore patient/consumer satisfaction.

educated guess

Using test-taking strategies to choose a right answer when you're unsure from content alone (when none of the options seem to jump out at you).

When you delegate tasks, you're accountable for decisions made, actions taken, and patient responses during delegation. What to remember when delegating:

When you delegate tasks, teach and supervise as needed. Follow up after tasks are done by assessing patient responses yourself. This does two things: (1) you have firsthand knowledge of how the patient responded to care; and (2) when workers know that you check results directly with the patient, they're more likely to do a good job

nurse residencies

apprenticeship programs that include a series of learning sessions and work experiences aimed at developing essential clinical and professional skills

true competency is when you have completed tests and checklists and then consistently display_______________ and ___________ at the point of care

appropriate behaviors / sound judgments

Quick priority assessments (QPA)

With predictive models and rapidly unfolding situations, it's important to know how to do a quick priority assessment (QPA). These are short, focused assessments that you do to gain the most important information you need to have first

Summative Evaluation

are done at the end of the learning period to determine whether learners have achieved skills, outcomes, and competencies needed to practice independently.

Your clinical performance is linked to your ______________ and ________________ skills.

critical thinking / clinical reasoning

If you diagnose a problem, it means that you accept ____________ for accurately naming and managing it.

accountability

The _______________ of EHR and decision support systems depends on YOUR ability to assess, interpret, and record your______________ signs and symptoms.

accuracy / patients'

ADL

activities of daily life

As a key user of HIT, you have the power to improve it. A lot of what surrounds EHR is medically/legally driven, security driven, or done to maximize reimbursement—don't let ____________, _________________, _________________ ______________, and ____________________ get lost in the process

actual nursing, clinical reasoning, clinical judgment, and decision-making

PPMP is based on evidence. Thanks to research, we can predict when people are at risk for certain problems and, if needed, begin ______________________________. Sometimes prevention requires treatment (called ______________________).

an aggressive prevention plan / prophylaxis

Evaluation and feedback should be ___________________, not something that happens only during formal evaluations

an ongoing process

As a nurse, you may not be the one who actually gives the _______________—for example, cancer diagnoses are given by physicians only—but you're likely to be the one who needs to be there to help patients deal with the___________ of the bad news.

bad news / impact

conceptual learning is done by prioritizing what you study by focusing on the ________ before the ___________

big ideas / details

While practice standards and guidelines are key tools that help you make care decisions, don't_______________ without reflecting and considering whether they apply to your patient's situation.

blindly follow them

Medication reconciliation

checking to ensure that the patient's medication orders and history are up-to-date and complete. the first step to reducing complications.

"Big ideas" of conceptual learning

concepts, principles, examples

There are many types to consider when it comes to ways people cope with _____________

conflict

Nothing makes people bristle more quickly than unfair, unskillful, or unsolicited criticism. Knowing how to give_______________________ in a supportive way can make the difference between alienating others and helping them learn. Knowing how to respond to criticism—to be objective and work through the____________________ of feedback—reduces your stress and helps you understand exactly what you need to work on.

constructive feedback / negative aspects

during test anxiety, the hormones _____________ and ___________ cause a viscous cycle that can make you even more stressed

cortisol and epinephrine

Tell yourself to stay calm, take a deep breath, ingest Vitamin C, relax your muscles, and just do the best you can. these tactics can prevent a ______________

cortisol surge

If you allow signs and symptoms (cues) to persist without ensuring that a ____________________—the most correct diagnosis—has been made, you may cause harm and be accused of ______________.

definitive diagnosis / negligence

EHR

electronic health record

Be sure you have a structured tool or coaching plan that specifies goals, expectations, outcomes, and/or behaviors to serve as a reference point for___________________

evaluation

Sound clinical reasoning often includes using both_____________ (knowing without evidence) and_____________(rational thinking based on evidence).

intuition / logic

Use ______________as a guide to search for evidence. Use____________ to formulate and double-check your thinking, ensuring that your conclusions are based on the best available facts.

intuition / logic

_________________ are problems that are still unclear

issues

competency-based learning: uses 4 inter-related components:

knowledge, skills, behavior, and judgment.

