N412 Exam 2

Passive communication

- influenced or acted upon without acting in return - uses apologetic words with hidden meanings - seems disconnected and fails to say what is meant

Legally non-delegable by RN

-Assessments -Surveillance of patient status -Care Planning -Educating -Evaluation -any task requiring judgement by the RN - task requiring critical thinking by RN

Chief Nursing Officer

-Chief executive level --CNO --VP -Senior Management Responsibility -Administrator of Nursing Services at the Organizational Level -MSN/MBA/ DNP/PHD -Visionary Thinking -Program Management -Strategic Planning -Systems thinking -Fiscal management -Collaboration -Communication

Team Nursing

-RN is a leader of a small group of patients, RN assesses and passes medications etc -benefit patient centered, more expensive -drawbacks- nurse needs leadership skills, continuity suffers, requires time delegating

A report from hematology has just been received in the electronic medical record. The patient's Hemoglobin is 6.5 gm/dl and white blood count (WBC) is 18,000. The nurse is thinking that the doctors will make rounds as usual this afternoon and will see the lab reports. Based on the legal responsibilities of the RN, has this nurse acted according to standards for communication of patient lab tests?

-RN needs to page MD -needs to make sure MD or someone in the chain of command is contacted about the critical lab -once contacted RN needs to document -the RN CANNOT assume it will be communicated with the MD -the RN is legally responsible for the critical lab to be resolved

Director of Service line

-administrator of a service line in the org. -macrosystem responsibility for a patient care service line in the hospital -MSN/MBA/DNP -skills needed -visionary thinking -program management -strategic planning -systems thinking -long-range planning -collab -communication

TeamSTEPPS- Mutual Support

-anticipate and support other team members by having knowledge of their responsibilities, skills, and workload -role supplementation -role flexibility -task assistance- offer help -feedback- respectful, constructive information for improvement as needed -advocacy: provide support to promote the rights of others and protection for the vulnerable -assertion; use firm but respectful corrective action

TeamSTEPPS Shared Mental Model

-assure that all on the team have shared perception --perception --understanding& knowledge of a situation or process among all team members

Passive-Aggresive Communication

-avoid direct confrontation -manipulate others to achieve their personal goals -appear to be honest but undermine others through gossip, playing the victim, etc. -win in situations by making others look bad

aggressive

-claims basic rights in ways that violate the well-being of others -commanding, dominant, superior attitude -make accusations that blame or put down others -conveys dominance and implies an inclination to start quarrels or fights

Team STEPPS Elements (Check Back) (Call-Out)

-closed loop communication -ensure that info conveyed is received & understood by the receiver -repeating back a verbal order

Clinical Nurse Leader

-educated at MSn level -AACN certified -Purposed to improve quality efficiency and safety of care -provided bedside leadership to staff nurses -population focus on microsystem level

Democratic/Participative leadership

-encourage participation in decision making -involves staff in planning stages -effective communication -regular feedback Strengths & Weaknesses -builds responsibility in people -works well with competent, motivated people -decision making by consensus is time consuming -may lead to analysis paralysis

laissez-faire leadership

-low level of guidance -unable to make decisions -does not provide feedback -initiates little change -indirect communications Strengths & Weaknesses -may work well with professionals -does not work well when staff need guidance, education and training -fails to lead & motivate others

Autocratic (authoritarian) Leadership

-makes policies and all decisions -does not invite ideas -dictates work -control processes -little feedback Strengths & Weaknesses -good with staff with little education or training -leads to faster decisions or processes -does not work well with educated adults

Nurse Manager

-manages at the unit level -BSN/MSN/MBA -Skills needed -planning -organizing -staffing -directing -controlling

Impact of leadership & Management in Nursing

-nursing satisfaction & retention -increased patient satisfaction -reduction of errors -increased quality of care -promotion of EBP -increased efficiency- decreased length of stay

Assertive

-pronounces basic rights without violating the rights of others -states wants, needs, desires, and feelings using objective, direct comments -connotes style of positive declaration and confidence -preferred communication style for professional nurses -to speak assertively --state facts --consider options --exude confidence while making the observation, request, or point

Legalities related to delegation

-regulations for delegation are governed by the state boards of nursing- 4723-13- at times overstepped by organization -organizational policy cannot override the law & rule of the board of nursing -nurse needs to know and check the non-delegable functions of the RN with BON

TeamSTEPPS: Two challenge rule

-use when initial assertion is ignored -team members responsibility to voice the assertion at least two times to ensure that it is heard and understood

An experienced nurse is orienting a new nurse. The new nurse is asking how to prioritize the care requirements between 4 assigned patients. List the general rules that the experienced nurse should coach the new nurse to follow when prioritizing patient care requirements.

