Exam II RNSG 2173 Evidenced Based Practice, Patient Centered Care, Safety, Quality Improvement

According to the NINR (Nat'l Institute of Nursing Research), the goals of nursing research are to:

Build the scientific foundation for clinical practice Prevent disease and disability Manage and eliminate symptoms caused by illness Enhance end-of-life and palliative care

Proxemics affect the message being sent:

Distance may imply a lack of trust or warmth, whereas inadequate space, as defined by cultural norms, may make people feel threatened or intimidated.

Monitoring and Managing UTIs

Early recognition of UTI and prompt treatment are essential to prevent recurrent infection and the possibility of complications, such as renal failure, sepsis (urosepsis), strictures, and obstructions. The goal of treatment is to prevent infection from progressing and causing permanent renal damage and failure. Thus, the patient must be educated to recognize early signs and symptoms, to test for bacteriuria, and to initiate treatment as prescribed. Appropriate antimicrobial therapy, liberal fluid intake, frequent voiding, and hygienic measures are commonly prescribed for managing UTIs. The patient is instructed to notify the primary provider if fatigue, nausea, vomiting, fever, or pruritus occurs. Periodic monitoring of renal function and evaluation for strictures, obstructions, or stones may be indicated for patients with recurrent UTIs.

Facial Expression and Timing

Effective communication requires a facial expression that agrees with your message. Staff perceive managers who present a pleasant and open expression as approachable. Likewise, a nurse's facial expression can greatly affect how and what clients are willing to relate. On the other hand, *hesitation often diminishes the effect of your statement or implies untruthfulness.*

Effective communication requires

Effective communication requires the sender to validate what receivers see and hear

Non-verbal communication should be congruent with verbal communication

Effective leaders are congruent in their verbal and nonverbal communication so that followers are clear about the messages they receive.

Environment/Communication

Ex: A meeting in the cafeteria will probably be taken less seriously than a meeting in a supervisors office

Eye Contact

Eye contact invites interaction and emotional connection. Likewise, breaking eye contact suggests that the interaction is about to cease. It signals to your listeners that you are not interested in them and that you are not engaged in the conversation (Decker). Blinking, staring, or looking away when speaking also makes it difficult to connect with others emotionally. However, one must always remember, that like space, the presence or absence of eye contact is strongly influenced by cultural standards.

Evidenced Based Practice

Nursing care provided that is supported by sound scientific rationale. In nursing is a problem-solving approach to making clinical decisions, using the best evidence available (considered "best" because it is collected from sources such as published research, national standards and guidelines, and reviews of targeted literature).

Five factors affecting the success of implementation

(1) organizational stability and implementation team leadership, (2) implementation timelines (3) equipment availability and reliability (4) staff training (5)changes in workfow

Health is wellness. The four components of wellness are:

(1) the capacity to perform to the best of one's ability, (2) the ability to adjust and adapt to varying situations, (3) a reported feeling of well-being, and (4) a feeling that "everything is together" and harmonious.

Four concepts common in nursing theory:

(1) the person [patient: *the most important* ](2) the environment, (3) health, and (4) nursing.

Consumer Bill of Rights aka Patient's Bill of Rights 3 Goals:

(1) to help patients feel more confident in the US healthcare system (2) to stress the importance of a strong relationship between patients and their health-care providers (3) to stress the key role patients play in staying healthy by laying out rights and responsibilities for all patients and health-care providers

Five factors needed for successful implementation

(1) whether there was support for change from both leaders and staff (2) development of a gradual and flexible implementation approach (3) allocation of adequate resources for equipment and infrastructure, hands-on support, and deployment of additional staff (4) how the implementation team planned for setbacks, and continued the process to achieve success.

The Institute of Medicine's Key Messages and Recommendations for the Future of Nursing:

*Key Message I* Nurses should practice to the full extent of their education and training. *Key Message II* Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. *Key Message III* Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. *Key Message IV* Effective workforce planning and policy making require better data collection and an improved information infrastructure. *Recommendation 1:* Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. *Recommendation 2:* Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Private and public funders, health care organizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities to diffuse successful practices. *Recommendation 3:* Implement nurse residency programs. State boards of nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses' completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advance practice degree program or when they are transitioning into new clinical practice areas. *Recommendation 4:* Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80 percent by 2020. These leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the lifespan. *Recommendation 5:* Double the number of nurses with a doctorate by 2020. Schools of nursing, with support from private and public funders, academic administrators and university trustees, and accrediting bodies, should double the number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty and researchers, with attention to increasing diversity. *Recommendation 6:* Ensure that nurses engage in lifelong learning. Accrediting bodies, schools of nursing, health care organizations, and continuing competency educators from multiple health professions should collaborate to ensure that nurses and nursing students and faculty continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan. *Recommendation 7:√ Prepare and enable nurses to lead change to advance health. Nurses, nursing education programs, and nursing associations should prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses. *Recommendation 8: *Build an infrastructure for the collection and analysis of interprofessional health care workforce data. The National Health Care Workforce Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible.