The terms diagnose and diagnosis have _________ implications

legal

Studies show that hand-offs—when nurses transfer patient care from one nurse to another—are vulnerable to________________________ that cause errors, missed care, and harm. To improve communication and prevent errors, safety initiatives encourage the use of standard ____________________ and patient participation in the process.

miscommunications / hand-off tools

Whether or not feedback is useful depends on the relationship you have with the person giving or receiving the feedback. Without ________________, feedback is unlikely to be viewed constructively.

mutual trust

To keep patients safe, use _______________________________. When you have a creative idea, determine what principles support or negate it.

principle-centered creativity

Nursing Accountability

not only being responsible but also being answerable for your actions or inactions (what you did or didn't do while carrying out your responsibilities).

Advanced beginner

notices recurring situational themes & issues in care apprenticeship with deliberate clinical practice and reflection coaching plans guide the team development of reasoning skills and clinical judgment

Realize that you may be an expert nurse, but if the circumstances change and you're unfamiliar with giving care under those circumstances, you are more like a _______________.

novice

what are some of the most important aspects of nurses thinking in respect to their role on a day-to-day bases?

nurses work to keep caring practices in the forefront. Activities of daily living (ADLs) management Risk identification, complication prevention, and health promotion. Monitoring patients to detect risks and implementing plans to manage them Surveillance. Monitoring to detect signs and symptoms (cues) that indicate deviations from expected patterns of health, illness, or recovery Ensuring patients and families have the knowledge and skills they need to successfully manage their health Ensuring optimum mobility in all patients. Medication regimen management. looking for adverse effects, making sure medications do not interfere, allergies to medications, cost effectiveness of medication, etc Physical and emotional comfort. Promoting physical comfort through holistic and prescribed strategies; promoting emotional comfort through therapeutic communication Care coordination. Coordinating care to ensure treatment regimens meet individual needs Delegation. Maximizing time and resources by supervising and delegating care to unlicensed assistive personnel Documentation. Ensuring that patient care is recorded accurately and as completely as needed to communicate the most important aspects of care Population-based, culturally competent care. Identifying individual needs of diverse patient populations (e.g., patients of certain cultures, age groups, languages, or gender identity)

Some technology used at the bedside incorporates HIT, sending data directly to the __________________.

patient record

How RRT and Code H work

patients and visitors can call a code number, which goes directly to hospital operators. The operators are trained to ask questions according to an algorithm. Callers who report something important, such as bleeding or chest pain, are routed immediately to the RRT. If the call is about problems like delays in getting pain medications, lack of communication, or some issue that doesn't require the RRT, the operator triggers a Code H. In this case, only the nurse manager responds (within minutes of the call). Even if the Code H turns out to be something very mild, families feel reassured to know that they will be heard. Using RRT and Code H saves lives and improves job satisfaction because nurses get help when they need it.

Drawing conclusions about someone's thinking requires focusing on________over time, not _______________________.

patterns / single incidences. For example, it's normal to have occasional communication issues, but if these happen frequently, there's a pattern of miscommunication that needs to be investigated.

The NCLEX® is a _________________, not a _________________. Work slowly and accurately, rather than rapidly and carelessly.

power test / speed test

We also have __________________________ (PrEP), meaning that there are recommendations to give people who are at substantial risk of getting HIV to get preventive medications.

pre-exposure prophylaxis

When you treat signs and symptoms or start people on diet or exercise routines, always ask: "Have these signs and symptoms been evaluated by the _______________________________?"

primary care provider

Nursing Responsibility

refers to a duty or task that you are legally and morally required to do

Clinical reasoning requires using your whole brain—both the intuitive-_____________________and logical-______________________.