1. ABC's airway, breathing, circulation a. Oxygenation, perfusion, or acute change in vital signs 2. Acute changes in status a. Safety issues b. Mental status c. Elimination status d. Pain status e. Abnormal critical lab f. Acute risk 3. Routine scheduled tasks or process or maintenance task on stable patients a. Maintenance tasks on stable patients 4. Longer term care needs a. Rest, coping, education

8-10 Leadership competencies

1. Effective communication 2. Effective listening 3. Problem solving skills 4. Conflict Resolution skills 5. Crisis management skills 6. Relationship management 7. Honesty & integrity 8. Role modeling 9. Knowledge of own weaknesses 10. Mentors other staff

Role of RN Care Coordinator: Domain 1

1. Population Health Management •Identifying populations in need. •Identifying & stratifying their risks. •Identifying gaps in care. •Program Planning •Engaging patients in management of care. •Measuring outcomes.

Seven Characteristics of a Delegable task to UAP

1. no judgement is required to do the task 2. Task si predictable 3. Task is standardized & performed with unchanged directions 4. results of tasks are predictable 5. tasks do not require critical thinking 6. task does not require assessment 7. Minimal risk if done incorrectly

8-10 management competencies

1. planning 2. organizing 3. staffing 4. directing 5. controlling 6. organization skills 7. budgeting 8. comfort with conflict 9. analytic skills 10. ability to evaluate staff and provide feedback

Positive Communication Techniques

1.Establishing eye contact-shows confidence and concern (can be aggressive in some cultures) 2.Keeping promises- fulfilling expectations 3.Expressing empathy-understanding another's experiences 4.Open ended communication-statements that require more than a yes or no answer 5.Clarifying information- "What I hear you saying is" "I understand you mean" 6.Body language-open stance, leaning in toward patient 7.Using touch- a gentle touch on the shoulder or arm also respect personal space and cultural differences

Role of RN Care Coordinator: Domain 2

2. Comprehensive Assessment & Care Planning •Having thorough knowledge of chronic disease management. •Keeping abreast of EBP guidelines / protocols for chronic disease categories (i.e.. CHF, COPD, Diabetes, asthma or depression)

Team Leader

A team leader manages assistive staff of a small group. They assess the patient and plan cares. They delegate to assistive staff, and they report to the charge

An RN is working on a hospital floor that has 4 RNS and 2 LPNs. The RN is functioning as the Charge Nurse today. Which of the following patients could the nurse legally assign the LPN with med training to take care of?

A. A patient that has 2 oral antibiotics ordered at 9am. B. A patient that is 2 days post-operative with a Foley catheter. C. A patient that will need an intermittent infusion devise flushed at 10am. D. A patient that will require a blood transfusion this morning. E. A patient with an IV of normal saline with 20 meq potassium chloride ( KCL) additive. F.A patient only needing diabetic teaching prior to discharge this morning A & B

Closed Communication Styles

Asking yes/no questions Making inquiries or statements that require single-word answers and limit the response Crossing arms, hands on the hips Avoiding eye contact Turning away or moving away from the individual •Blocking-noncommittal or generalized answers • •False Assurances-similar to blocking • •Conflicting messages-verbal and nonverbal messages that don't match

TeamSTEPPS: Conflict Resolution Process: DESC

D- describe the situation or problem E- Express your concern about the action S- suggests alternatives or solutions C- State the consequences if relevant

What does the nurse need to know about implementing an order written by a medical student?

