ATI Leadership and Management !!!

Staffing

Acquisition and management of adequate staff and staffing mix

Leadership styles

Authoritative. Democratic. Laissez-faire. Transformational. Transactional.

Assertive communication

Can be necessary during conflict negotiation. Allows expression in direct, honest, and nonthreatening ways that do not infringe upon the rights of others. A communication style that acknowledges and deals with conflict, recognizes others as equals, and provides a direct statement of feelings.

Sentinel event

Client death or client care resulting in serious physical injury.

Clinical judgment

Decision made regarding a course of action based on a critical analysis of data. Clinical judgment considers the client's needs when deciding to take an action, or modify an intervention based on the client's response.

Planning

Decisions regarding what needs to be done, how it will be done, and who is going to do it.

Outcome audits

Determine what results, if any, occurred as a result of the nursing care provided.

Considerations for selection of an appropriate delegatee

Education, training, and experience. Knowledge and skill to perform the task. Level of critical thinking required to complete the task. Ability to communicate with others as it pertains to the task. Demonstrated competence. The delegatee's culture. Agency policies and procedures and licensing legislation (state nurse practice acts).

Qualities of leaders

Initiative. Inspiration. Energy. Positive attitude. Communication skills. Respect. Problem-solving and critical-thinking skills.

Laissez‑faire

Makes very few decisions, and does little planning. Motivation is largely the responsibility of individual staff members. Communication occurs up and down the chain of command and between group members. Work output is low unless an informal leader evolves from the group. Effective with professional employees.

Examples of tasks nurses may delegate to PN

Monitoring findings (as input to the RN's ongoing assessment). Reinforcing client teaching from a standard care plan. Performing tracheostomy care. Suctioning. Checking NG tube patency. Administering enteral feedings. Inserting a urinary catheter. Administering medication (excluding IV medication in some states).

Organizing

Organizational structure that determines the lines of authority, channels of communication, and where decisions are made.

Who RNs may delegate to

Other RNs, PNs, and APs.

Five major management functions

Planning. Organizing. Staffing. Directing. Controlling.

Process audits

Review how care was provided and assume a relationship exists between nurses and the quality of care provided.

5 rights of delegation

Right task. Right circumstance. Right person. Right direction/communication. Right supervision/evaluation.

5 stages of conflict

Stage 1: Latent conflict. Stage 2: Perceived conflict. Stage 3: Felt conflict. Stage 4: Manifest conflict. Stage 5: Conflict aftermath.

Cost‑effective

Strategies that achieve optimal results in relation to the money spent to achieve those results. In other words cost‑effective means "getting your money's worth." Example: Spending increased money on staff training for transmission‑based precautions resulting in the increased and effective use of PPE for client care. These actions have the end result of a decrease in infection transmission and an overall savings in the cost of caring for clients who would have acquired these infections.

Types of audits

Structure audit. Process audit. Outcome audit.

Proficient nurse

These are nurses who have a significant amount of experience upon which to base their practice. Enhanced observational abilities allow nurses to be able to conceptualize situations more holistically. Well‑developed critical thinking and decision‑making skills allow nurses to recognize and respond to unexpected changes.

Role of licensed nurse for delegating and supervising:

A licensed nurse is responsible for providing clear directions when a task is initially delegated and for periodic reassessment and evaluation of the outcome of the task. RNs must be knowledgeable about the applicable state nurse practice act and regulations regarding the use of PNs and APs. RNs must delegate tasks so that they can complete higher level tasks that only RNs can perform. This allows more efficient use of all members of the health care team.

3. A PN ending her shift reports to the RN that a newly hired AP has not calculated the intake and output for several clients. Which of the following actions should the RN take? A. Complete an incident report. B. Delegate this task to the PN, C. Ask the AP if she needs assistance. D. Notify the nurse manager.

A. An incident report is indicated when a critical incident has occurred. It is not necessary to complete an incident report in this situation. B. The nurse should not redelegate a task. C. CORRECT: The nurse should find out what the AP knows about performing the task and provide education for the AP if indicated. D. The RN is capable of handling the situation. It is not necessary to notify the nurse manager.

5. A nurse manager is providing information about the audit process to members of the nursing team. Which of the following information should the nurse manager include? (Select all that apply.) A. A structure audit evaluates the setting and resources available to provide care. B. An outcome audit evaluates the results of the nursing care provided. C. A root cause analysis is indicated when a sentinel event occurs. D. Retrospective audits are conducted while the client is receiving care. E. After data collection is completed, it is compared to a benchmark.

A. CORRECT: A structure audit evaluates the setting in which care is provided and includes resources such as equipment and staffing levels. B. CORRECT: An outcome audit evaluates the effectiveness of nursing care. It should include observable data, such as infection rates among clients. C. CORRECT: A root cause analysis is indicated when a sentinel event occurs. A sentinel event is a serious problem such as injury to or death of a client. Immediate investigation of the problem is indicated. The health care team can use root cause analysis to study the problem and take measures to prevent reoccurrence. D. Retrospective audits are conducted when the client is no longer receiving care. E. CORRECT: The benchmark is set at the beginning of the process and then it is compared to the data after collection is completed.

Conflict resolution strategies

Avoiding/withdrawing. Smoothing. Competing/coercing. Cooperating/accommodating. Compromising/negotiating. Collaborating.

Avoiding/withdrawing

Both parties know there is a conflict, but they refuse to face it or work toward a resolution. Can be appropriate for minor conflicts or when one party holds more power than the other party or if the issue can work itself out over time. Because the conflict remains, it can surface again at a later date and escalate over time. This is usually a lose‑lose solution.

