Prof Issues Exam 2
Pros/Cons of Whistle-Blowing: Cons
•Poses personal & professional risks •Casts doubt on motives •Job loss or employer retaliation •Tiring, anxiety-provoking, frustrating experience •Extra work •No legal protection for whistle-blowers
Principles of Communication in Collaborative Relationships
•Presence •Empathy •Respect •Genuineness
Pros/Cons of Whistle-Blowing: Pros
•Protects patients •Improves quality of care •Meets professional expectations & standards •Satisfies ethical duty •Brings problems into the open •Moral "rightness"
Culture and Non-Verbal Communication
•Proximity/Spacing •Touching •Gestures •Eye contact •Silence •Body Language
Clearly defined organization structure
•RN recognized as leader of health care team •Clear job descriptions defining roles and responsibilities, consistent with state nurse practice acts •Worker credentials on nametags
Verbal Communication
•Requires functional physiologic, cognitive mechanisms that produce, recognize, receive speech •Developmental age -verbal, cognitive ability •Cultural heritage -connotative meanings
Sender and Receiver Responsibilities Sender Should
•State one idea at a time, simply and clearly •Monitor tone and tempo •Explain when needed •Repeat if necessary •Encourage feedback
Guidelines for Whistle-Blowing
•Stay calm; think about risks before acting •Know your legal rights (state laws vary r/t whistle-blowing) •First, confirm (be certain!) there is really a problem •Seek validation from colleagues that there really is a problem (but don't let them sway your actions) •Follow chain of command when reporting concerns whenever possible •Present just the •Use the internal processes/mechanisms for your institution •Document the problem you've observed & detail ALL steps you've taken to rectify the situation •Do not expect to be thanked or vilified for your actions
Communication Styles
•Styles -assertive -aggressive -passive -passive-aggressive Goal: meaning of message is understood by both the sender and the receiver
Sources of Law
•United states constitution •Federal and state legislatures •Administrative agencies •Courts
Types of Communication
•Verbal •Non-Verbal •Intrapersonal •Interpersonal •Group -public speaking
Factors Affecting
•Vocabulary •Denotative vs. Connotative Meaning •Pacing of conversation •Intonation: tone, pitch, cadence, volume •Timing •Relevance of information •Credibility of the sender •Humor
Communication 101
•Words 7% •Vocal Tone 55% •Body Language 38%
RN must always be:
•accountable for care given •responsible for instructing UAP as to who needs what kind of care and when
Fragmentation: The opposite of Care Coordination
•characterized by weak connections among multiple component part •makes simple tasks difficult •makes difficult tasks impossible •signs: poor communication, repetition of services (tests), increased costs
What you need for alleviating results of fragmentation?
•good communication •relentless patient advocacy •good teamwork
Lower professional nursing staff on a equals?
•higher number of med errors •nosocomial infections and wound infections •higher fall rates •increased levels of restraint usage •higher medication errors in assisted living, school settings
UAP accountable for knowing:
•how to perform care properly, following institutional best-practice policies •when others need to be called in for tasks beyond limits of knowledge and training
Two Types
•internal •external
Motivation to use UAP
•maximize human resources •cost reduction
Educational Requirements of UAP's Varies
•minimum of 75 hours of theory and practice with successful completion of competency exam in both areas •most UAP training in facility with no formal certification: training is institution-specific and "often inadequate" •formal training at vocational schools and community colleges -focus on long-term care -certification to meet state requirements
Unlicensed Assistive Personnel (UAP)
•nurse aides •nurse extenders •healthcare aids •technicians •orderlies •assistants or attendants
Delegation Decision Tree
•right task •right circumstance •right person •right direction/monitoring/communication •right supervision/evaluation
Delegation definition ANA
"The transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome."