Which method of communication is more reliable: verbal or non-verbal?

*Non-verbal.* Because nonverbal communication indicates the emotional component of the message, it is generally considered more reliable than verbal communication.

The American Association of Critical-Care Nurses Standards for Establishing and Sustaining Healthy work Environments

*Skilled Communication.* Nurses must be as proficient in communication skills as they are in clinical skills. *True Collaboration.* Nurses must be relentless in pursuing and fostering true collaboration. *Effective Decision Making.* Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. *Appropriate Staffing.* Staffing must ensure the effective match between patient needs and nurse competencies. *Meaningful Recognition.* Nurses must be recognized and must recognize others for the value each brings to the work of the organization. *Authentic Leadership.* Nurse leaders must fully embrace the imperativeness of a healthy work environment, authentically live it, and engage others in its achievement.

Steps that are crucial in improving performance

1. Discover a problem. 2. Plan a strategy using indicators. 3. Implement a change. 4. Assess the change; if the outcome is not met, plan a new strategy.

Risks that are not discussed "undiscussables" include

1) dangerous shortcuts, (2) incompetence, and (3) disrespect

Nursing Values Central to Advocacy

1. Each individual has a right to autonomy in deciding what course of action is most appropriate to meet his or her health-care goals. 2. Each individual has a right to hold personal values and to use those values in making health-care decisions. 3. All individuals should have access to the information they need to make informed decisions and choices. 4. The nurse must act on behalf of patients who are unable to advocate for themselves. 5. Empowerment of patients and subordinates to make decisions and take action on their own is the essence of advo

The Seven Crucial Conversations in Health Care

1. Broken rules 2. mistakes 3. lack of support 4. incompetence 5. poor teamwork 6. disrespect 7. micromanagement

The Institute of Medicine's Committee on Quality of Health Care in America suggests 10 rules to redesign and improve care:

1. Care based on continuous healing relationships 2. Customization based on patient needs and values 3. The patient as the source of control 4. Shared knowledge and the free flow of information 5. Evidence-based decision making 6. Safety as a system priority 7. The need for transparency 8. Anticipation of patient's needs 9. Continuous decrease in waste 10. Cooperation among clinicians

Leadership Roles in Advocacy

1. Creates a climate where advocacy and its associated risk taking are valued. 2. Seeks fairness and justice for individuals who are unable to advocate for themselves. 3. Seeks to strengthen patient and subordinate support systems to encourage autonomous, well- informed decision making. 4. Influences others by providing information necessary to empower them to act autonomously. 5. Assertively advocates on behalf of patients and subordinates when an intermediary is necessary. 6. Participates in professional nursing organizations and other groups that seek to advance the profession of nursing. 7. Role models proactive involvement in health-care policy through both formal and informal interac- tions with the media and legislative representatives. 8. Works to establish the creation of a national, legally binding Bill of Rights for Patients. 9. Speaks up when appropriate to advocate for health-care practices necessary for safety and qual- ity improvement. 10. Advocates for social justice in addition to individual patient advocacy. 11. Appropriately differentiates between controlling patient choices (domination and dependence) and in assisting patient choices (allowing freedom.)

Common Areas Requiring Nurse-Patient Advocacy

1. End-of-life decisions 2. Technological advances 3. Health-care reimbursement 4. Access to health care 5. Provider-patient conflicts regarding expectations and desired outcomes 6. Withholding of information or blatant lying to patients 7. Insurance authorizations, denials, and delays in coverage 8. Medical errors 9. Patient information disclosure (privacy and confidentiality) 10. Patient grievance and appeals processes 11. Cultural and ethnic diversity and sensitivity 12. Respect for patient dignity 13. Inadequate consents 14. Incompetent health-care providers 15. Complex social problems including AIDS (acquired immunodeficiency syndrome), teenage preg- nancy, violence, and poverty 16. Aging Population

UTIs: Expected Patient Outcomes

1. Experiences relief of pain a. Reports absence of pain, urgency, frequency, nocturia, or hesitancy on voiding b. Takes analgesic, antispasmodic, and antibiotic agents as prescribed 2. Explains UTIs and their treatment a. Demonstrates knowledge of preventive measures and prescribed treatments b. Drinks 8 to 10 glasses of fluids daily c. Voids every 2 to 3 hours d. Produces urine that is clear and odorless 3. Experiences no complications a. Reports no symptoms of infection (fever, frequency) b. Has normal renal function, negative urine and blood cultures c. Exhibits normal vital signs and temperature; no signs or symptoms of sepsis (urosepsis) d. Maintains adequate urine output more than 0.5 mL/kg/hr

Group Task Roles

1. Initiator. Contributor who proposes or suggests group goals or redefines the problem. There may be more than one initiator during the group's lifetime. 2. Information seeker. Searches for a factual basis for the group's work. 3. Information giver. Offers an opinion of what the group's view of pertinent values should be. 4. Opinion seeker. Seeks opinions that clarify or reflect the value of other members' suggestions. 5. Elaborator. Gives examples or extends meanings of suggestions given and how they could work. 6. Coordinator. Clarifies and coordinates ideas, suggestions, and activities of the group. 7. Orienter. Summarizes decisions and actions, identifies and questions departures from predetermined goals. 8. Evaluator. Questions group accomplishments and compares them with a standard. 9. Energizer. Stimulates and prods the group to act and raises the level of its actions. 10. Procedural technician. Facilitates group action by arranging the environment. 11. Recorder. Records the group's activities and accomplishments.