If a medical student puts in an order the MD needs to co-sign

Qualities of Team Based Communication

Inter-professional- this occurs between professionals of different professions. Intra-professional- this occurs between professional of the same profession. Use I statements instead of you, and always seek to understand then to be understood. Use ISBAR-identify, situation, background, assessment, recommendation, CUS- I am concerned... , TeamSTEPPS-calllout, check back, situational monitoring, two challenge rule

Team Based Communication

It enhances collaboration and effectiveness of a team, and it decreases errors, increases safety & quality of care -types: interprofessional, intra-professional, centered on team functioning, and professional relationships

Qualities of therapeutic communication

Open, honest, Non-judgmental 1. Occurs between nurse & patient 2. The nurse must be present 3. Active listening a. Paraphrasing what the patient said b. Open body language c. Looking the patient in the eye d. Open ended questions e. Acknowledging what the patient says f. Reflecting on patients emotion 4. Empathetic 5. Responding to a. Concerns b. Physical concerns c. Emotional concerns 6. Explaining what is going on 7. Encouraging the patient to express emotions 8. Educating the patient

Total Patient Care

RNs perform all the required care three 8 hour shifts per patient works best in critical care Benefits- holistic care, unfragmented, strong communication, clear line of responsibility and accountability for care, and highest quality of care

Communications subcomponents

Reception & Interpretation of information •Influences •Coding & encoding of message •Complexity of the message •Transmission - Channel & noise on channel •Precipitating event •Preconceived ideas •Style of transmission •Experiences •Personal perceptions

Effective Conflict Resolution- Confronting

Speaking for yourself so others hear your concern.

TeamSTEPPS

Team Strategies and Tools to Enhance Performance and Patient Safety

Coercive power

The ability of a manager to punish others

Delegation

The assignment of new or additional responsibilities to a subordinate -downward, nurse to PCA, nurse is still responsible for the task being completed

Nurse manager on a unit at a hospital staffed with 10 RNS at 8 PCAs. Most of the staff have been on the unit 3-5 years. The unit is also transitioning to a new electronic records system.

The best management style for this floor would be democratic. The nurses have all been there for 3-5 years, and they have an abundance of experience. Democratic allows the nurses to give feedback on how the new electronic system is working out for them.

A unit has experienced a lot of turnover from chronic low staffing. The unit has just hired 8 new graduate RNs.

The best management style would be a mix between autocratic and democratic. I chose these too because there is a high turnover rate for this floor, which is not a good sign. The managers need to evaluate what is going on, on this floor that is causing such a high turnover rate. This would be democratic because they are getting feedback from the staff, and they are involving the staff in the changes. They should also be autocratic because they just hired a bunch of new nurses. They need direction, and pretty much just told what to do while they are novice nurses.

Nurse manager of a unit at a skilled nursing facility staffed with 10 new STNAs, 2 LPNs and 1 new RN.

The nursing style best used in this situation would be autocratic. There are an abundance of new employees on the floor, so they need a lot of direction. Autocratic managers tend to make all the decisions, and they just communicate the policies from the top down.

Management

The process of accomplishing the goals of an organization through the effective use of people and other resources.

A hospital employs PCAs which are unlicensed assistive nursing assistants on a medical surgical unit. The hospital decides to train the UAWs to start IVs and to flush IV access devices. The training is now completed, and the policy went into effect this week. An RN is assigned to the nursing care of patients on this floor and is told about the new policy by the Charge Nurse. The RN is wondering if this policy is OK since the hospital trained the PCAs and the Charge nurse assigned the PCAs to start IVs and flush IV access devices today. The RN has 2 patients with IV access devices. What should the RN do?

This is a nondelegable task. The nurse should tell the PCAs that she will be taking care of the IVs today. The nurse should tell her manager about how this is an non-delegable task & bring it up in their next staff meeting

A nurse has a personal facebook account. The nurse had a busy day at the hospital today. The nurse posts on facebook that the L&D unit at Capital Hospital was so busy today. She posted that she was frustrated since 2 RNs called off ill today. The nurse was careful not to mention any names in her post. She also did not mention that there was a fetal demise on the unit today and that she had to comfort the nurse that attended that delivery. Discuss if this Facebook post met legal and ethical guidelines.

This post is unethical because now I know where the nurse works, and what floor she works on. I now know that a patient on the floor lost a baby that day, and that they were short staffed.