Novice nurse

Can be students or newly licensed nurses who have minimal clinical experience. They approach situations from theoretical perspective relying on context‑free facts and established guidelines. Rules govern practice.

Benchmarks

Goals that are set to determine at what level the outcome indicators should be met.

Orientation

Helps newly licensed nurses translate the knowledge, skills, and attitudes learned in nursing school into practice.

5 stages of nursing ability

Novice nurse. Advanced beginner. Competent nurse. Proficient nurse. Expert nurse.

Licensed personnel

Nurses who have completed a course of study, successfully passed either the NCLEX-PN or NCLEX-RN exam, and have a nursing license issued by a board of nursing.

Competing/coercing

One party pursues a desired solution at the expense of others. Managers can use this when a quick or unpopular decision must be made. The party who loses something can experience anger, aggravation, and a desire for retribution. This is usually a win‑lose solution.

Assistive personnel

Specifically trained to function in an assistive role to licensed nurses in client care activities. These individuals can be nursing personnel, such as certified nursing assistants (CNAs) or certified medical assistants (CMAs) or they can be nonnursing personnel to whom nursing activities can be delegated, such as dialysis technicians, monitor technicians, and phlebotomists. Some health care entities can differentiate between nurse and nonnurse assistive personnel by using the acronym NAP for nursing assistive personnel.

Latent conflict

The actual conflict has not yet developed; however, factors are present that have a high likelihood of causing conflict to occur. Example: A new scheduling policy is implemented within the organization. The nurse manager should recognize that change is a common cause of conflict.

Competent nurse

These are usually nurses who have been in practice for 2 to 3 years. They demonstrate increasing levels of skill and proficiency and clinical judgment. They exhibit the ability to organize and plan care using abstract and analytical thinking. They can anticipate the long‑term outcomes of personal actions.

Felt conflict

Those involved begin to feel an emotional response to the conflict. Example: A nurse feels anger towards the nurse manager after finding out that she is scheduled to work two holidays in a row.

Acute vs. chronic, urgent vs. nonurgent, stable vs. unstable

A client who has an acute problem takes priority over a client who has a chronic problem. A client who has an urgent need takes priority over a client who has a nonurgent need. A client who has unstable findings takes priority over a client who has stable findings.

Perceived conflict

A party perceives that a problem is present though an actual conflict might not actually exist. Example: A nurse perceives that a nurse manager is unfair with scheduling. The nurse might not be aware that in reality it is only because the nurse manager misunderstood the nurse's scheduling request.

Grievances

A wrong perceived by an employee based on a feeling of unfair treatment that is considered grounds for a formal complaint. Grievances that cannot be satisfactorily resolved between the parties involved can require management by a third party. Facilities have a formal grievance policy that should be followed when a conflict cannot be resolved. The steps of an institution's grievance procedure should be outlined in the grievance policy.

2. An RN on a medical‑surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the PN? A. Obtain vital signs for a client who is 2 hr postprocedure following a cardiac catheterization. B. Administer a unit of packed red blood cells (RBCs) to a client who has cancer. C. Instruct a client who is scheduled for discharge in the performance of wound care. D. Develop a plan of care for a newly admitted client who has pneumonia.

A. CORRECT: It is within the scope of practice of the PN to monitor a client who is 2 hr postprocedure for a cardiac catheterization. B. The RN is responsible for administering blood components including packed RBCs because this outside of the scope of practice for the PN. C. The RN is responsible for client education. It is within the scope of practice of the PN to reinforce but not provide initial client education. D. The RN is responsible for developing a plan of care for a client. It is within the scope of practice for the PN to suggest additions to but not develop the plan of care. NCLEX

1. A nurse enters the room of a client who is on contact precautions and finds the client lying on the floor. Which of the following actions should the nurse take first? A. Call the provider. B. Ask a staff member for assistance getting the client back in bed. C. Inspect the client for injuries. D. Instruct the client to ask for help if he needs to get out of bed.

A. The nurse should notify the provider to determine whether the client needs further examination and treatment, but there is another action the nurse should take first. B. The nurse should seek assistance in returning the client to bed to prevent further harm to the client, but there is another action the nurse should take first. C. CORRECT: The first action the nurse should take using the nursing process is to assess the client. D. The nurse should instruct the client to ask for help if he needs to get out of bed to help prevent future falls, but there is another action the nurse should take first.

The nurse uses clinical judgment to

Analyze data and related evidence. Ascertain the meaning of the data and evidence. Apply knowledge to a clinical situation. Determine client outcomes desired and/or achieved as indicated by evidence-based practices.

Collaborating

Both parties set aside their original individual goals work together to achieve a new common goal. Requires mutual respect, positive communication, and shared decision‑making between parties. This is a win‑win solution.

Actions to take when a nurse receives an unsafe assignment

Bring the unsafe assignment to the attention of the scheduling/charge nurse and negotiate a new assignment. If no resolution is arrived at, take the concern up the chain of command. If a satisfactory resolution is still not arrived at, the nurse should file a written protest to the assignment, such as an assignment despite objection (ADO) or document of practice situation (DOPS) with the appropriate administrator. Failure to accept the assignment without following the proper channels can be considered client abandonment.