Strategies to Promote Evidenced-Based Practice

1. Keep abreast of the evidence—subscribe to professional journals and read widely. 2. Use and encourage use of multiple sources of evidence. 3. Use evidence not only to support clinical interventions but also to support teaching strategies. 4. Find established sources of evidence in your specialty—do not reinvent the wheel. 5. implement and evaluate nationally sanctioned clinical practice guidelines. 6. Question and challenge nursing traditions and promote a spirit of risk taking. 7. dispel myths and traditions not supported by evidence. 8. collaborate with other nurses locally and globally. 9. interact with other disciplines to bring nursing evidence to the table.

American Nurses Association/National Council of State Boards of Nursing Principles for Social Networking:

1. Nurses must not transmit or place online individually identifiable patient information. 2. Nurses must observe ethically prescribed professional patient-nurse boundaries. 3. Nurses should understand that patients, colleagues, institutions, and employers may view post- ings. 4. Nurses should take advantage of privacy settings and seek to separate personal and profes- sional information online. 5. Nurses should bring content that could harm a patient's privacy, rights, or welfare to the attention of appropriate authorities. 6. Nurses should participate in developing institutional policies governing online conduct.

health

:according to the World Health Organization (2006), a "state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity" (p. 1); often viewed as equivalent to wellness

Conceptual Framework or Model

A group of concepts that follows an understandable pattern.

Communication clarity

A message's clarity is greatly affected by the mode of communication used. In general, the more direct the communication, the greater the probability that it will be clear. The more people involved in filtering the communication, the greater the chance of distortion.

Key Points in General Systems Theory

A system is a set of interacting elements, all contributing to the overall goal of the system. The whole system is always greater than the sum of its parts. Systems are hierarchical in nature and are composed of interrelated subsystems that work together in such a way that a change in one element could affect other subsystems, as well as the whole. Boundaries separate systems both from each other and from their environments. A system communicates with and reacts to its environment through factors that enter the system (input) or are transferred to the environment (output). An open system allows energy, matter, and information to move freely between systems and boundaries, whereas a closed system does not allow input from or output to the environment (no totally closed systems are known to exist in reality). To survive, open systems maintain balance through feedback.

Communication, personal space, and cultural preferences:

All of us have an invisible zone of psychological comfort that acts as a buffer against unwanted touching and attacks. The degree of space we require depends on who we are talking to as well as the situation we are in (Loo). It also varies according to cultural norms. Some cultures require greater space between the sender and the receiver than others. In the United States, between 0 and 18 inches of space is typically considered appropriate only for intimate relationships; between 18 inches and 4 feet is appropriate for personal interactions; between 4 and 12 feet is common for social exchanges; and more than 12 feet is a public distance (Loo). Most Americans claim a territorial personal space of about 4 feet.

Assertive Communication

Assertive communication is not rude or insensitive behavior, rather, it is having an informed voice that insists on being heard.

When does communication begin?

Communication begins the moment that two or more people become aware of each other's presence

When can confidentiality be breached?

Confidentiality can be breached legally only when one provider must share information about a patient so that another provider can assume care.

Posture

Sitting up straight indicates focus and that you are paying attention

Descriptive Theories of Nursing

Descriptive theories describe a phenomenon, an event, a situation, or a relationship. They further identify the properties and components of each of these as well as the circumstances in which it occurs.

Gender, Power, and Status affect communication

Differences in gender, power, and status significantly affect the types and quality of organizational and unit-level communication.

Model for Improvement AKA Rapid Test Cycling

Forming the Team Including the right people on a process improvement team is critical to a successful improvement effort. Teams vary in size and composition. Each organization builds teams to suit its own needs. Setting Aims Improvement requires setting aims. The aim should be time-specific and measurable; it should also define the specific population of patients or other system that will be affected. Establishing Measures Teams use quantitative measures to determine if a specific change actually leads to an improvement. Selecting Changes Ideas for change may come from the insights of those who work in the system, from change concepts or other creative thinking techniques, or by borrowing from the experience of others who have successfully improved. Testing Changes The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting—by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method adapted for action-oriented learning (see figure on right side). Implementing Changes After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team may implement the change on a broader scale—for example, for an entire pilot population or on an entire unit. Spreading Changes After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or in other organizations.