Transcription Process

Transcription Process •1. Read original orders •2. Verify requisitions for lab, diagnostic tests, medications or referrals •3. Verify correct transcription of medication or treatment orders •Transcription may be done by unit clerks or UAP/UAW's; However, sign off of orders must be done by RN

Care coordination in nursing

Using the nursing process to develop plan of care for patient; using interdisciplinary care teams working together to achieve optimal health for the patient

Transformational Leader

a leader who is able to instill in the members of a group a sense of mission or higher purpose, thereby changing the nature of the group itself -looks at they future. They focus on achieving goals. They mentor and identify their vision and directions.

Information Power

access to and control over important information

Functional Nursing

charge nurse assigns all task on all patients to a larger group than directly to patients one RN passes meds, one RN assesses benefits- most economical drawback- fragmented, low nurse autonomy, low staff satisfaction

Charge Nurse

charge nurse manages the functioning of the unit during a shift. They make the assignments for the nurses and STNAs, and they respond to emergencies.

TeamSTEPPS call out

communicating important information. It calls attention to what is relevant. It identifies, labels, and communicates the facts. An example would be when you are intubating a patient you call out to the doctor and person documenting the medications you are given as you are giving them.

Ineffective Conflict Resolution- Avoiding

conscious avoidance of a problem thus not believing there is a problem.

Unfreezing

getting the people affected by change to believe that change is needed

Referent Power

influence based on identification with a person who has desirable resources or personal traits

Assignment

lateral transfer of assignment. a nurse assigns another nurse to give a medication the nurse & nurse being assigned are now both responsible for the patient

Transactional Leader

looks at day to day tasks. They look at work performance, and they reward for that work performance. They wait for a problem to arise then they deal with that problem.

Primary Care

nurse has 24 hour responsibility for planning, directing, and evaluating care through discharge -associate nurses care for patient when nurse is off duty but consult with the primary RN -benefits- RN is directing care, strong communication -drawback- implementation is difficult, it is expensive, some RNs do not want to be on call

What does the nurse need to know about transcribing orders from a nurse practitioner?

nurse needs to know that nurse practitioners have restrictions on schedule drugs and have to be in collaborative agreement with the MD

Communication components

people, message, channel, feedback, noise, shared meaning

Reward Power

power that comes from the ability to provide rewards or favors

Expert Power

power that is based on the special knowledge, skills, and expertise that a leader possesses

Refreezing

supporting and reinforcing new changes so that they stick

Connection Power

the ability to call on connections and networks both inside and outside the organization for support in getting things done and in meeting one's goals

Leadership

the ability to motivate individuals and groups to accomplish important goals

Relationship Based Communication

the building relationship of mutual respect, responsiveness, and values. It enhances patient and professional experience -types: intrapersonal, interpersonal, and transpersonal, therapeutic, and patient centered

Changing

the phase where a planned change actually takes place

Legitimate Power

the power a person receives as a result of his or her position in the formal hierarchy of an organization

Effective Conflict Resolution- Bargaining/Negotiating

to reach a level of agreement.

TEAMSTEPPS: situation monitoring

when you scan or survey the situation while anticipating the needs. This skill requires mutual respect and accountability of the team. For example, when we were in an ERT I saw the nurse was drawing a lactate, so I ran and grabbed a biohazard bag, and I filled it with ice.

Supervision

•"Active process of directing, guiding and influencing the outcome of... the performance of a task." (ANA, 2005). • •"The provision of guidance and direction, oversight, evaluation and follow up by the licensed nurse for accomplishment of a nursing task delegated to nursing assistive personnel." (NCSBN, 2005).

Impact of Care Coordination Estimates

•24% Reduction in hospital use •15% Fewer emergency department visits •37% Reduction in days in skilled nursing facilities •75% Less in charges to Medicare/Medicaid over uncoordinated care •$133.5 Billion in annual healthcare spending •$75.000 in Medicare savings / care coordinator nurse hired.