External
reporting concerns outside organization •this is more standard understanding of true whistle blowing, especially if media is involved)
Internal
reporting concerns via chain of command
Connotative
represents the various social overtones, cultural implications, or emotional meanings associated with a sign
Genuineness
state of being real, honest, sincere
Minimizing Malpractice Risk Continued
•Maintain client confidentiality •Provide education and counseling •Delegate, assign, and supervise properly •Accept appropriate assignments •Participate in continuing education •Observe professional boundaries •Observe mandatory reporting regulations •Be aware of legal safeguards for nurses
Personal Risks Associated with Whistle-Blowing
•Negative reactions from coworkers •Loss of job •Employer retaliation •Legal retaliation •Treatment as traitor •Professional reprisals (threats) •Reprimands •Referral to psychiatrist •Pressure to resign
Professional Communication Routes
•Nurse to Nurse •Nurse to/from interdisciplinary team member (physician, PT, OT, Resp) •Nurse to/from Manager •Nurse to/from Patient-Therapeutic Communication
Minimizing Malpractice Risk
•Observe mandatory standards of care •Use nursing process; follow professional standards •Avoid medication and treatment errors •Report and document accurately •Obtain informed consent •Attend to client safety
Common Malpractice Claims
•Failure to assess and diagnose •Failure to plan •Failure to implement a plan of care •Failure to evaluate
Negligence
•Failure to perform as a reasonable, prudent person would •Failure to follow standards of practice •No intent to harm is present
LNA Requirements
•Federal Law=must keep a state registry •NH has MNA or LNA •Scope of practice of LNA •2 part testing for licensure: written and performance based
Whistle Blowing=avoiding "Groupthink"
"Groupthink definition: inappropriate conformity to group norms, attitudes, and opinions •cones with significant personal, professional risks •tendency is to ignore problem until crisis occurs or problem becomes public •reality: professionals torn between what they believe they should do, what they actually do=MORAL/ETHICAL DILEMMA
SUMMARY of ANA Pearls: for RNs working with UAPs
1. Recognize & use the legal authority vested in RNs to delegate non-professional tasks to trained UAPs 2. Understand & practice the supervisory role expected of RNs regarding the delegation of tasks to UAPs 3. Understand employer rules, regulations, policies & procedures pertaining to the use of UAPs 4. Know the skill set(s) that UAPs possess, which should be documented & easily accessible at the institution employing the UAP 5. Exercise decision-making authority regarding whether to delegate nursing tasks to UAPs, using professional nursing judgments in planning patient care
Creating a Safe Work Environment
A. Clearly defined organization structure B. uniform training, orientation programs for UAP C. Adequate program development in leadership and delegation skills for RNs prior to supervision of UAPs
Which of the following would be appropriate for a nurse to delegate to a UAP? A. Vital sign measurements B. Care planning C. Patient assessment D. Patient teaching
A. Vital Sign Measurements
Whistle-Blowing
Act of going outside organization for public's best interest when organization unresponsive to reporting danger thought organization's proper channels
Presence
All energy is focused on interpersonal interaction •presence precedes -genuineness -empathy
Activities NEVER to be delegated to UAP/LNA(NAP)
All parts of the nursing process (ADPIE) •pt assessment •nursing diagnosis •care planning •pt teaching •health education •outcomes evaluation RN ultimately responsible for ensuring pt's receive appropriate high-quality care
In which of the following circumstances might the nurse advocate to defer obtaining informed consent for care and treatment of a patient? A. The patient is brought to the emergency department in cardiac arrest and no family is present. B. An unconscious client scheduled to receive a central intravenous catheter is admitted to the unit with no family present. C. The surgeon requests that the patient be sent to the surgical suite before the consent form is signed. D. The patient is confused and agitated and cannot understand or sign the consent form.
B. An unconscious client scheduled to receive a central intravenous catheter is admitted to the unit with no family present.
Why is nursing care coordination imperative?