Stages of Group Process

Forming: Testing occurs to identify boundaries of interpersonal behaviors, establish dependency relationships with leaders and other members, and determine what is acceptable behavior Storming: resistance to group influence is evident as members polarize into subgroups; conflict ensues and members rebel against demands imposed by the leader Norming: consensus evolves as group cohesion develops; conflict and resistance are overcome Performing: interpersonal structure focuses on task and its completion; roles become flexible and functional; energies are directed to task performance

GRRR as a listening tool

G Greeting: Offer greetings and establish positive environment R Respectful listening: Listen without interrupting and pause to allow others to think R Review: summarize message to make sure it was heard accurately R Recommend or request more information: seek additional information as necessary R Reward:recognize that a collaborative exchange has occurred by offering thanks

Clients with UTIs are at increased risk for

Gram-Positive Sepsis

Diagonal Communication

In diagonal communication, the manager interacts with personnel and managers of other departments and groups such as physicians, who are not on the same level of the organizational hierarchy. Although these people have no formal authority over the manager, this communication is vital to the organization's functioning. Diagonal communication tends to be less formal than other types of communication.

Downward Communication

In downward communication, the manager relays information to subordinates. This is a traditional form of communication in organizations and helps to coordinate activities in various levels of the hierarchy.

Horizontal Communication

In horizontal communication, managers interact with others on the same hierarchical level as themselves who are managing different segments of the organization. The need for horizontal communication increases as departmental interdependence increases.

Interprofessional Collaborative Practice

Involves employing multiple health professionals to work together with patients, families, and communities to deliver best practices, thus assuring best patient outcomes

Prescriptive Theories of Nursing

Prescriptive theories address nursing interventions and the consequences of those interventions; they are designed to control, promote, and change clinical nursing practice.

Focal Points for Nursing, Education, and Research

Promotion of health and wellness Promotion of safety and quality of care Care, self-care processes, and care coordination Physical, emotional, and spiritual comfort, discomfort, and pain Adaptation to physiological and pathophysiological processes Emotions related to the experience of birth, growth and development, health, illness, disease, and death Meanings ascribed to health, illnesses, and other concepts Linguistic and cultural sensitivity Health literacy Decision making and the ability to make choices Relationships, role performance, and change processes within relationships Social policies and their effects on health Health care systems and their relationships to access, cost, and quality of health care The environment and the prevention of disease and injury

SBAR communication tool:

Situation: introduce yourself and the patient and briefly state the issue that you want to discuss (generally the patient's condition) Background: describe the background or context (patient's diagnosis, admission date, medical diagnosis, and treatment to date) Assessment: summarize the patient's condition and state what you think the problem is Recommendation: identify any new treatments or changes ordered and provide opinions or recommendations for further action

Last stage of Group Process

Some experts suggest, however, that there is another phase: termination or closure. In this phase, the leader guides members to summarize, express feelings, and come to closure. A celebration at the end of committee work is a good way to conclude group effort.

Prioritizing/unit manager:

Setting new priorities or adjusting priorities to reflect ever-changing work situations is an ongoing reality for the unit manager.

ISBAR

Some health-care organizations have chosen to include an introduction step (ISBAR) to SBAR because they feel it is important that the clinicians start off with an introduction if they do not actively know the person they are speaking with during a patient handoff or over the phone (ISBAR, 2013). This step includes an introduction of the person doing the handoff, their role in the patient's care, and the unit they are calling from if the handoff occurs over the phone (ISBAR).

Steps in Implementing Evidenced Based Practice

Step 1: Ask a question about a clinical area of interest or an intervention. Step 2: Collect the most relevant and best evidence. Step 3: Critically appraise the evidence. Step 4: Integrate the evidence with clinical expertise, patient preferences, and values in making a decision to change. Step 5: Evaluate the practice decision or change.

Systematic Review

Summarized findings from multiple studies of a specific clinical practice question or topic that recommend practice changes and future directions for research; one of the strongest sources of evidence for evidence-based practice

The Art of Nursing

Takes into consideration patient preferences and values, as well as the clinical experiences of the nurse.

The actions of an advocate:

The actions of an advocate are to inform others of their rights and to ascertain that they have sufficient information on which to base their decisions.

In decision-making

The greater the number of alternatives that can be generated, the greater the chance that the final decision will be sound.

The Science of Nursing

The information that is collected is analyzed and used to answer questions.

The internal climate of communication

The internal climate includes the values, feelings, temperament, and stress levels of the sender and the receiver.

The leader who actively listens

The leader who actively listens gives genuine time and attention to the sender, focusing on verbal and nonverbal communication

Grapevine Communication

The most informal communication network is often called the grapevine. Grapevine communication flows quickly and haphazardly among people at all hierarchical levels and usually involves three or four people at a time. Senders have little accountability for the message, and often the message becomes distorted as it speeds along. Given the frequency of grapevine communication in all organizations, all managers must attempt to better understand how the grapevine works in their own organization as well as who is contributing to it.