Orientation to the unit

Classroom orientation usually moves onto the unit and is continued with an assigned preceptor. Preceptors assist in orienting newly licensed nurses to a unit and supervising their performance and acquisition of skills. Preceptors are usually assigned to newly licensed nurses for a limited amount of time. Mentors can also serve as a newly licensed nurse's preceptor, but their relationship usually lasts longer and focuses more on assumption of the professional role and relationships, as well as socialization to practice. Coaches establish a collaborative relationship to help a nurse establish specific individual goals. The relationship is often task related and typically time limited.

Categories of factors to consider in making assignments

Client factors. Healthcare team factors.

Client factors in making assignments

Condition of the client and level of care needed. Specific care needs (cardiac monitoring, mechanical ventilation). Need for special precautions (isolation precautions, fall precautions, seizure precautions). Procedures requiring a significant time commitment (extensive dressing changes or wound care).

Disciplinary action

Deficiencies identified during a performance appraisal or the course of employment should be presented in writing, and corrective action should be based on institutional policy regarding disciplinary actions and/or termination of employment. Evidence regarding the deficiency must support such a claim. Some offenses, such as mistreatment of a client or use of alcohol or other substances while working, warrant immediate dismissal. Lesser infractions should follow a stepwise manner, giving the staff member the opportunity to correct unacceptable behavior. Staff members who witness an inappropriate action by a coworker should report the infraction up the chain of command. At the time of the infraction, this might be the charge nurse. The unit manager should also be notified, and written documentation by the manager is placed in the staff member's permanent file.

Structure audits

Evaluate the influence of elements that exist separate from or outside of the client‑staff interaction.

Controlling

Evaluation of staff performance and evaluation of unit goals to ensure identified outcomes are being met.

Transactional leaders

Focus on immediate problems, maintaining the status quo and using rewards to motivate followers.

Clinical reasoning supports the clinical decision-making process by

Guiding the nurse through the process of assessing and compiling data. Selecting and discarding data based on relevance. Using nursing knowledge to make decisions about client care. Problem solving is a part of decision-making.

The emotionally intelligent leader

Has insight into the emotions of members of the team. Understands the perspective of others. Encourages constructive criticism and is open to new ideas. Is able to maintain focus while multitasking. Manages emotions and channels them in a positive direction, which in turn helps the team accomplish its goals. Is committed to the delivery of high-quality client care. Refrains from judgment in controversial or emotionally charged situations until facts are gathered.

Characteristics of managers

Hold formal positions of authority and power. Possess clinical expertise. Network with members of the team. Coach subordinates. Make decisions about the function of the organization, including resources, budget, hiring, and firing.

Circulation interventions

Identify circulation concern (hypotension, dysrhythmia, inadequate cardiac output, compartment syndrome). Institute appropriate actions to reverse or minimize circulatory alteration.

Democratic

Includes the group when decisions are made. Motivates by supporting staff achievements. Communication occurs up and down the chain of command. Work output by staff is usually of good quality: good when cooperation and collaboration are necessary.

Basis of delegation decisions

Individual client needs. Facility policies and job descriptions. State nurse practice acts. Professional standards (ANA codes of standards). Other legal/ethical concerns.

Common causes of conflict

Ineffective communication. Unclear expectations of team members in their various roles. Poorly defined or actualized organizational structure. Conflicts of interest and variance in standards. Incompatibility of individuals. Management or staffing changes. Diversity related to age, gender, race, or ethnicity.

Critical thinking skills

Interpretation. Analysis. Evaluation. Inference. Explanation.

Categories of conflict

Intrapersonal. Interpersonal. Intergroup.

Safety/risk reduction

Look first for a safety risk. For example, is there a finding that suggests a risk for airway obstruction, hypoxia, bleeding, infection, or injury? Next ask, "What's the risk to the client?" and "How significant is the risk compared to other posed risks?" Give priority to responding to whatever finding poses the greatest (or most imminent) risk to the client's physical well‑being.

Advanced beginner

Most new nurses function at the level of the advanced beginner. They practice independently in the performance of many tasks and can make some clinical judgments. They begin to rely on prior experience to make practice decisions.

Things an RN cannot delegate to PN or AP

Nursing process. Client education. Tasks that require clinical judgment. Any tasks not appropriate for the skill and education level of that particular health care team member.

Supervision

Occurs after delegation. A supervisor oversees a staff member's performance of delegated activities and determines if: Completion of tasks is on schedule. Performance was at a satisfactory level. Unexpected findings were documented and reported. Assistance is needed to complete assigned tasks in a timely manner. Assignment should be re‑evaluated and possibly changed.

Intergroup conflict

Occurs between two or more groups of individuals, departments, or organizations and can be caused by a new policy or procedure, a change in leadership, or a change in organizational structure. Example: There is confusion as to whether it is the responsibility of the nursing unit or dietary department to pass meal trays to clients.

Interpersonal conflict

Occurs between two or more people with differing values, goals, or beliefs. Interpersonal conflict in the health care setting involves disagreement among nurses, clients, family members, and within a health care team. Bullying and incivility in the workplace are forms of interpersonal conflict. This is a significant issue in nursing, especially in relation to new nurses, who bring new personalities and perspectives to various health care settings. Interpersonal conflict contributes to burnout and work‑related stress. Example: A new nurse is given a client assignment that is heavier than those of other nurses, and when he asks for help, it is denied.

Intrapersonal conflict

Occurs within the person and can involve internal struggle related to contradictory values or wants. Example: A nurse wants to move up on the career ladder but is finding that time with her family is subsequently compromised.

Smoothing

One party attempts to "smooth" another party by trying to satisfy the other party. Often used to preserve or maintain a peaceful work environment. The focus can be on what is agreed upon, leaving conflict largely unresolved. This is usually a lose‑lose solution.