right side / left side

Competent

sees and treats patient holistically adapts to emergent issues developmental plan focused on ethics, demeanor, formation as professional

Gaining control over the time you have by_______________ and applying the insights and strategies in this section reduces your __________________ and improves your performance.

setting priorities / stress

a nursing frame of mind means

staying centered on preventing problems and promoting health by focusing on the whole person, identifying individual needs, and monitoring responses to interventions (e.g., surgery) and life challenges (e.g., becoming a parent, getting diagnosed with a terminal illness). Nurses' holistic thinking seeks to answer questions like: How are these health issues or challenges affecting this patient's ability to function as a bio-psycho-social human being?

Report _______________ within EHR, and communicate suggestions for improvement in___________________ or ________________ to your leaders and informaticists

weaknesses / efficiency or effectiveness

To test your memory, quiz yourself without ___________. You may think you know the material when you're actually depending on cues from visual materials, not memory

your notes

To meet practice standards—regardless of the record-keeping system used—nursing records should reflect use of ADPIE, with special attention to the following

• Assessment: What you assessed in the patient. • Diagnosis/Decision/Clinical Judgment: What you concluded about your patient; be sure the facts that support your conclusions can be found in the record in the appropriate place. • Interventions and Evaluation: What you did, and how the patient responded; remember AAR (assess, act, reassess). • Safety Measures: Anything you did to correct or prevent adverse response

Clinical, Functional, and Other Outcomes

• Clinical outcomes: To what degree are the patient's health problems resolved? For example, is the hip healed? • Functional outcomes: To what degree is the patient able to function independently, physically, cognitively, and socially? For example, is the person able to do required daily activities without help? Are there problems with cognitive function? • Symptom severity and quality-of-life outcomes: To what degree is the patient free of symptoms and able to do desired, as well as required, activities? For example, is there any hip pain, and is the person able to meet physical work requirements and do favorite activities? • Risk reduction outcomes: To what degree is the patient able to demonstrate ways to reduce health risks? For example, is he or she able to explain ways of improving safety, such as using a cane when fatigued? Does he or she keep the home free from hazards that may cause falls? • Protective factor outcomes: To what degree does the patient's environment protect against deteriorating health? For example, when bedridden, are bedrails up as needed and skin care protocols followed? • Therapeutic alliance outcomes: To what degree does the patient express a positive relationship between himself or herself and health care professionals? For example, when asked, does he or she state that he or she feels free to ask questions? • Satisfaction outcomes: To what degree do the patient and family express satisfaction with care given? For example, when asked, do they state that they had competent, efficient treatment? Were services convenient? • Use of services outcomes: To what degree were appropriate nursing services used? For example, was a case manager used if needed?

educating patients and seeing them as healthcare learners requires that we:

• Consider the learner's health literacy level and ensure clear communication between you and the learner throughout the process. -Glean what patient knows, then determine: 1. Desired learning outcomes (what exactly the person must be able to do) 2. How much time you have before the person must be able to do it • Give a compelling reason to learn. • Determine readiness to learn • Promote curiosity and inquisitiveness. • Identify learning barriers -Learn how to communicate effectively with patients with physical, cognitive, or psychological disabilities • Ask about preferred learning styles (e.g., doing, observing, listening, or reading), and use this information to plan teaching • Encourage people to get involved by asking them to explain their preferred learning method(s) • Reduce anxiety by offering support to a new learner • Minimize distractions, and teach at appropriate times. • Use pictures, diagrams, and illustrations to promote comprehension and retention. • Encourage people to think out loud, using their own words. • Tune in to your learners' responses and change the pace, techniques, or content if needed • Summarize main points, and don't leave learners empty-handed. Give them the important points in print or online so that they can refresh their memory later • Evaluate what's been learned by asking learners to teach back what they have learned

Process of Diagnosis (Problem Identification)