Relieving Pain with UTIs

The pain associated with a UTI is quickly relieved once effective antimicrobial therapy is initiated. Antispasmodic agents may also be useful in relieving bladder irritability and pain. Analgesic agents and the application of heat to the perineum help relieve pain and spasm. The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to promote renal blood flow and to flush the bacteria from the urinary tract. Urinary tract irritants (e.g., coffee, tea, citrus, spices, colas, alcohol) are avoided. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely, because doing so can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection

Proxemics

The study of how space and territory affect communication

source oriented record

documentation system in which each health care group records data on its own separate form

Business memos have a two-fold purpose:

They bring attention to problems and they solve problems.

General Systems Theory

This theory describes how to break whole things into parts and then to learn how the parts work together in "systems." It emphasizes relationships between the whole and the parts and describes how parts function and behave. Developed by Ludwig von Bertalanffy in the 1920s for universal application.

Misconceptions about assertiveness

To be assertive is to not be aggressive, although some cultures find the distinction blurred. Even when faced with someone else's aggression, the assertive communicator does not become aggressive; it is not feminine to be assertive (not true)

Gestures

Too many gestures can be distracting. Some cultures are more tactile than others; the use of touch is one gesture that often sends messages that are misinterpreted by receivers from different cultures.

Channels of Communication (in a nutshell)

Upward: from subordinate to superior Downward: from superior to subordinate Horizontal: From peer to peer Diagonal: Between individuals at differing hierarchy levels and job classifications Grapevine: informal, haphazard, and random, usually involving small groups

Quality Improvement

Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality of safety of health care systems.

ANA Standards of Professional Nursing Practice: The registered nurse integrates evidence and research findings into practice.

Utilizes current evidence-based nursing knowledge, including research findings, to guide practice. Incorporates evidence when initiating changes in nursing practice. Participates as appropriate to education level and position, in the formulation of evidence-based practice through research. Shares personal or third-party research findings with colleagues and peers.

Ventilator-Associated Pneumonia

VAP occurring within 96 hours of the onset of mechanical ventilation is usually due to antibiotic-sensitive bacteria that colonize the patient prior to hospital admission, whereas VAP developing after 96 hours of ventilatory support is more often associated with MDR (multiple drug resistant) bacteria.

Vocal Expression

Vocal clues such as tone, volume, and inflection add to the message being transmitted. Tentative statements sound more like questions than statements, leading listeners to think that you are unsure of yourself, and speaking quickly may be interpreted as being nervous. The goal, then, should always be to convey confidence and clarity.

Model for Improvement AKA Rapid Test Cycling asks:

What are trying to accomplish? How will we know that change is an improvement? What changes can we make that will result in an improvement?

In decision making, brainstorming helps

seek out all the possible options/alternatives in order to make the best decision, the status quo is usually the right alternative

Managers must be well grounded in group dynamics

While managers must understand group dynamics and roles to facilitate communication and productivity, leaders tend to make an even greater impact on group effectiveness. Dynamic leaders inspire followers toward participative management by how they work and communicate in groups. Leaders keep group members on course, draw out the shy, politely cut off the garrulous *(Hmm I wonder who that might be? :P)*, and protect the weak.

evidence-based practice (EBP)

a best practice derived from valid and reliable research studies that also considers the health care setting, patient preferences and values, and clinical judgment

Focus (DAR) charting

a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format

pay for performance

a health insurance model that reimburses health care provider groups, hospitals, and health care agencies for either meeting or exceeding metrics that demonstrate that the care and treatments rendered are both cost-efficient and of best quality; also known as value-based purchasing

Quality and Safety Education for Nurses (QSEN)

a project whose aim is to develop curricula that prepare future nurses with the knowledge, skills, and attitudes (KSAs) required to continuously improve the quality and safety of the health care system through demonstrating competency in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics

variance report

a report of any event that is not consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a patient, employee, or visitor

Bundle

a set of three to five evidence-based practices that, when implemented appropriately, can measurably improve patients' outcomes

nursing

according to the American Nurses Association (2010b), "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations" (p. 3)

National Patient Safety Goals (NPSGs)

areas of patient safety concern identified annually by the Joint Commission that, if rectified, may have the most positive impact on improving patient care and outcomes

core measures

benchmark standards of best practices used to gauge how well a hospital gives care to its patients who are admitted to seek treatment for a specific disease (e.g., heart failure) or who need a specific treatment (e.g., an immunization)

The nursing values central to advocacy emphasize:

caring, autonomy, respect, and empowerment.

collaborative pathway

case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

The primary purpose of the patient record is to help health care professionals from different disciplines (who interact with the patient at different times)

communicate with one another

Nursing Theory

developed to describe nursing. Nursing theory differentiates nursing from other disciplines and activities in that it serves the purposes of describing, explaining, predicting, and controlling desired outcomes of nursing care practices.