Cooperating/ accommodating

One party sacrifices something, allowing the other party to get what it wants. This is the opposite of competing. The original problem might not actually be resolved. The solution can contribute to future conflict. This is a lose‑win solution.

Time management

Organize care according to client care needs and priorities. What must be done immediately (administration of analgesic or antiemetic, assessment of unstable client)? What must be done by a specific time to ensure client safety, quality care, and compliance with facility policies and procedures (routine medication administration, vital signs, blood glucose monitoring)? What must be done by the end of the shift (ambulation of the client, discharge and/or discharge teaching, dressing change)? What can the nurse delegate? What tasks can only the RN perform? What client care responsibilities can the nurse delegate to other health care team members, such as practical nurses (PNs) and assistive personnel (APs).

Delegating

Process of transferring the authority and responsibility to another team member to complete a task, while retaining the accountability.

Assigning

Process of transferring the authority, accountability, and responsibility of client care to another member of the health care team. Assigning is performed in a downward or lateral manner with regard to members of the health care team.

Process indicators

Reflect how client care is provided and are established by policies and procedures (clinical practice guidelines). Provide important information about how a procedure is being carried out.

Structure indicators

Reflect the setting in which care is provided and the available human and material resources.

Critical thinking

Reflects upon the meaning of statements, examines available data, and uses reason to make informed decisions. Critical thinking is necessary to reflect and evaluate from a broader scope of view. Sometimes one must think "outside the box" to find solutions that are best for clients, staff, and organization

Exposure interventions

Remove the client's clothing to allow for a complete assessment or resuscitation. Implement measures to reduce the risk for hypothermia by providing warm blankets and IV solutions and using a heating device if needed.

Conflict

Result of opposing thoughts, ideas, feelings, perceptions, behaviors, values, opinions, or actions between individuals. Inevitable part of professional, social, and personal life and can have constructive or destructive results. Nurses must understand conflict and how to manage it. Nurses can use problem‑solving and negotiation strategies to prevent a problem from evolving into a conflict. Lack of conflict can create organizational stasis, while too much conflict can be demoralizing, produce anxiety, and contribute to burnout. Conflict can disrupt working relationships and create a stressful atmosphere. If conflict exists to the level that productivity and quality of care are compromised, the unit manager must attempt to identify the origin of the conflict and attempt to resolve it.

Timing of audits

Retrospective audits occur after the client receives care. Concurrent audits occur while the client is receiving care. Prospective audits predict how future client care will be affected by current level of services.

Least restrictive/least invasive

Select interventions that maintain client safety while posing the least amount of restriction to the client. For example, if a client who has a high fall risk index is getting out of bed without assistance, move the client closer to the nurses' work area rather than choosing to apply restraints. Select interventions that are the least invasive. For example, bladder training for the incontinent client is a better option than an indwelling urinary catheter.

Elements of assertive communication

Selecting an appropriate location for verbal exchange. Maintenance of eye contact. Establishing trust. Being sensitive to cultural needs. Speaking using "I" statements and including affective elements of the situation. Avoiding "you" statements that can indicate blame. Stating concerns using open, honest, direct statements. Conveying empathy. Focusing on the behavior or issue of conflict and avoiding personal attacks. Concluding with a statement that describes a fair solution.

Maslow's hierarchy

Self actualization. Self esteem. Need for love and belonging. Safety and security. Physiological.

Nurse's role in quality improvement

Serve as unit representative on committees developing policies and procedures. Use reliable resources for information (Centers for Disease Control and Prevention, professional journals, evidenced‑based research). Enhance knowledge and understanding of the facility's policies and procedures. Provide client care consistent with these policies and procedures. Document client care thoroughly and according to facility guidelines. Participate in the collection of information/data related to staff's adherence to selected policy or procedure. Assist with analysis of the information/data. Compare results with the established benchmark. Make a judgment about performance in regard to the findings. Assist with provision of education or training necessary to improve the performance of staff. Act as a role model by practicing in accordance with the established standard. Assist with re‑evaluation of staff performance by collection of information/data at a specified time.

Emotional intelligence.

The ability of an individual to perceive and manage the emotions of self and others. The nurse must be able to perceive and understand his own emotions and the emotions of the client and family in order to provide client-centered care

Using Maslow's hierarchy

The nurse should consider this hierarchy of human needs when prioritizing interventions. For example, the nurse should prioritize a client's: Need for airway, oxygenation (or breathing), circulation, and potential for disability over need for shelter. Need for a safe and secure environment over a need for socialization.

Manifest conflict

The parties involved are aware of the conflict and action is taken. Actions at this stage can be positive and strive towards conflict resolution or they can be negative and include debating, competing, or withdrawal of one or more parties from the situation. Example: The nurse manager and nurses on a unit agree that the current scheduling system is causing a conflict and agree to work together to come up with a solution.

Steps in quality improvement process

A standard is developed and approved by a facility committee. Standards are made available to employees by way of policies and procedures. Quality issues are identified by staff, management, or risk management department. An interprofessional team is developed to review the issue. The current state of structure and process related to the issue is analyzed. Data collection methods are determined. Quantitative methods are primarily used in the data collection process, although client interview is also an option. Data is collected, analyzed, and compared with the established benchmark. If the benchmark is not met, possible influencing factors are determined. A root cause analysis can be done to critically assess all factors that influence the issue. Potential solutions or corrective actions are analyzed and one is selected for implementation. Educational or corrective action is implemented. The issue is reevaluated at a preestablished time to determine the efficacy of the solution or corrective action. Example: The use of incentive spirometers in postoperative clients can be determined to be 92% (process indicator), but the rate of postoperative pneumonia can be determined to be 8% (outcome indicator). If the benchmark is set at 5%, the benchmark for that outcome indicator is not being met and the structure and process variables need to be analyzed to identify potential areas for improvement.