• Creating a list of suspected problems/diagnoses (Generating hypotheses) • Ruling out similar problems/diagnoses • Naming actual and potential problems/diagnoses and clarifying what's causing or contributing to them • Determining risk factors that must be managed • Identifying resources, strengths, and health promotion opportunities

Principles of Clinical Reasoning

• Engaging patients, families, and caregivers and ensuring their safety and welfare must be top priority in all reasoning and decision-making • All reasoning depends on the quality of communication. Has there been mutual exchange of information, thoughts, and feelings? Is the information that's been exchanged factual and complete? • Critical thinking in nursing (clinical reasoning, judgment, and decision-making) is purposeful, informed, outcome-focused thinking. It also requires the presence of CTI's in clinical nursing. • While clinical reasoning centers on patients and families, it begins with YOU. Your personal qualities—your ability to demonstrate personal critical thinking indicators (CTIs) • Critical thinking and clinical reasoning are thinking processes; clinical judgment is the result (outcome) of thinking (the opinions you form or decisions you make) • While you'll use many resources to gather patient information (e.g., health records, family interviews), always consider your direct patient assessment to be the primary source of information. Studies show that assessment omissions are a major cause of adverse patient outcomes • Clinical reasoning happens in a context of unfolding (evolving) human situations. It's fluid, dynamic, and nonlinear, requiring systems thinking.

Strategies to Identify, Interrupt, and Correct Errors

• Error identification strategies: Knowing the patient, knowing the "players," knowing the plan of care, surveillance, knowing policy/procedure, double-checking, using systematic processes, and questioning. • Error interruption strategies: Offering help, clarifying, and verbally interrupting. • Error correction strategies: Persevering, being physically present, reviewing or confirming the plan of care, offering options, referencing standards or experts, and involving another nurse or physician.

During Outcome-focused, Evidence-based care, we must ask the following questions:

• Exactly what does the patient, family, client, or group need to achieve? • Have the best-qualified professionals decided what can be achieved, based on the circumstances? • Have the key stakeholders been included in decision-making? • What evidence indicates that the outcomes are likely to be achieved in this situation?

Strategies to help you be a safe, effective user of HIT:

• Focus on the patient more than the technology. it's possible to catch errors if your clinical reasoning causes you to believe the patient should not receive a certain medication or care order. Don't blindly follow the technology if you think something is wrong in the situation. • Keep an open, active mind, looking for flaws. HIT recommendations aren't prescriptive for individual patient circumstances, and they don't replace the need for you to use clinical judgment. • Follow policies for documentation carefully (e.g., correct errors and omissions as indicated). Standard policies ensure that data within the EHR are understood in the same way across the care team. • Some electronic fields are auto-populated (default data appears automatically). Pay attention to default data and whether it applies to your specific patient situation. • Without human interpretation, HIT is prone to errors. If the technology readings are fine but your patient looks distressed, focus on the patient. If your patient seems fine but the technology says otherwise, check the technology. • You can't depend on the system to be aware of the relationships among coexisting diseases, issues, and treatments • Because EHR and HIT may cue you to important information, interventions, diagnostic tests, or consultations that should be considered, it's more important than ever to chart as soon as you can. Timely documentation improves accuracy and helps you notice patterns. If you can't get to a patient right away, jot important data down on a personal worksheet (don't rely on memory). • Don't just "dump data into the record." Find ways to reflect on the big picture of patient care (use printouts or summary screens) • Be aware that when you're learning HIT, a lot of your brainpower goes toward learning the technology. This decreases your ability to think about patient care. • HIT may impede thinking in those who are task oriented, rather than thought oriented (a common issue with novice or inexperienced workers). • Think about back up plans. Electronic devices fail. Plan ahead and think about what you'll do if the device or system fails. This is why having a patient workbook is important. if there is a system diagnostic occurring jot dow