Role of RN Care Coordinator: Domain 3

•3. Communication •Skills for collaboration & teamwork •Active listening skills •Counseling skills •Interviewing skills •Conflict resolution skills •Group dynamics management •Skills in effective team building •Skills in relationship management

Role of RN Care Coordinator: Domain 4

•4. Education / Coaching •Knowledge of adult education principles •Teaching/learning techniques •Barriers to learning •Skills in facilitating behavior change

Role of RN Care Coordinator: Domain 5

•5. Health Insurance & Benefits •Knowledge of health insurance systems •Knowledge of payer sources & benefits •Knowledge of managed care •Knowledge of public & private program benefits

Role of RN Care Coordinator: Domain 6

•6. Community Resources •Familiarity with public & private community providers & services • •Knowledge of support services in geographic area

Role of RN Care Coordinator: Domain 7

•7. Research & Evaluation •Skills in EBP evaluation process. •Understanding of quality improvement techniques. •Skill in collecting, analyzing and synthesizing population outcome data. •Writing competency for grant proposals to fund programs to improve health outcomes related to prevention and management of chronic diseases in populations.

Prioritization

•A decision-making process. •Deciding which needs / problems require immediate action over other needs that can be delayed. •Consider relationship between task and outcome. •Consider likely outcome if delayed. •Consider time to complete task.

Lateral/horizontal Violence

•An act of aggression towards another colleague (physicians, nurses) •Verbal or Emotional •Overt or covert •Physical •Belittling •Withholding of information •Excluding a colleague from a group activity

Care Coordination Strategies at Staff Nurse Level- Improving Patient Engagement & Self Care Practices

•Assessing health status. •Developing plan of care •Evaluating capacity, readiness, energy level, social supports, and skills to organize and manage their plan. •Coaching & educating family.

Non-delegable functions of the room

•Assessments that identify needs, problems or diagnoses •Surveillance of patient status •Care planning •Health counseling or teaching (i.e.. Pre-op teaching, discharge teaching, teaching of therapeutic regimens) •Evaluation •Any task requiring judgment of RN •Tasks requiring complex observations or critical decisions

Warning signs of violence

•Attendance issues •Carelessness in work habits •History of physical violence •Performance problems •Personality changes •Poor hygiene •Substance abuse •Patient emotional escalation •Family members escalation in frustration •Unfamiliar or agitated visitors

Ineffective Communication

•Careless comments can have significant and enduring negative effects on relationships.

Conflict

•Communication that results in disagreement and misunderstanding. • •Interaction involves stress, competition, hostility or opposition. • •Productive Conflict: Can result in constructive and positive outcomes. • •Unproductive Conflict: Can cause damage to relationships, processes or functioning.

Conflict Resolution

•Conflict is seldom created intentionally •May occur because of lack of awareness of how our own behavior contributes to interpersonal problems •FIRST STEP: Recognize one's own conflict resolution style •Common conflict resolution styles •Avoidance: one person uses passive behaviors and withdraws from the conflict; neither person is able to pursue goals •Accommodation: one person puts aside his/her goals in order to satisfy the other person's desires •Force: one person achieves his/her own goals at the expense of the other person •Compromise: both people give up something to experience partial goal attainment •Collaboration: both people actively try to find solutions that will satisfy them both Second step is to engage in active listening ØReduces the emotional charge from the situation ØActive listening techniques I.Paraphrasing II.Reflecting III.Open questioning IV.Acknowledging V.Summarizing VI.Framing VII.Reframing Third step is that all people involved must view their conflict as a problem to be solved mutually

Communication of Critical Patient Tests

•Critical Lab or Test Values •Often reported by labs or departments to RN •Require communication to practitioner with scope of practice to act on result •Avoid assuming that the report is also being communicated to prescriber MD, PA, or APRN •Communicate and document •If prescriber is unavailable follow chain of command to make contact with the one responsible in interim •Trying to contact is not enough •RN is legally responsible to assure resolution

Ineffective Methods without Care Coordination

•Discharge Summaries Transfer Reports Lab Reports Reports of procedures/interventions Fragmented approach •One-way communication •Potential for informational gaps or misunderstanding •Does not assist patient with navigation of system •Lacks follow up to assure patient understanding or adherence to treatment plan

Vertical Violence

•Disruptive behavior, conflict or communication violence between managers and staff •Abusive communication •Harsh Criticism •Aggressive / authoritarian •Overuse/inappropriate use of legitimate power •Harassment

Assignment

•Distribution of work to staff members responsible that are accountable for the work in the legal scope of practice, job description, training and experience •Lateral level distribution of work •Example: Care of a group of patients on an inpatient unit are assigned by a charge nurse to an RN for a shift •Example: RN asking another RN to hang a piggyback antibiotic on assigning RN's patient •UAP/UAW's and LPN's are assigned to a nurse and are delegated tasks to perform (NOT patients to care for). •RN is responsible for coordination of other interdisciplinary team members. •Other disciplines have own scope of practice and supervisors. •RN works collaboratively with other licensed disciplines. •RN is still accountable for the patient status.