7. A nurse is hired to replace a staff member who has resigned. After working on the unit for several weeks, the nurse notices that the unit manager does not intervene when there is conflict between team members, even when it escalates. Which of the following conflict resolution strategies is the unit manager demonstrating? A. Avoidance B. Smoothing C. Cooperating D. Negotiating.

A. CORRECT: The goal in resolving conflict is a win‑win situation. The unit manager is using an ineffective strategy, avoidance, to deal with this conflict. She is aware of the conflict but is not attempting to resolve it. B. The goal in resolving conflict is a win‑win solution. When smoothing is used, one person attempts to "smooth" the other party and/or point out areas in which the parties agree. This is typically a lose‑lose solution. C. The goal in resolving a conflict is a win‑win solution. When cooperating is used, one party allows the other party to win. This is a lose‑win solution. D. The goal in resolving a conflict is a win‑win solution. When negotiating is used, each party gives up something. If one party gives up more than the other, this can become a win‑lose solution.

4. A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following information should the manager include in the plan? (Select all that apply.) A. Skill proficiency B. Assignment to a preceptor C.Budgetary principles D.Computerized charting E. Socialization into unit culture F. Facility policies and procedures

A. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include evaluation of skill proficiency and provide additional instruction as indicated. B. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include assignment of a preceptor to ease the transition of the newly licensed nurse. C. Budgetary principles are an administrative skill that is usually the responsibility of the unit manager. D. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include computerized charting, which is an essential skill for the newly licensed nurse. E. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include socialization to the unit as a way to ease the transition of the newly licensed nurse. F. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. The nurse manager should include information about facility policies and procedures, which is essential information for the newly licensed nurse.

6. A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following information will provide data regarding the efficacy of the procedure? A. Frequency with which procedure is performed B. Client satisfaction with performance of procedure C. Incidence of complications related to procedure D. Accurate documentation of how procedure was performed

A. The frequency with which the procedure is performed is important. The team can take the frequency in which the procedure is performed under consideration in the planning process, but this information does not address the efficacy of the procedure. B. The team should take client satisfaction under consideration in the planning process, but this information does not address the efficacy of the procedure. C. CORRECT: The incidence of complications related to the procedure is an outcome measure directly related to the efficacy of the procedure. D. The team can take accuracy of documentation under consideration in the planning process, but this information does not address the efficacy of the procedure.

Competence

Ability of an employee to meet the requirements of a particular role at an established level of performance. Nurses usually progress through several stages of proficiency as they gain experience in a particular area. Patricia Benner (1984) identified five stages of nursing ability, which are based on level of competence. Level of competence is directly related to length of time in practice and exposure to clinical situations. When nurses move to a new clinical setting that requires acquisition of new skills and knowledge, their level of competence will return to a lower stage.

Examples of tasks nurses may delegate to AP

Activities of daily living (ADLs). Bathing. Grooming. Dressing. Toileting. Ambulating. Feeding (without swallowing precautions). Positioning. Routine tasks. Bed making. Specimen collection. Intake and output. Vital signs (for stable client).

Quality improvement

Also called performance improvement or quality control. Process used to identify and resolve performance deficiencies. Quality improvement includes measuring performance against a set of predetermined standards. In health care, these standards are set by the facility and consider accrediting and professional standards. Standards of care should reflect optimal goals and be based on evidence. The quality improvement process focuses on assessment of outcomes and determines ways to improve the delivery of quality care. All levels of employees are involved in the quality improvement process. The Joint Commission's accreditation standards require institutions to show evidence of quality improvement in order to attain accreditation status.

Staff education

Also called staff development. Process by which a staff member gains knowledge and skills. The goal of staff education is to ensure that staff members have and maintain the most current knowledge and skills necessary to meet the needs of clients.

Right person

Assess and verify the competency of the health care team member. The task must be within the team member's scope of practice. The team member must have the necessary competence/training. Continually review the performance of the team member and determine care competency. Assess team member performance based on standards and, when necessary, take steps to remediate a failure to meet standards. Examples: Delegate a PN to administer enteral feedings to a client who has a head injury (right). Delegate an AP to administer enteral feedings to a client who has a head injury (wrong).

Disability interventions

Assess for current or evolving disability (neurological deficits, stroke in evolution). Implement actions to slow down development of disability.

Breathing interventions

Assess the effectiveness of breathing (apnea, depressed respiratory rate). Intervene as appropriate (reposition, administer naloxone).

Right circumstance

Assess the health status and complexity of care required by the client. Match the complexity of care demands to the skill level of the health care team member. Consider the workload of the team member. Examples: Delegate an AP to measure the vital signs of a client who is postoperative and stable (right). Delegate an AP to measure the vital signs of a client who is postoperative and received naloxone to reverse respiratory depression (wrong).

Peer review should

Begin with an orientation of staff to the peer review process, their professional responsibility in regard to promoting growth of colleagues, and the disposition of data collected. Focus on the peer's performance in relation to the job description or an appraisal tool that is based on institutional standards. Be shared with the peer and usually the manager. Be only part of the data used when completing a staff member's performance appraisal. The employee should be given the opportunity to provide input into the evaluation.