learning strategies for clinicals

• Keep in mind that if you're a beginner, you may not know what you don't know • Develop empowered partnerships (preceptorships, etc) • Ask for a tool that clearly details expectations about content (what's to be learned) and process (how the learning process will progress) • Use a tool to help you pay attention to the most important information and reminders you need during your clinical day. (a clinical worksheet) • Keep references—texts, handheld electronic devices, pocket guides, and personal "cheat sheets"—handy. • Learn terminology and concepts.(learning in action) • Become familiar with normal findings • Ask why. Find out why normal and abnormal findings occur • Learn problem-specific facts. You need to know how health issues usually present themselves (their signs and symptoms), what usually causes them, and how they're managed • As you go through the day, make ADPIE—assess, diagnose, plan, implement, and evaluate—a "guiding mantra" in your head. • Use debriefing. You make the most of your learning when you engage in debriefing and dialogue with your instructor or in groups in post-care conferences • Seek out role models and ask them questions, these individuals can be your best teachers You're accountable for ensuring that patients, families, and caregivers you supervise have the knowledge and skills they need to proceed with care safely and effectively.

Taking Constructive Feedback

• Keep in mind that receiving constructive feedback is a complex issue that's closely linked to self-esteem. Being told that you could improve or do things differently often brings up feelings of being wrong or not good enough. These gut reactions cloud key issues and hinder your ability to be objective. Remember, it's your fault if consumer satisfaction suffers just because you get frustrated that someone belittles you all the time. Try to remember that they are doing this because they hate themselves, and you're better than them anyway. • If you find yourself getting the intense negative feelings that come with receiving negative feedback, say to yourself, "I'm getting upset. I'd better take a deep breath, calm down, and listen. If I work to be objective and not take things personally, I might learn something when I think about this later when I'm less stressed." Remember that your emotions don't matter or save it for your therapy session. • Learn to befriend negative feedback, evaluating it objectively. If you always feel insufficient, remember that your mom wants you to succeed, and that's all that matters. Not all feedback is given constructively but it's your job to suck it up and focus on what you can learn, and you can wait until you get home to cry about it. • Ask yourself, "Have I heard this same feedback from other people?" If so, you'll probably get fired or demoted. • If you agree with the negative feedback, acknowledge that the feedback is useful and think about what you can do about it. • Don't make excuses, don't be defensive, and try to see the benefits of the feedback. Remember, you can always drink it off later. • Practice personal feedback by monitoring your own behavior and paying attention to how others respond to you. • Don't let false pride, rationalization, or other negative feelings get in the way of your growth. • Remember that no one's perfect, but we can all improve. Be prepared to expend a lot of physical and emotional energy to change. Make extra appointments with your therapist. • Don't dwell on negative feedback when you're tired—wait until a day or two later when you're refreshed and more likely to accept the fact that you suck at your job.

debriefing (learning after a cliinical simulation

• Keep in mind that the purpose of debriefing is to reflect on the experience and promote learning by identifying what you did well, what you can do to improve, and the biggest lessons you learned to take with you for the future. • Remember that feedback on performance can feel like criticism; stay positive and learn how to give and take feedback, a critical learning skill

preparing for tests

• Know yourself. Identify your usual test-taking behaviors • Know the test plan. Find out what types of questions are going to be asked and what information is the most important to study. If the teacher doesn't share this information, review course objectives, text objectives, and summaries—often these will help you decide what's most important. • Find out how long you have to take the test, what resources you're allowed to bring • Prepare with an attitude of "I can do this—I just have to figure out how." • Get organized and budget your time. • Know the parts of a question, how to read questions, and how to make educated guesses

These 2 important shifts in perspective empower patients and families to manage their own care:

• Move from "I know what's best for you" to "I want to empower you to make your own decisions." • Change "I'm here to take care of you" to "I'm here to make sure you know how to take care of yourself when I'm not here."