Care Coordination Activities

•Exchange of information among care participants responsible for different aspects of care (McDonald et al, 2014). • Organization of personnel & resources to carry out required patient care activities among providers and organizations

Care Coordination Strategies at the Staff Nurse Level- Promoting safety & reducing risks in and out of hospital

•Falls Prevention •Medication Error Prevention •Improved Inter / Intra Professional Communication •Improved Teamwork •Education for patient to recognize problems or adverse events early & report

Role Of LPNs

•Functions at the direction of the RN. •Dependent role •Contributes to assessments & re-assessments. •Collects data on patient health status. •Contributes to nursing care plan. •Administers meds and treatment that they are authorized to by ORC 4723. •Documents data and interventions. •May delegate to UAP/UAW's under direction of RN •RN is accountable for all aspects of nursing care. •RN does not need to co-sign documentation unless co-sig of 2 is required or if LPN is performing as a delegatee for RN •RN must be on-site for supervision of IVs if LPN is qualified for peripheral IV therapies. •LPN's many NOT teach nursing practice. •LPN's may NOT practice without RN direction.

Regulations for Delegation

•Governed by State Boards of Nursing (BON). •Ohio Administrative Code: 4723-13. •At times restricted or over-stepped (not legal) by individual organizations. •An organizational job description or policy cannot override the law and rule of the Board of Nursing. •Know and check non-delegable functions of the RN with BON.

Care Coordination Strategies at the Staff Nurse Level- Reducing Healthcare Acquired Conditions

•Hand hygiene •Influenza prevention •CLABSI prevention •CAUTI prevention •Pressure ulcer prevention

Care Coordination Strategies at Staff Nurse Level- Medication Management

•Improve patient understanding of instructions for newly prescribed, ongoing or discharge meds. •Improve patient understanding of early warning signs & symptoms. •Improving access to patient with health information ("go-to") resource to prevent crises r/t med issues. •Stressing use of decision aids and reminders.

Impact of Care Coordination

•Improved patient experience •Better long-term outcomes •Fewer re-admissions •Fewer repeated tests •Fewer conflicting prescriptions •Clearer course of treatment •Estimated $133 billion in annual healthcare cost savings

Other Non-Delegable Tasks under ORC

•Initiating or Managing IVs (can with IV-med certification) •IV push meds (can with IV-med certification) •Piggyback meds or IVs with additives (can with IV-med certification; not cannot initiate first dose) •Changing IV tubing, programming infusion pumps; flushing intermittent IV access devices (can with IV-med certification) •Infusing blood products (cannot at all; except stop w/possible complication) •Cancer chemotherapies (cannot at all) •Mixing or reconstituting meds (can with IV-med certification) •Managing /infusing via/ flushing or discontinuing central lines. (cannot at all)

lateral violence

•Interpersonal Conflict-Nurse-Nurse, Nurse-Physician, Nurse-multidisciplinary communication......... •Harassment •Intimidation •Tall Poppy Syndrome: Cutting down those who succeed. •Harsh criticism •Sabotage •Targeting blame •Gossiping •Physical and/or Emotional Abuse

Delegation to LPN's at the direction of the RN

•LPN's with extra course (40 hr) in medication and IV therapy may be qualified and have restricted role in medication administration and IV infusions in adults. •May initiate or maintain IV of D5W, NS, LR, sodium chloride.45, .03 or 0.2. •May regulate peripheral IV's at prescribed flow rate. •May change routine peripheral or central line dressings. •May change tubing on peripheral line. •May D/C peripheral IV •May prepare IV antibiotics. •Initiate or maintain IV with antibiotic; may not initiate additives that are not antibiotics; can manage after initiated by RN. •Hang subsequent IV solutions if RN initiated the same solution. •May flush intermittent infusion device with NS or Heparin flush only. •May administer PO, IM, SQ meds.