PIE charting

documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)-intervention (I)-evaluation (E) format, and evaluated each shift

nursing research

encompasses both research to improve the care of people in the clinical setting and to study people and the nursing profession, including education, policy development, ethics, and nursing history

Decision making should be

evidenced-based

Group Communication Stages

forming, storming, norming, and performing

evidence-based practice guidelines:

guidelines written by a panel of experts that synthesize information from multiple studies and recommend best practices to treat patients with a disease, a symptom, or a disability

Nurses may act as advocates by:

helping others make informed decisions, by acting as an intermediary in the environment, or by directly intervening on behalf of others

Advocacy

helping others to grow and self-actualize—is a critically important leadership role; protecting and defending what one believes in for both self and others

Concepts

ike ideas, are abstract impressions organized into symbols of reality. Concepts describe objects, properties, and events and relationships among them.

What is the common goal of nursing theories?

improved patient care

Upward Communication

in upward communication, the manager is a subordinate to higher management. Needs and wants are communicated upward to the next level in the hierarchy. Those at this higher level make decisions for a greater segment of the organization than do the lower-level managers.

The external climate of communication

includes external factors such as the weather, temperature, timing, status, power, authority, and the organizational climate itself.

Information and communication are different, however, they are

interdependent

clinical nurse leader (CNL)

is a certified nurse generalist with a master's degree in nursing and a special background in clinical leadership, educated to help patients navigate the complex health care system. The CNL has the knowledge and authority to delegate tasks to other health care personnel, as well as supervise and evaluate these personnel and the outcomes of care.... The CNL is accountable for improving individual care outcomes and processes in a quality, cost-effective manner

Assertive Communication

is a way of communicating that allows people to express themselves in direct, honest, and appropriate ways that do not infringe on another person's rights. A person's position is expressed clearly and firmly by using "I" statements as well as direct eye contact and a calm voice. In addition, assertive communication always requires that verbal and nonverbal messages be congruent. To be successful in the directing phase of management, the leader must have well-developed skills in assertive communication.

Passive-Aggressive Communication

is an aggressive message presented in a passive way. It generally involves limited verbal exchange (often with incongruent nonverbal behavior) by a person who feels strongly about a situation. This person feigns withdrawal in an effort to manipulate the situation. For example, the passive-aggressive communication may say yes when they want to say no or be sarcastic or complain about others behind their backs (Mayo Clinic Staff, 2011). Over time, this type of behavior damages relationships and undercuts mutual respect (Mayo Clinic Staff).

Theory

is composed of a group of concepts that describe a pattern of reality.

Aggressive Communication

is generally direct, threatening, and condescending. It infringes on another person's rights and intrudes into that person's personal space. This behavior is also oriented toward "winning at all costs" or demonstrating self-excellence. Thus, it is a bullying type of communication and a form of dominance (

Advocating vs Controlling

it is important for the patient advocate to be able to differentiate between controlling patient choices (domination and dependence) and in assisting patient choices (allowing freedom.)

B. T. Chapman's Group Roles Taxonomy for Productive Meetings

l Facilitator: creates the final meeting agenda and estimates the time for each agenda item. runs the meeting and gives notice when a decision is to be made or when future action is needed. l Minutes keeper: records the meeting's minutes but does not take down every word. records directions given, decisions, or actions made and approved by the group. l Time keeper: Keeps the group on schedule by tracking the time allotted for each issue on the agenda. seeks agreement from the group before allowing discussion on an issue to go over the predesignated time limit. l Next agenda person: records issues for the next meeting and helps to create the following agen- da. includes on the next agenda who is responsible for what issue and the time that should be allowed for discussion. l action plan keeper: records decisions for action in two ways; 30 days or long term. if something must be done before the next meeting, it goes on the 30-day list. More complex projects go on the long-term list, which is reviewed at each meeting.

Key Concepts of Communication (Summary)

l communication forms the core of management activities and cuts across all phases of the management process. it is also the core of the nurse-patient, nurse-nurse, and nurse-physician relationship. l depending on the manager's position in the hierarchy, the overwhelming majority of managerial time is often directed at some type of organizational communication; thus, organizational communication is a high-level management function. l Because most managerial communication time is spent speaking and listening, managers must have excellent interpersonal communication skills. l communication in large organizations is particularly difficult due to their complexity and size. l Managers must understand the structure of the organization and recognize whom their decisions will affect. Both formal and informal communication networks need to be considered. l The clarity of the message is significantly affected by the mode of communication used. in general, the more direct the communication, the greater the probability of clear communication. The more people involved in filtering the communication, the greater the chance of distortion. l Written communication is used most often in large organizations. l a manager's written communication reflects greatly on both the manager and the organization. Thus, managers must be able to write clearly and professionally and use understandable language. l The incongruence between verbal and nonverbal messages is the most significant barrier to effective interpersonal communication. l effective leaders are congruent in their verbal and nonverbal communication so that followers are clear about the messages they receive. Likewise, leaders are sensitive to nonverbal and verbal messages from followers and look for inconsistencies that may indicate unresolved problems or needs. l To be successful in the directing phase of management, the leader must have well-developed skills in assertive communication. l sBar and isBar provide structured, orderly approaches to provide accurate, relevant information, in emergent patient situations as well as routine handoffs. l Most people hear or retain only a small amount of the information given to them.