Right direction/communication

Communicate either in writing or orally. Data that needs to be collected. Method and time line for reporting, including when to report concerns/findings. Specific task(s) to be performed; client‑specific instructions. Expected results, time lines, and expectations for follow‑up communication Examples: Delegate an AP to assist Mr. Martin in room 312 with a shower before 0900 (right). Delegate an AP to assist Mr. Martin in room 312 with morning hygiene (wrong).

Conflict aftermath

Conflict aftermath is the completion of the conflict process and can be positive or negative. Example: Positive conflict aftermath: the nurse manager and nurses on a unit are satisfied with the newly revised scheduling system and feel valued for being included in the conflict resolution process. Example: Negative conflict aftermath: the nurse manager and nurses are unable to come up with a scheduling solution that meets the needs of both parties. They agree to continue with the current system however tensions still remain increasing the risk of a recurrence of the conflict.

Time wasters

Documenting at the end of the shift all client care provided and assessments done. Making repeated trips to the supply room for equipment. Providing care as opportunity arises regardless of other responsibilities. Missing equipment when preparing to perform a procedure. Failing to plan or managing by crisis. Being reluctant to delegate or underdelegating. Not asking for help when needed or trying to provide all client care independently. Procrastinating: delaying time‑consuming, less desirable tasks until late in the shift. Agreeing to help other team members with lower priority tasks when time is already compromised. Setting unrealistic standards for completion of care and level of performance within constraints of assignment and resources. Starting several tasks at once and not completing tasks before starting others. Not addressing low level of skill competency, increasing time on task. Providing care without a written plan. Socializing with staff during client care time.

Time savers

Documenting nursing interventions as soon as possible after completion to facilitate accurate and thorough documentation. Grouping activities that are to be performed on the same client or are in close physical proximity to prevent unnecessary walking. Estimating how long each activity will take and planning accordingly. Mentally envisioning the procedure to be performed and gathering all equipment prior to entering the client's room. Taking time to plan care and taking priorities into consideration. Delegating activities to other staff when client care workload is beyond what can be handled by one nurse. Enlisting the aid of other staff when a team approach is more efficient than an individual approach. Completing more difficult or strenuous tasks when energy level is high. Avoiding interruptions and graciously but assertively saying "no" to unreasonable or poorly timed requests for help. Setting a realistic standard for completion of care and level of performance within the constraints of assignment and resources. Completing one task before beginning another task. Breaking large tasks into smaller tasks to make them more manageable. Using an organizational sheet to plan care. Using breaks to socialize with staff.

Compromising/negotiating

Each party gives up something. To consider this a win/lose‑win/lose solution, both parties must give up something equally important. If one party gives up more than the other, it can become a win‑lose solution.

Transformational leaders

Empower followers to assume responsibility for a communal vision, and personal development is a secondary outcome.

Expert nurse

Expert nurses have garnered a wealth of experience so they can view situations holistically and process information efficiently. They make decisions using an advanced level of intuition and analytical ability. They do not need to rely on rules to comprehend a situation and take action.

Steps in progressive discipline

First infraction: Informal reprimand. Manager and employee meet. Discuss the issue. Suggestions for improvement/correction. Second infraction: Written warning. Manager meets with employee to distribute written warning. Review of specific rules/policy violations. Discussion of potential consequences if infractions continue. Third infraction: Employee placed on suspension with or without pay. Time away from work gives the employee opportunity to examine the issues and consider alternatives. Fourth infraction: Employee termination. Follows after multiple warning have been given and employee continues to violate rules and policies.

Root cause analysis

Focuses on variables that surround the consequence of an action or occurrence. Is commonly done for sentinel events, but can also be done as part of the quality improvement process. Investigates the consequence and possible causes. Analyzes the possible causes and relationships that can exist. Determines additional influences at each level of relationship. Determines the root cause or causes.

Typical steps of the grievance process

Formal presentation of the complaint using the proper chain of command Formal hearing if the issue is not resolved at a lower level Professional mediation if a solution is not reached during a formal hearing.

Airway interventions

Identify an airway concern (obstruction, stridor). Establish a patent airway if indicated. Recognize that 3 to 5 min without oxygen causes irreversible brain damage secondary to cerebral anoxia.

Steps in providing educational programs

Identify and respond: To identify need for knowledge or skill proficiency. Analyze: Deficiencies, and develop learning objectives to meet need. Research: Resources available to address learning objectives based on evidence‑based practice. Plan: Program to address objectives using available resources. 5. Implement: Program(s) at time conducive to staff attendance; consider online learning modules. 6. Evaluate: Use materials and observations to measure behavior changes secondary to learning objectives.

Steps of the problem‑solving process

Identify the problem. State it in objective terms, minimizing emotional overlay. Discuss possible solutions. Brainstorming solutions as a group can stimulate new solutions to old problems. Encourage individuals to think outside the box. Analyze identified solutions. The potential pros and cons of each possible solution should be discussed in an attempt to narrow down the number of viable solutions. Select a solution. Based on this analysis, select a solution for implementation. Implement the selected solution. A procedure and time line for implementation should accompany the implementation of the selected solution. Evaluate the solution's ability to resolve the original problem. The outcomes surrounding the new solution should be evaluated according to the predetermined time line. The solution should be given adequate time to become established as a new routine before it is evaluated. If the solution is deemed unsuccessful, the problem‑solving process will need to be reinstituted and the problem discussed again.