Better Patient Outcomes Such As: •Reductions in emergency department visits •Noticeable decreases in medication costs •Reduced inpatient charges •Reduced overall charges •Average savings per patient •Significant increases in survival with fewer readmissions •Lower total annual Medicare costs for those beneficiaries participating in pilot projects compared to control groups •Increased patient confidence in self-managing care •Improved quality of care •Increased safety of older adults during transition from an acute care setting to the home •Improved clinical outcomes and reduced costs •Improved patient satisfaction overall
Which action associated with the use of restraints can be delegated to the LNA? A. Assessment of patient's safety needs B. Evaluation of patient's response to treatment C. Range of motion after the release of the restraint D. Selecting the appropriate type of restraint
C. Range of motion after the release of the restraint
UAP Shortage
Current nationwide shortage of well-trained UAP due to high turnover rate for nursing assistants because of: •Low pay •Physical and emotional job demands •Negative messages from managers, supervisors, coworkers •Lack of employer-paid benefits, health insurance coverage •Limited career paths •Less-than-ideal working conditions; high turnover rate leaving others short-handed •Outdated federal regulations for minimum standards for staffing in nursing homes
On admission to Hospital A, the patient indicates that he would like information about making a living will. The nurse informs the patient that the hospital does not have a process in place to facilitate this. Hospital A is not in compliance with the A. Health Insurance Portability and Accountability Act B. EMTALA C. Americans with Disabilities Act D. Patient Self-Determination Act
D. Patient Self-Determination Act
SBAR: Background
Give other information pertinent to the situation-not the patient's entire history since admission, but circumstances leading up to the situation (ex. medications, lab results, current symptoms)
Maximize Human Resources
•Free professional nurses from tasks and assignments not requiring independent thinking and professional judgment using the nursing process •Examples: Bed making, vital signs, feeding, I/O, weight, height
The nurse is expected to:
Demonstrate responsibility and accountability for practice and decisions. Indicators: •exhibits ethical behaviors •establishes and maintains therapeutic boundaries •limited practice to current knowledge, skills and abilities •clarifies expectations of the role •intervene when unsafe nursing practice occurs •practices within the legal authority granted by the jurisdiction •implements professional development activities based on assessed needs
Denotative
Denotation represents the explicit or referential meaning of a sign. Denotation refers to the literal meaning of a word, the 'dictionary definition.'
T/F: The RN is responsible for instructing UAP in how to properly perform the assigned care.
False
T/F: There are no legal consequences for nurses who do not follow the ANA Standards of Professional Performance as these are not laws.
False
Malpractice
Four elements necessary to collect damages •Existence of a duty •Breach of the duty •Causation •Damages
Lack of coordination =
Fragmentation
Accountability-Patient Report
Guidelines for clear and complete reporting •Organize the report before beginning •Give client room #, name, age, diagnosis, and physician •Provide brief account of patient condition -include new or changed orders •Mention PRN's given •Refer to VS, temp change, IV fluids, and I/O •Use standardized process
SBAR: Situation
In 10 seconds, identify yourself and the pt. and describe the present situation that prompted you to call. State: •your name •your unit •the patient's name and room number •the problem
The nurse is expected to: demonstrate responsibility and accountability for practice and decisions
Indicators: •Exhibits ethical behaviors •Assures client welfare prevails •Establishes and maintains therapeutic boundaries •Limits practice to current knowledge, skills and abilities •Clarifies expectations of the role •Intervenes when unsafe nursing practice occurs •Practices within the legal authority granted by the jurisdiction •Implements professional development activities based on assessed needs
Nursing Assistive Personal (NAP)
LNA
Care coordination is indispensable to ____ nursing care
Quality
Other Guidelines for Nursing Practice
•Institutional polices and procedures •Nursing Codes of Ethics •Patient Care Partnership -(Formerly Bill of Rights) •ANA Bill of Rights for Nurses
State Laws Guiding Nursing Practice
Mandatory Reporting Laws •nurses are mandatory reporters in state of NH •communicable disease •abuse Good Samaritan Laws •differ by state Nurse Practice Acts •credentialing •licensing •discipline
Teamwork and Effective Communication
Teamwork and effective communication •Effective communication: is a marker of safe and highly reliable care •Use of effective communication by leaders=role modeling •Administrative structures should support and require effective communication and teamwork •Ability to manage/confront conflicts arising out of poor communication
Standards of Practice
Standard of Care •What a reasonable and prudent nurse would do in a given situation based on: -Nurse Practice Acts (mandatory standard) -Professional Organizations (voluntary) *joint commission *ANA *Other specialty organizations
SBAR: Assessment
State the problem and what you think is causing it. This is an inference rather than traditional data collection
SBAR: Recommendation
State what you think will correct the problem, or what you need from the physician
Communication: NOF Competency
The Nurse of the Future will interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes.