Staffing Needs Key Concepts

l the manager has both a fiscal and an ethical duty to plan for adequate staffing to meet patient care needs. l innovative and creative methods of staffing and scheduling should be explored to avoid understaffing and overstaffing as patient census and acuity fluctuate. l staffing and scheduling policies must not violate labor laws, state or national laws, or union contracts. l Workload measurement tools include NCh/ppd, pCs, and workload measurement systems. all workload measurement tools should be periodically reviewed to determine if they are a valid and reliable tool for measuring staffing needs in a given organization. l Mandatory overtime should be a last resort, not standard operating procedure because an institution does not have enough staff. l research clearly shows that as professional nursing representation in the skill mix increases, patient outcomes generally improve and adverse incidents decline. l those with staffing responsibility must remain cognizant of mandatory staffing ratios and comply with such mandates. l Managers should attempt to have a diverse staff that will meet the cultural and language needs of the patient population. l Fair and uniform staffing and scheduling policies and procedures must be written and communicated to all staff. l Existing staffing policies must be examined periodically to determine if they still meet the needs of the staff and the organization.

To become better listeners:

leaders must first become aware of how their own experiences, values, attitudes, and biases affect how they receive and perceive messages. Second, they must overcome the information and communication overload inherent in the middle-management role. It is easy for overwhelmed managers to stop listening actively to the many subordinates who need and demand their time simultaneously. Finally, the leader must continually work to improve listening skills by giving time and attention to the message sender. The leader's primary purpose is to receive the message being sent rather than forming a response before the transmission of the message is complete.

Electronic Health Record/meaningful use

meaningful use (capturing the right data that can improve patient outcomes)

SOAP format

method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)

Client coordination failure

occurs when a patient is readmitted to the hospital shortly after discharge with the same condition for which he or she had been originally hospitalized.

Passive Communication

occurs when a person suffers in silence although he or she may feel strongly about the issue. Thus, passive communicators avoid conflict, often at the risk of bottling up feelings which may lead to an eventual explosion

inductive reasoning

one builds from specific ideas or actions to conclusions about general ideas.

Developmental Theory

outlines the process of growth and development of humans as orderly and predictable, beginning with conception and ending with death. Although the pattern has definite stages, the progress and behaviors of an individual within each stage are unique. Heredity, temperament, emotional and physical environment, life experiences, and health status influence the growth and development of an individual. (Erickson & Maslow's theories are based off of this.)

Four types of communication exist:

passive, aggressive, indirectly aggressive or passive-aggressive

Continued medical errors and staff turnover are directly related to

poor communication and collaboration

consultation

process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution

research

process that uses observable and verifiable information (data), collected in a systematic manner, to describe, explain, or predict events

Memos should only be

sent to a small-moderate number of people and should not be used for highly sensitive messages (these should be conducted face to face.)

inadequate communication between care providers or between care providers and patients/families as a consistent root cause of

sentinel events

Adaptation Theory

the adjustment of living matter to other living things and to environmental conditions. Adaptation is a continuously occurring process that effects change and involves interaction and response. Human adaptation occurs on three levels: the internal (self), the social (others), and the physical (biochemical reactions).

meaningful use

the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid

AACN's goals are

to actively promote the creation of healthy work environments that support and foster excellence in patient care

hand-offs

verbal exchange of information, which occurs between two or more health-care providers about a patient's condition, treatment plan, care needs, etc.

deductive reasoning

when one examines a general idea and then considers specific actions or ideas

Individuals Roles of Group Members

• Aggressor. Expresses disapproval of others' values or feelings through jokes, verbal attacks, or envy. • Blocker. Persists in expressing negative points of view and resurrects dead issues. • Recognition seeker. Works to focus positive attention on himself or herself. • Self-confessor. Uses the group setting as a forum for personal expression. • Playboy. Remains uninvolved and demonstrates cynicism, nonchalance, or horseplay. • Dominator. Attempts to control and manipulate the group. • Help seeker. Uses expressions of personal insecurity, confusion, or self-deprecation to manipulate sympathy from members. • Special interest pleader. Cloaks personal prejudices or biases by ostensibly speaking for others.

When should hand hygiene be performed in the care of a patient with a central venous line?

• All clinicians who provide care to the patient should adhere to good hand hygiene practices, particularly: • Before and after palpating the catheter insertion site • With all dressing changes to the intravascular catheter access site • When hands are visibly soiled or contamination of hands is suspected • Before donning and after removing gloves

When should central venous lines be discontinued?

• Assessment for removal of central venous lines should be included as part of the nurse's daily goal sheets. • The time and date of central venous line placement should be recorded and evaluated by staff to aid in decision making. • The need for the central venous line access should be reviewed as part of multidisciplinary rounds. • During these rounds, the "line day" should be stated to remind everyone how long the central venous line has been in place (e.g., "Today is line day 6"). • An appropriate timeframe for regular review of the necessity for a central venous line should be identified, such as weekly, when central venous lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration).

