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a nurse manager is providing an inservice program about delegation to AP with staff nurses on the unit. Which of the following statements by a staff nurse indicates an understanding of the teaching? Responsibility of the nurse: client education, data interpretation, client status, accountability, delegation decisions

"The nurse should consider the AP's level of experience when making delegation decisions." When delegating a task, the nurse should delegate the task to the right person. The nurse should consider the AP's job description, level of knowledge, and individual level of experience.

Meso Systems

-"The container", the middle ground. -collection of multiple microsystems that are present in a macro system -Example: Dignity Health-St Josephs Hospital, it is the Container for the larger Macrosystem and holds many Microsystems -Example: CHI Health- St. Francis in Grand Island would be considered a Mesosystem of the larger Macrosystem and holds many Microsystems. -Definition: the organization, a collection of interrelated microsystems that provide care to.a shared population of patients

Microsystem

-"the inside" -small groups of people who provide care to a subpopulation of patients -This would be one unit or department within the Mesosystem (Container) or hospital -Definition: the front lines of care where patients, families, and care teams meet

Nursing Assistant/UAP Responsibilities

-Bathing, feeding, I&O, vital signs, ambulation -no legal scope of practice -knowledge of basic tasks

Macro Systems

-Broad, "the outside", the largest part of the system -Examples: US healthcare system, a global health system or an individual health care system. Dignity Health, CHI health or the combined larger entity Common Spirit Health -Examples: Public Health System, Environmental Health, Global Health System, Health Care System

Application to Critical Thinking/Clinical Judgment

-Staffing/Floating who should? new nurse? seasonsed? expert? inbetween? take turns

LPN Responsibilities

-dependent role with limited scope -IV's per institution/state -scope of practice cannot be expanded, only limited by institution

Delegation Communication

-focus on outcomes of patient care -who, what, when, where, how -key components: trust, communication, feedback -patient advocacy requires critical communication Template: •State exactly what is being delegated and what the expected outcome is. •Convey recognition of the authority to perform what is expected. •Identify priorities. •Acknowledge monitoring activities you may perform. •Specify any performance limitations, such as time limits on performing a procedure. •Specify deadlines, including exact timing if that is important. •Specify report time lines and data expected. •Specify parameter deviations, including when immediate action must be taken. •Identify appropriate resources, including people who may be consulted. •Be clear about what may not be delegated

RN

-independent and dependent -scope of practice cannot be expanded only limited

HCO Interrelated Concepts

-informatic -leadership -communication -healthcare quality -professionalism -health policy economics

Right Task

-is it appropriate to delegated based on legal and facility? -is the person able and willing to do this specific task?

A nurse is planning care for a group of clients. the nurse should delegate obtaining vital signs to an AP for which of the clients?

1. An older adult client who has a history of heart failure and is ready for discharge 2.A young adult client who is 24 hr postoperative following an appendectomy 3. An older adult client who is 36 hr postoperative from a traditional cholecystectomy Rationale: The nurse should delegate obtaining vital signs for clients who are stable or have a chronic condition.

4 Things RN CANNOT delegate

1. Assessment 2. Planning 3. Evaluation 4. Nursing Judgement

Nonlinear approach to change

1. Chaos theory •In a rapidly changing world/environment - emphasis on rules and policies is shortsighted, wastes time, and fails to accomplish goals over time •Constant adaptation •Cycle of change - periods of stability interrupted by periods of intense transformation 2. Learning Organization Theory •Emphasis on flexibility and responsiveness •Senge's (1990) five disciplines 1. Systems thinking 2. Personal mastery 3. Mental models 4. Shared vision 5. Team learning 3. Kotter's 8 Step Model 1. Create Urgency 2. Form A powerful Coalition 3. Create a vision for change 4. Communicate the Change Vision 5. Remove Obstacles 6. Create short-term wins 7. Build on Change 8. Anchor the Changes in the culture

Critical Communication

1. State the facts (this care is substandard). If that does not correct the situation... 2. Challenge (use his or her first name and a qualifier [e.g., Susan, isn't this a sterile procedure?]), and if that does not correct the situation... 3.Take action (intervene).