Clinical Reasoning and Systems Thinking

• Recognize relationships among key pieces of the whole • Think about the consequences of actions • Gain insight into how things tend to unfold over time • Clinical reasoning is iterative (repetitive), meaning you go through repeated rounds of analysis and actions, fine-tuning information and getting closer to the best results with each repetition. • The most common clinical reasoning framework used across health care professionals is ADPIE • Using ADPIE guides clinicians to document in a way that clearly communicates care to the interprofessional team, meets legal standards, and provides the data researchers need to develop evidence-based practices. • Nurses use a variety of reasoning patterns alone or in combination (you may use ADPIE together with ABC (airway, breathing, circulation) to set initial priorities. Maslow's Hierarchy of Human Needs is also often used to set priorities). • Accurately defining health problems requires differential diagnosis (weighing the symptoms that suggest one diagnosis against a closely related diagnosis with similar symptoms) • Tanner describes reasoning patterns as noticing, interpreting, responding, and reflecting. • Diagnosis (problem and risk identification) is most of the work of the clinical reasoning process. • Diagnosis (problem identification) is incomplete until you've determined what's causing or contributing to the problems and risks. • Understanding "the why" behind judgments and decisions is crucial to sound reasoning and patient safety • Assessing and reflecting play important roles in all phases of clinical reasoning. • Remember: "Assess, act, reassess." • A common clinical reasoning error is jumping to conclusions. • Developing competence—your ability to reason and make sound judgments while handling complex clinical situations—requires on-the-job experiential learning with guidance from educators, mentors, preceptors, etc. • To prioritize reasoning and think about the most important things first: • Start by considering whether your patient's signs and symptoms could be related to medical problems, medications, or allergies. (MMA) • Rule out "the bad things" (worst-case scenarios) first • After you've ruled out worst-case scenarios, consider the most comm

Use a comprehensive approach to assessing and managing conflict:

• Recognize that it takes courage to confront. People who confront usually have given a lot of thought to what's happening and have been struggling with how things are going for a while). • Don't jump to conclusions: Hold your opinions until you're sure of all the facts. Check your strong feelings and assume the person has good intentions (it may not seem like it, but most people don't intend to offend or do wrong). • Remember that there are three ways to view the situation: (1) the way you see it, (2) the way the other person sees it, and (3) the way it really is. • Stay focused on the relationship and common values and goals (e.g., "We're both committed to good patient care."). Don't nitpick on small issues—look at the big picture and address the impact that the major behaviors have on achieving goals. • Choose an appropriate time and place to open discussion (ensure privacy and find a convenient time for those involved). • Foster an atmosphere of trust and sincere desire to face issues together; encourage free exchange of ideas, feelings, and attitudes. • Be willing to persevere until you clearly understand the issues, values, and goals of the key players involved. • Look for win-win solutions (you may have to compromise a little bit). Try to find several solutions to the problems, evaluating each solution with the key players involved. Remember a solution is always there, you just have to find it. • Make a conscious effort to stay calm, help others stay calm, and keep the focus on the positive outcomes of resolving the conflict and building the relationship. • Take a break, ask for a truce, or get help from outside sources as needed. Allow for time out but keep interacting until all parties agree to the solution. • Set up a time to revisit issues to see if the solutions are being carried out and help to reduce the problem.

Two commonly used hand-off tools:

• SBAR (Situation, Background, Assessment, and Recommendation). Some places use I-SBAR, putting an I at the beginning, which stands for introduction (identify yourself, your unit, the patient's name, and date of birth; request the name of the person to whom you are speaking). • I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis). With Synthesis, the person receiving the hand-off gives a summary of what's been communicated, repeating back the most important information.