Right task

Identify what tasks are appropriate to delegate for each specific client. A right task is repetitive, requires little supervision, and is relatively noninvasive for the client. Delegate tasks to appropriate levels of team members (PN, AP) based on standards of practice, legal and facility guidelines, and available resources. Examples: Delegate an AP to assist a client who has pneumonia to use a bedpan (right). Delegate an AP to administer a nebulizer treatment to a client who has pneumonia (wrong).

Resource management

Includes budgeting and resource allocation. Human, financial, and material resources must be considered. Budgeting is usually the responsibility of the unit manager, but staff nurses can be asked to provide input. Resource allocation is a responsibility of the unit manager as well as every practicing nurse. Providing cost‑effective client care should not compromise quality of care.Resources (supplies, equipment, personnel) are critical to accomplishing the goals and objectives of a health care facility, so it is essential for nurses to understand how to effectively manage resources.

Healthcare team factors

Knowledge and skill level of team members. Amount of supervision necessary. Staffing mix (RNs, PNs, AP). Nurse‑to‑client ratio. Experience with similar clients. Familiarity of staff member with unit.

Directing

Leadership role assumed by a manager that influences and motivates staff to perform assigned roles.

Authoritative

Makes decisions for the group. Motivates by coercion. Communication occurs down the chain of command. Work output by staff is usually high: good for crisis situations and bureaucratic settings. Effective for employees with little or no formal education.

Priority setting frameworks

Maslow's hierarchy. ABC framework. Safety/risk reduction. Assessment/data collection first. Survival potential. Least restrictive/least invasive. Acute vs. chronic, urgent vs. nonurgent, stable vs. unstable.

Clinical reasoning

Mental process used when analyzing the elements of a clinical situation and using analysis to make a decision. The nurse continues to use clinical reasoning to make decisions as the client's situation changes.

Staff education

Nurse's involvement in the orientation, socialization, education, and training of fellow health care workers to ensure the competence of all staff and to help them meet standards set forth by the facility and accrediting bodies. The process of staff education is also referred to as staff development. The quality of client care provided is directly related to the education and level of competency of health care providers. The nurse leader has a responsibility in maintaining competent staff. Nurse leaders work with a unique, diverse workforce. The nurse should respect and recognize the health care team's diversity

Task factors to consider in delegating client care

Predictability of outcome: Will the completion of the task have a predictable outcome? Is it a routine treatment? Is it a new treatment? Potential for harm: Is there a chance that something negative can happen to the client (risk for bleeding, risk for aspiration)? Is the client unstable? Complexity of care: Are complex tasks required as a part of the client's care? Is the delegatee legally able to perform the task and does he have the skills necessary? Need for problem solving and innovation: Is nursing judgment required while performing the task? Does it require nursing assessment skills? Level of interaction with the client: Is there a need to provide psychosocial support or education during the performance of the task.

Prioritization principles in client care

Prioritize systemic before local ("life before limb"). Prioritizing interventions for a client in shock over interventions for a client who has a localized limb injury. Prioritize acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation). Prioritizing the care of a client who has a new injury/illness (e.g., mental confusion, chest pain) or an acute exacerbation of a previous illness over the care of a client who has a long‑term chronic illness. Prioritize actual problems before potential future problems. Prioritizing administration of medication to a client experiencing acute pain over ambulation of a client at risk for thrombophlebitis. Listen carefully to clients and don't assume. Asking a client who has a new diagnosis of diabetes mellitus what he feels is most important to learn about disease management. Recognize and respond to trends vs. transient findings. Recognizing a gradual deterioration in a client's level of consciousness and/or Glasgow Coma Scale score. Recognize indications of medical emergencies and complications vs. expected findings. Recognizing indications of increasing intracranial pressure in a client who has a new diagnosis of a stroke vs. the findings expected following a stroke. Apply clinical knowledge to procedural standards to determine the priority action. Recognizing that the timing of administration of antidiabetic and antimicrobial medications is more important than administration of some other medications.

Socialization

Process by which a person learns a new role and the values and culture of the group within which that role is implemented. Successful socialization helps new staff members fit in with already established staff on a client care unit. Staff development educators and unit managers can begin this process during interviewing and orientation. Nurse preceptors/mentors are frequently used to assist newly licensed nurses with this process on the clinical unit.

Performance appraisal

Process by which a supervisor evaluates an employee's performance in relation to the job description for that employee's position as well as other expectations the facility can have. Performance appraisals are done at regular intervals and can be more frequent for new employees. Performance expectations should be based on the standards set forth in a job description and written in objective terms. Performance appraisals allow nurses the opportunity to discuss personal goals with the unit manager as well as to receive feedback regarding level of performance. Performance appraisals can also be used as a motivational tool. Deficiencies identified during a performance appraisal or reported by coworkers might need to be addressed in a disciplinary manner. A formal system for conducting performance appraisals should be in place and used consistently. Performance appraisal tools should reflect the staff member's job description and can be based on various types of scales or surveys. Various sources of data should be collected to ensure an unbiased and thorough evaluation of an employee's performance. Data should be collected over time and not just represent isolated incidents. Actual observed behavior should be documented/used as evidence of satisfactory or unsatisfactory performance. These can be called anecdotal notes and are kept in the unit manager or equivalent position's files. Peers can be a valuable source of data (peer review). The unit manager should host the performance appraisal review in a private setting at a time conducive to the staff member's attendance. The unit manager should review the data with the staff member and provide the opportunity for feedback. Personal goals of the staff member are discussed and documented, including avenues for attainment. Staff members who do not agree with the unit manager's evaluation of their performance should have the opportunity to make written comments on the evaluation form and appeal the rating.