Delegation
Transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for the delegation
T/F: RN is legally liable if negligent in supervision of UAP at time of negligent act
True: RN must have awareness of UAP's job description, knowledge base, demonstrated skills
Purpose of whistle blowing
advocating for others who may be harmed
Interpersonal
refers to relationships or actions that take place between two or more people while
Intrapersonal
refers to things that go on exclusively within one person
Presence
being there, or gift of self produces deep personal connection for participants
Effective inter professional teams leads to?
better patient outcomes
Examples of Roles LPN
care for stable patients with predictable outcomes, works under supervision of the RN
Empathy
communicating understanding of how others feel, what or why they feel the way they do
Examples of Roles Physicians
experts in physiology, disease, pathways, and treatment
Respect
feeling or showing deferential regard or esteem
Examples of Roles OT and PT
focus on improving functional capacity
Examples of Roles Pharmacist
medication experts
Poor communication and lack of respect leads to?
poor patient outcomes
Examples of Roles Nurse Practitioner
possess advanced nursing skills including diagnosis, treatment and prescribing
Examples of Roles Social Workers
trained in family dynamics
Examples of Roles: Nurses
treat client from a disease management perspective but also from holistic perspective: psychosocial, spiritual, family
Delegation Dos and Don'ts Do's
•Know your state nurse practice act •Know agency policy •Know the training and background of people to whom you delegate tasks •Decide which tasks can be safely delegated •Consider specific needs of each client
Handoff Communication
•Legal Issue •Continuity of Care Issue •Patient Safety Issue
UAP/LNA Scope of Practice
•Like nursing, no universally nationally accepted scope of practice exists •In NH: LNA must work under "supervision of RN" •Scope of practice focuses on: -helping pt's maintain "functional ability" -documentation -upholding pt rights -skills that are delegated to them
Sender and Receiver Responsibilities Receiver Should
•Listen carefully, concentrate •Evaluate-think and process info •Provide feedback •Interpret the message •Verify interpretation of the message
Techniques to Improve Communication
•Be assertive •Listen •Use "I" statements
The Four Agreements
•Be impeccable with your word •Don't take anything personally •Don't make assumptions •Always do your best
Federal Laws Guiding Nursing Practice
•Bill of Rights •Emergency Medical Treatment and Active Labor Act (EMTALA) •Americans With Disabilities Act •Patient Self-Determination Act •Health Insurance Portability and •Accountability Act (HIPAA)
Communication Challenges: Situations that require a conversation
•Broken Rules: shortcuts, not following procedures •Mistakes: poor clinical judgment, inadequate assessments •Lack of support: refusing to help or share info •Incompetence: lack of knowledge and skills •Poor teamwork: cliques, upstaging •Disrespect: condescending, dismissive tone •Micromanagement: misuse of authority
Whistle Blowing in Nursing
•Complaints of unsafe staffing •Inappropriate use of UAP's •RNs asked to participate in illegal/unethical activites including fraud •Primary reason for not raising a concern: nothing would be done •Whistle-blowing rarely first solution; need to follow chain of command
Cost Reduction
•Conflicting research results about to actual cost-effectiveness •Consideration of lower-paid UAPs vs. higher paid RNs: research has shown that more number of RNs decreases cost related to decreased length of stay •Pt. outcomes in terms of money: poorer outcomes and longer stays in hospital=higher costs per pt.
Delegation Dos and Don'ts: Dont's
•Delegate components of nursing process to UAP •Assume the person you are delegating to knows how to perform the task •Delegate medication administration unless person is appropriately licensed to administer that med
Healthcare Team
•Doctors •Physician Assistants •Nurses •Pharmacists •Dentists •Technologists and Technicians •Social Worker •Therapists and rehabilitation specialists (PT, Speech, OT, Respiratory) •Emotional, Social and Spiritual Support providers (hospital chaplain) •Administrative and Support Staff •Community Health Workers and Patient navigators
Adequate program development in leadership and delegation skills for RNs prior to supervision of UAPs
•Educational programs for new graduates •Continuing education for practicing RNs
Tips on being assertive
•Ensure congruence between verbal and nonverbal messages •Guide the direction of the discussion •Use "I" statements •Focus on the issues •Do not invite negative responses •Avoid self-effacing statements •Maintain eye contact, as culturally appropriate •Speak clearly and firmly •Project a clear tone of voice •Communicate self-confidently •Maintain professional composure •Communicate in a positive manner •Refrain from sarcasm
Laws
•Established to protect society •Nursing practice guided by legal principles •Purpose of laws -Protect clients/society -Define scope of nursing practice -Identify minimum level of care to be provided
Factors Affecting Nonverbal Communication
•Facial expression: communicates feelings behind a message •Posture and gait: clue to attitude, self-concept •Personal appearance: clue to socioeconomic status, culture, feelings •Distance: indicates extent of familiarity •Gestures: emphasize and clarify spoken word; can have different meanings •Touch: can be misinterpreted