Key Terms Related to Examining Mistakes

• SENTINEL EVENT: A patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm. The following are also considered sentinel events: (1) suicide of any patient receiving care, treatment, and services in a staffed around-the clock care setting or within 72 hours of discharge, including from the hospital's emergency department (ED); (2) unanticipated death of a full-term infant; (3) discharge of an infant to the wrong family; and (4) abduction of any patient receiving care, treatment, and services. The term sentinel is used because of its relationship to a sentinel guard—a soldier who stands guard to keep people safe. Sentinel events are so serious that they signal the need for immediate investigation to ensure they don't happen again. • CLOSE CALL, NEAR MISS, OR "GOOD CATCH": A safety event that did not reach the patient but poses a significant chance of a serious adverse outcome if it happens again. Example: If a physician almost operates on the wrong site but this is caught just in time, it's a near miss. Near misses may be considered sentinel events, but they may not be reviewed by The Joint Commission under its sentinel event policy. • HAZARDOUS CONDITION: Any set of circumstances (other than the patient's own disease or condition) that significantly increases the probability of a serious adverse event. Example: Nurses who have too many acutely ill patients to give appropriate care. • NO HARM EVENT: A safety event that reaches the patient but does not cause harm. Example: A patient who has been prescribed a regular diet receives an 1800-calorie diabetic lunch tray.

thinking in action during simulations (VR headset tests, robotic patient simulations)

• Try to stay calm, even when you make mistakes (mistakes are common; that's why you're there). • Focus on safety; acknowledge and correct your mistakes as soon as possible, then move on. • Think out loud so that the facilitator understands your reasoning

Being Assertive Without Being Aggressive

• Try to understand completely before responding. To be sure you understand correctly, paraphrase what you heard (e.g., "I understand you're completely frustrated."). • State your own feelings, thoughts, and needs clearly, in a nonthreatening way. • Stand up for your own rights while showing respect for the rights of others. • Pay attention to cultural and personality differences. • Convey needs and wants by using "I" messages to address how you feel about the specific behavior that disturbs you (e.g., "I was embarrassed and hurt when I saw you walk away from our conversation" rather than, "You made me feel like such a jerk when ..."). • Value yourself and act with confidence—don't feel guilty when you say "no" ("I'm sorry, but I can't do that."). Setting boundaries keeps us safe. • Own responsibility and speak with authority—use eye contact, a direct body posture, and a controlled voice volume and tone (you may need to adapt this if cultural differences are involved).

Strategies for Developing Clinical Judgment

• Work on becoming a confident learner (getting stressed reduces your brainpower). Remember that beginners often don't know what they don't know. When in doubt, get help from a qualified professional. Asking questions or getting help is "the default solution" for uncertainty. • Be a self-starter , identifying experiences you would like to have (e.g., "I haven't looked after someone in traction and would like to have the opportunity to do this"). • Learn the "big ideas" —the major principles and concepts—first. Review "Principles of Clinical Reasoning" earlier in this chapter. • Keep references—texts, handheld devices, pocket guides, and personal "cheat sheets"—handy, and be sure that you: • Learn terminology and concepts. If you encounter words like embolus, thrombus, or phlebitis and you don't know what they mean, look them up as you encounter them so that they become part of your long-term memory. Learning terms in context helps your brain store information in related groups rather than as isolated facts. • Become familiar with normal findings (e.g., normal lab values, assessment findings, disease progression, growth and development) before being concerned with abnormal findings. Once you know what's normal, you'll readily recognize when you encounter information that's outside the norm (abnormal) .• Ask, "Why?" Find out why normal and abnormal findings occur (e.g., "Why is there edema in heart failure, yet none when the heart is functioning normally?"). • Turn errors into learning opportunities. If you aren't making mistakes, maybe you're not trying new things. • To develop sound reasoning habits, consistently use approaches that help you think in organized ways. For example, let ADPIE resound in your head and reflect on it to decide whether you've considered each phase. • Don't just enter data into the computer. Reflect on what you entered, looking for patterns and things you may have forgotten to do. Keep your own personal notes or use a worksheet to keep track of information, stay organized, and jog your mind (brain overload in the clinical setting is a common issue that needs solutions). • Practice your assessment skills and learn from your peers' experiences. Collaborating with peer