Negotiation

Process by which interested parties: Resolve ongoing conflicts. Agree on steps to take. Bargain to protect individual or collective interests. Pursue outcomes that benefit mutual interests. Negotiation can involve the use of several conflict resolution strategies. The focus is on a win‑win solution or a win/lose‑win/lose solution in which both parties win and lose a portion of their original objectives. Each party agrees to give up something and the emphasis is on accommodating differences rather than similarities between parties. Example: One nurse offers to care for Client A today if the other will care for Client B tomorrow.

Supervising

Process of directing, monitoring, and evaluating the performance of tasks by another member of the health care team. RNs are responsible for the supervision of client care tasks delegated to APs and PNs.

Right supervision/evaluation

Provide supervision, either directly or indirectly (assigning supervision to another licensed nurse). Provide clear directions and expectations of the task to be performed (time frames, what to report). Monitor performance. Provide feedback. Intervene if necessary (unsafe clinical practice). Evaluate the client and determine if client outcomes were met. Evaluate client care tasks and identify needs for quality improvement activities and/or additional resources. Examples: Delegate the ambulation of a client to an AP, observe the AP to ensure safe ambulation of the client, and provide positive feedback to the AP after completion of the task (right). Delegate the ambulation of a client to an AP without supervision to determine the need for intervention and failing to provide feedback to the AP (wrong).

Cost-effective strategies

Providing clients with needed education to decrease or eliminate future medical costs associated with future complications. Example: The teaching a client who has a new diagnosis of diabetes mellitus how to adjust the dosage of insulin depending on activity level reducing the risk of hypoglycemia resulting in the need for medical care. Promoting the use of evidence‑based care resulting in improved client care outcomes.Example: Implementing the use of evidence‑based techniques to care for clients who have indwelling catheters resulting in a decreased incidence of catheter‑acquired urinary tract infections. Promoting cost‑effective resource management. Example: Using all levels of personnel to their fullest when making assignments. Delegating effectively to members of the nursing care team. Example: Providing necessary equipment and properly charging clients. Example: Returning uncontaminated, unused equipment to the appropriate department for credit. Example: Using equipment properly to prevent wastage. Example: Providing training to staff unfamiliar with equipment. Example: Returning equipment (IV pumps) to the proper department (central service, central distribution) as soon as it is no longer needed. This action will prevent further cost to client.

Outcome (clinical) indicators

Reflect desired client outcomes related to the standard under review. Measures whether a procedure is effective in meeting the desired benchmark.

Cost‑containment

Strategies that promote efficient and competent client care while also producing needed revenues for the continued productivity of the organization Example: Use of managed care strives to provide clients with a plan designed to meet the needs of their individual medical problem while eliminating the unnecessary use of resources or extended hospital stays.

Airway breathing circulation (ABC) framework

The ABC framework identifies, in order, the three basic needs for sustaining life. An open airway is necessary for breathing, so it is the highest priority. Breathing is necessary for oxygenation of the blood to occur. Circulation is necessary for oxygenated blood to reach the body's tissues. The severity of manifestations should also be considered when determining priorities. A severe circulation problem can take priority over a minor breathing problem. Some frameworks also include a "D" for disability and "E" for exposure.

Leadership

The ability to inspire others to achieve a desired outcome. Effective managers usually possess good leadership skills. However, effective leaders are not always in a management position. Leaders have a combination of personality traits and leadership skills. Great leaders were once thought to be born with skills that could not be acquired. Contemporary leadership theory supports the belief that leaders can develop the necessary skills. Leaders influence willing followers to move toward a goal. Leaders have goals that might not reflect those of the organization.

Orientation to the institution

The newly licensed nurse is introduced to the philosophy, mission, and goals of the institution and department. Policies and procedures that are based on institutional standards are reviewed. Use of and access to the institution's computer system is a significant focus. Safety and security protocols are emphasized in relation to the nurse's role.

Management

The process of planning, organizing, directing, and coordinating the work within an organization.

Nursing‑sensitive outcomes

Those that are directly affected by the quality of nursing care. Examples include client fall rates and the incidence of nosocomial infections.

Time management is a cyclic process.

Time initially spent developing a plan will save time later and help to avoid management by crisis. Set goals and plan care based on established priorities and thoughtful utilization of resources. Complete one client care task before beginning the next, starting with the highest priority task. Reprioritize remaining tasks based on continual reassessment of client care needs. At the end of the day, perform a time analysis and determine if time was used wisely. Teamwork. Self-care: Take breaks. Eat meals.

Actions to promote open communication and de‑escalate conflicts

Use "I" statements, and remember to focus on the problem, not on personal differences. Listen carefully to what others are saying, and try to understand their perspective. Move a conflict that is escalating to a private location or postpone the discussion until a later time to give everyone a chance to regain control of their emotions. Share ground rules with participants. For example, everyone is to be treated with respect, only one person can speak at a time, and everyone should have a chance to speak.

Assessment/data collection first

Use the nursing process to gather pertinent information prior to making a decision regarding a plan of action. For example, determine if additional information is needed prior to calling the provider to ask for pain medication for a client.

Survival potential

Use this framework for situations in which health resources are extremely limited (mass casualty, disaster triage). Give priority to clients who have a reasonable chance of survival with prompt intervention. Clients who have a limited likelihood of survival even with intense intervention are assigned the lowest priority.