Five Rights of Delegation

1. right task 2. right circumstance 3. right person 4. right direction and communication 5. right supervision

Historical Perspective

6 aims for improvement based on core healthcare needs: •Safety •Patient-centered •Effective (based on EBP) •Timely services •Efficient services Equitable care delivery IOM 10 Rules for Redesign (of the HC system): •Care is based on continuous healing relationships. •Care is customized according to patient needs & values. •The patient is the source of control. •Knowledge is shared & information flows freely. •Decision making is evidence-based •Safety is a system property. •Transparency in necessary •Needs are anticipated. •Waste is continuously decreased. Cooperation among clinicians is a priority

a nurse in the med-surg unit is assigning client care to a nurse who is floating from the PACU. the nurse should recognize that the float nurse is more qualified to care for which of the following clients?

A client who is postoperative following a lobectomy and has a chest tube Rationale: According to evidence-based practice, the nurse from the PACU is most qualified to care for the postoperative client. Nurses in the PACU care for clients with chest tubes after surgery. This is the right client, the right task, and the right circumstances for this nurse.

Organization

A group of people who come together for a purpose or as a collection of people brought together for a predetermined purpose in a defined environment. Components: Structured social arrangements using systematic strategies to combine and coordinate resources (people and capital $$) to provide specfic products or services Formal Properties: rules, policies & Procedures Informal Properties: customs, norms and values

Critical Thinking and Clinical Judgement

Ability to use the cognitive skills of interpretation, analysis, evaluation, inference, and explanation to formulate judgments about a patient's needs and to make effective decisions about an actual or potential clinical situation or problem.

An AP reports a client's vitals as 98.8 F, 92 bpm, 18 breaths/min, BP 80/58 mmHg. Which vitals should the nurse re-take?

BP Rationale: A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.

Linear vs Non-Linear

Classic Lewin's Change Model vs. Chaos Theory and Learning Organization Theory and Kotter's Eight Step Model

Supervision

Definition: The active process of directing, guiding, and influencing the outcome of an individual's performance of an activity Supervising the delegatee. RN is responsible for: 1. analyzing data gathered 2. accountable for initial assessment 3. accountable for intermittent evaluation RN Delegator: amount of direct care work may decrease, supervisory work increases

Organizational Culture

Definition: The reflection of the norms or traditions of the organization as exemplified through behaviors that illustrate the values and beliefs of the organization. -(dis)connect between written word and how people actually perform with the mission -Values and beliefs and how they are enacted are also evident in the characteristics of organizational structures

Organizations in Healthcare

Goal: be a change agent How: nurses who know their organizational culture --> transform it 1. Know the mission (the design) -it leads the direction for the journey the organization is on so that everyone can go in the same direction at the same time. 2. know the vision (the goal) -It sets the goal for everyone in the organization to strive towards. 3. Know the philosophy/values (the structure) -It conveys the core values that describe the culture of the organization.

National Standards can be limited by State _________ _______ ________. State Standards can be limited by Agency or Organization Policies.

Nurse Practice Act

Organizational Characteristics

Organizational designs are often classified by these characteristics: 1. Complexity -concerns the division of labor, how specialized that labor is, the number of hierarchical levels, and the geographic dispersion of the units 2. Formalization -amount of structure an organization has in terms of rules or policies. Often, highly specialized organizations with lots of professionals have little formalization 3. Centralization -where decisions are made -if everyone has to ask someone else, the organization is highly centralized, Highly centralized organizations delegate responsibility without authority to act, Patient-side nurses are often frustrated with this approach because they see the decisions to be made evolving as care is being provided. -If the organization is highly decentralized, each employee is charged with decision-making authority to provide the best inpatient care.

A nurse on the postpartum unit is caring for a group of clients with an AP. which tasks should the nurse delegate to the AP?

Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. Providing comfort measures is an appropriate task that can be delegated to the AP since it does not require nursing judgment.

HCO Consequences

Public trust: •Is a social contract between the public and the organization. •Fraud and abuse allegations and national corporate chains of for-profit institutions impact this trust. •Employee and staff satisfaction •Cost effective care •Able to meet MISSION AND MARGIN! •POSITIVE PATIENT OUTCOMES!