Transcription of Prescribed Orders

•Legal Nursing Responsibility •Verify orders •Assure orders are implemented correctly •Sign off on transcription •Legal Prescribers •MDs •Physicians Assistant: PA (with restrictions on scheduled drugs) •APRN's: NP, CNS, CNM (with restrictions on scheduled drugs and collaborative agreement with MD •Medical Students require MD co-signature

Response

•Maintain a calm, caring attitude. •Do not match the threats or give orders. •Reassure the person's feelings of being frustrated. •Remove yourself from the situation and call security for help. •Report any violence incidences to management.

Risks Of Delegation

•Miscommunication •Missed care requirements •Multiple assistive personnel report to multiple RNs in structure of care delivery. •Low quality nursing tasks •Lack of motivation of UAP/UAW's •Lack of skill or knowledge for the task •Mistaken assumptions of routine care; what is being done may not be what should be done

Types of Prescribed Orders

•One-time or continuing orders •PRN Order •Not permitted for restraints •Standing Order •Pre-signed set of orders for specific procedures or conditions •STAT Order •Order to be implemented one time & immediately •Verbal Order Order that nurse writes verbatim from prescriber via phone or in person

Prioritization Triage

•Priority 1 - Emergency •Life-threatening conditions • •Conditions requiring continuous care for survival • •Trauma, resp. distress, chest pain/MI/cardiac arrest, active bleeding, amputations, neurologic deficits, chemical splashes or contamination •Priority 2 - Urgent •Req. 30 - 60 minute evaluation •Conditions leading to severe complications if not treated in 1-2 hours. •Simple fracture, asthma without respiratory distress, fevers, HTN, ABD pain, renal or gall stones etc. •Priority 3 - Non-urgent •Needs treatment but not life-threatening or causing severe complication in next 2 hours. •Minor laceration, sprains, strains, cold/flu, minor infections, fevers

Role of RN in Care Coordination

•RNs have opportunity to play a significant role in care coordination now and in the future. • •Care Coordinator role has been well supported and highlighted in the literature: •The Future of Nursing (IOM, 2011; 2012). •U.S. Health and Human Services Department (2013). •Robert Wood Johnson, Leap Project (2012). •Strategies to improve patient adherence to plan of care. •Strategies to reduce barriers to adherence to plan of care. •Strategies to reduce likelihood of hospital re-admissions. •Strategies to improve safety & prevent healthcare acquired conditions

RN accountability for delegation

•The nurse retains the "accountability" for the delegation. •Assessment of the patient • •Supervision of the person the delegated to • •Evaluation of the task completed • •Evaluation of the patient status.

Impact from lack of care coordination

•Unnecessary medical procedures •Redundancy & over-use of tests and procedures •Conflicting care activities •Decreased patient adherence to treatment plan •Poorer patient outcomes

Signs of Physical Violence

•Use of profanity •Staring, gaze, pointing •Verbal threats •Clenched jaws or fists •Increased movements •Increased respirations •Mismatch between verbal and non-verbal signs

Professional Response to Verbal Conflict

•When conversation is escalating, try to move to private location •Speak in a normal tone of voice •Use "I" messages •Maintain eye contact throughout •Maintain an open body stance with your hands at your side or open toward the individual (but not invading the other person's space) •Do not physically back away unless you perceive you are actually in physical danger •Offer explanations, but do not make excuses •If you say you will take care of something, or report something, or change something, do it

violence risk factors

•Working with nurses under the influence of drugs and/or alcohol •Patients under the influence of drugs and/or alcohol •Patients and families under stress of illness, finances, etc. •Hospitals are open doors to the public; external conflicts can enter in •Understaffing •Working in community-based settings •Isolated work with patients undergoing exams and treatments

Effective Conflict Resolution- Problem Solving

•finding a workable solution for all involved.

Ineffective Conflict Resolution- Withholding or Withdrawing

•removing yourself from a situation but does not resolve the conflict.

Ineffective Conflict Resolution-Competing

•satisfying your needs at another's expense.

Ineffective Conflict Resolution-Reassuring

•try to make everyone happy about a situation, but may be a way to avoid or hinder open lines of communication.

Ineffective Conflict Resolution- Accommodating

•vertical conflict when one thing is important to somebody but unimportant to others.

Effective Conflict Resolution- Compromising

•working together for mutual solution.