Attributes of HCO

Purpose: help others regardless of the profit status or ownership arrangements, determined by the organization's mission, vision, and values. Major: 1. Must be Specialized: -Provide highly specialized care -Have a highly specialized workforce -Provide care that is complex with a narrow margin for error -Have little to no tolerance for mistakes that are life-threatening or costly 2. Must have Public Trust: -Have a social contract between the public and the organization -May do community health fairs, community gardens -Negative effects of public trust include fraud and abuse allegations Minor: These are the Formal Rules & Policies that govern organizational practices These are necessary for the integration of diverse functions and activities across the organization.

Health Care Organization (HCO)

Purposefully designed structured social system developed for the delivery of health care services by a specialized workforce to defined communities populations or markets Concept: A network of interdependent systems developed for the delivery of healthcare services by specialized workforce for defined communities, populations or markets

a nurse checks with AP on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

Right supervision Rationale: The nurse is demonstrating the right supervision when she assesses how the tasks are being accomplished and if any improvements are needed.

A nurse in a LTC is planning care for several clients. Which activities should the nurse delegate to the LPN? LPN cannot take part in the nursing process or things that require nursing judgment i.e. admission assessment, assessing changes, teaching, but they CAN reinforce prior teaching

Scheduling a diagnostic study for a client Rationale: The LPN can schedule a diagnostic study as this does not involve assessment or nursing judgment as part of the nursing process.

Systems Theory

Structure, Technology, People, Environment Focus: •Inputs- resources (Money, Materials •Through puts (Process that produces a product) •Outputs (The end product of the input and throughput)

when planning delegation of tasks to AP, a nurse considers the five rights of delegation. which of the following should the nurse consider when using one of the five rights of delegation?

The AP has the knowledge and skill to perform The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.

an RN is making nursing staff assignments for his team consisting of himself, 2 LPNs, and 1 AP. which of the following clients should he (RN) assumed responsibility for? LPN can: responsibility for ambulation and isolation and post-op dressing change AP can: delegated ambulation

The client who is actively dying and requires IV pain medication Rationale: The nurse should assume responsibility of this client because IV pain medications should be administered by RNs. Although this client may require less physical care, he may require more emotional care. The nurse should plan to spend extensive time with both the client and his family.

Assignment

The distribution of work that each staff member is responsible for during a given work period

a charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. which of the following factors should the charge nurse consider?

The physiologic status of the clients on the unit Rationale: Making assignments requires knowing the physiologic status of the clients on the unit, such as the stability of the client's' vital signs, the amount of health education they need, and the complexity of care involved. Clients who have an unstable physiologic status may require a higher level of skilled care.

Right Circumstance

The right circumstances include delegating tasks that do not require independent nursing judgment.

Right Communication

The right communication includes providing clear explanations about the tasks, client outcomes, and when the delegate should report to the nurse.

Right Person

The right person means delegating to the individual who is competent and qualified.

Delegation Definition

The transfer of authority to perform some type of task or work Care itself is not delegated - only the tasks

HCO Defining Characteristics

Things that qualify proper functioning: •Leadership •Critical thinking •Systems Thinking •Understanding of Profit / not for profit •Value based vs fee for service •Mission, Vision Philosophy Organization ownership

Purpose of Delegation

To effectively expand your care giving ability to a large group of clients

Delegation Process: 4 Client Factors

When transferring authority: 1. Safety 2. Critical Thinking 3. Stability 4. Time and Supervision

Mission, vision, and values/philosophy statements accomplish what

demonstrate how an organization will accomplish its work, operate productively within itself, and how processes will be influenced overall. All of these influence professional nursing practice, the place where nurses and future nurses practice the art and science of caring for patients.

Complexity theory attempts to explain complex behavior that emerges from dynamic _____-_________ systems

non-linear systems.

HCO Type of Care: Secondary

provides disease prevention or disease restorative care Purpose: prevention of disease complications Organization or Unit: home health care, ambulatory care centers, free standing ER, nursing centers

HCO Type of Care: Primary

providing first access or entry into the system Purpose: entry into system, health maintenance, chronic care, tx of temporary non incapacitating malfunction Organization or Unit Providing Services: ambulatory care centers, physician's office, nursing centers, health maintenance organizations, school health clinics

HCO Type of Care: Tertiary

rehabilitative and long term care Purpose: rehabilitation and LTC Organization/Unit: home health care, LTC facilities, rehabilitation centers, skilled nursing facilities, assisted living programs/retirement

Clinical Microsystems

•...a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients. It has clinical and business aims, linked processes, and a shared information environment, and it produces performance outcomes. •evolve over time and are often embedded in larger organizations •complex adaptive systems [responsible for] the primary work associated with core aims, meet the needs of internal staff, and maintain themselves over time as clinical units.

HCO Importance to Nurses

•As the largest health care workforce, nurses are found in nearly all health care organizations. •Nurses provide the knowledge and skills necessary for the delivery of health care services. •The multiple roles that nurses play are found in health care organizations.

Assumptions of Systems

•Bigger systems (macrosystems) are made of smaller systems •The smaller systems (microsystems) produce quality, safety, & cost outcomes at the front lines of care •The outcomes of the macrosystems can be no better than the microsystems of which they are composed

Linear Approach to change

•Change occurs in a sequential & directional way, guided by effective change agents •Assess barriers and facilitators •Three stages 1. Unfreezing (getting people on board) 2. Experiencing the change (going through the change) 3. Refreezing (sustaining the change)

Strategies of Change Management

•Consider demographic variables •Establish and promote constant feedback & communication loops •Support training - convenient and just in time •Involve early adopters from the beginning •Include change implementation in annual reviews •Create project priorities so staff not overwhelmed •Promote prioritization & accountability through entire process •Facilitation & support •Empowerment of staff through participation and involvement •Negotiation and agreement •Cooptation •Manipulation •Coercion •Information management Bringing people along

HCO Risk Factors

•Health Care Regulations- TJC, CMS, Think back to Scope and Standards lecture Accrediting bodies •Workforce- Nursing Shortage •Economics •Technology- EMR, Other state and national laws mandating safe transfer of PHI between providers. - Meaningful Use MACRA

Characteristics of Critical Thinking and Critical Judgment

•Interpersonal characteristics of the RN •Theoretical and Experiential Knowledge of the RN •Context/ Environment of care •Knowing YOUR patient(s) •Holistic view of the client situation •Process orientation •Reasoning and Interpretation

Accountability

•Means that someone must be able to explain actions and results •Legally - the RN is accountable for nursing care

Responsibility

•Means the reliability, dependability and obligation to accomplish work at an acceptable level

5 Functions of Change Management

•Planning (includes assessment) •Organizing •Implementing •Evaluating Seeking feedback -- key

Examples of Microsystems

•Public Health Departments •Community Clinics- children's clinic, primary care, etc. •Departments - laboratory, x-ray, nutrition services, administrative, etc. Units - surgical, psychiatric, medical, family care, etc

Principles of effective Change Implementation

•Recipients of change believe they own the change •Administrators and key personnel support the proposed change •Recipients of change anticipate benefit from the change •Recipients of change participate in identifying the problem warranting the change •The change holds interest for the change recipients and other participants •The change process is designed to provide regular feedback to participants

Examples of Macrosystems

•Society •Political systems •Economics •Ideas & attitudes •Broad healthcare systems •Public Health System •Environmental Health •Global Health •Healthcare System

Complex Adaptive Systems

•Theory based in research conducted in sciences (Mathematics, Biology, Physics, complexity science) •Look at how systems behave. •Identify that healthcare has interactions between social and technical forces that influence organizational design •Non Linear approach to change meaning the healthcare environment is complex unpredictable and interactive. •Key word: Adaptive- meaning in the health care environment organizations must be able to continuously and dynamically change. •Power is relocated to the point of service decision making (de-centralized) (Nurses making decisions at the bedside if the issue pertains to a patient issue where the bedside nurse is most directly involved) "A structure that allows for change and supports efficient work process and satisfaction is essential to achieve the desired excellence.A flat, decentralized structure is the hallmark of organizations who have achieved Magnet accreditation and high levels of excellence."

HCO Antecedents

•U.S. Healthcare system •Public Health, Government, Non Government •Local; regional and national •Payment systems •Value Based- pay based on performance (Quality) •Fee for Service- •Skills of workforce •Technology, teamwork, communication, culture, adaptation to change

Chaos Theory

•Universe is filled with unpredictable and random events Organization musts: •Be self organizing •Accept and adapt to changes •Managers must be creative, who can take risks, experiment with new ideas to respond to constant changing of situations.