Which antiseptic should be used to prepare the patient's skin for central venous line insertion?

• Chlorhexidine skin antisepsis has been proven to provide better skin antisepsis than other antiseptic agents, such as povidone-iodine solutions. • Chlorhexidine 2% in 70% isopropyl alcohol should be applied using a back-and-forth friction scrub for at least 30 seconds; this should not be wiped or blotted dry. • The antiseptic solution should be allowed time to dry completely before the insertion site is punctured/accessed (approximately 2 minutes).

Balancing Technology and the Human Element:

• Determining which technological advances can and should be used at each level of the organizational hierarchy to promote efficiency and effectiveness of communication • Assessing the need for and providing workers with adequate training to appropriately and fully utilize the technological communication tools that may become available to them • Balancing cost and benefits • Aligning communication technology with the organizational mission • Finding a balance between technological communication options and the need for human touch, caring, and one-on-one, face-to-face interaction *Even the most advanced communication technology cannot replace the human judgment needed by leaders and managers to use that technology appropriately*

Collaborative Practice Interventions to Prevent Ventilator-Associated Pneumonia

• Elevation of the head of the bed (30-45 degrees) • Daily "sedation vacations" and assessment of readiness to extubate (see below) • Peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]) • Deep venous thrombosis (DVT) prophylaxis (see below) • Daily oral care with chlorhexidine (0.12% oral rinses) What is meant by daily "sedation vacations," and how does this tie into assessing readiness to extubate? • Protocols should be developed so that sedative doses are purposely decreased at a time of the day when it is possible to assess the patient's neurologic readiness for extubation. • Vigilance must be employed during the time that sedative doses are lower to ensure that the patient does not selfextubate. What effect does DVT prophylaxis have on preventing VAP? • The exact relationship is unclear. However, when appropriate, evidence-based methods to ensure DVT prophylaxis are applied (see Chapter 30), then the rates of VAP also drops.

Group Building and Maintenance Roles

• Encourager. Accepts and praises all contributions, viewpoints, and ideas with warmth and solidarity. • Harmonizer. Mediates, harmonizes, and resolves conflict. • Compromiser. Yields his or her position in a conflict situation. • Gatekeeper. Promotes open communication and facilitates participation by all members. • Standard setter. Expresses or evaluates standards to evaluate group process. • Group commentator. Records group process and provides feedback to the group. • Follower. Accepts the group's ideas and listens to discussion and decisions.

Time-efficient work environment strategies:

• Gather all the supplies and equipment that will be needed before starting an activity. Breaking a job down mentally into parts before beginning the activity may help the staff nurse identify what supplies and equipment will be needed to complete the activity. • Group activities that are in the same location. If you have walked a long distance down a hallway, attempt to do several things there before going back to the nurses station. If you are a home health nurse, group patient visits geographically when possible to minimize travel time and maximize time with patients. • Use time estimates. For example, if you know an intermittent intravenous medication (IV piggyback) will take 30 minutes to complete, then use that time estimate for planning some other activity that can be completed in that 30-minute window of time. • Document your nursing interventions as soon as possible after an activity is completed. Waiting until the end of the workday to complete necessary documentation increases the risk of inaccuracies and incomplete documentation. • Always strive to end the workday on time. Although this is not always possible, delegating appropriately to others and making sure that the workload goal for any given day is reasonable are two strategies that will accomplish this goal.

What are the five key elements of the central venous line bundle?

• Hand hygiene • Maximal barrier precautions (see later discussion) • Chlorhexidine skin antisepsis • Optimal catheter site selection with avoidance of using the femoral vein for central venous access in adult patients • Daily review of line necessity, with prompt removal of unnecessary lines

Business memos should be comprised of the following elements:

• Header (includes the to, from, date, and subject lines): one-eighth of the memo • Opening, context, and task (includes the purpose of the memo, the context and problem, and the specific assignment or task): one-fourth of the memo • Summary, discussion segment (the details that support your ideas or plan): one-half of the memo • Closing segment, necessary attachments (the action that you want your reader to take and a notation about what attachments are included): one-eighth of the memo

What changes can be made to improve hand hygiene?

• Implement a central venous line procedure checklist that requires that clinicians perform hand hygiene as an essential step in care. • Post signage stating the importance of hand hygiene. • Have soap and alcohol-based hand sanitizers prominently placed to facilitate hand hygiene practices.

Suggestions for (written) professional correspondence

• Keep your message short and concise. Less than one page is always preferred. Use bullets to highlight key points. • Use the first paragraph to express the context or purpose of the memo and to introduce the problem. In next paragraphs, address what has been done or needs to be done to address the problem at hand. • Add a conclusion to summarize the memo, clarify what the reader is expected to do, and to address any attachments that are a part of the memo. • Focus on the recipient's needs. Make sure that your communication addresses the recipient's expectations and what he or she needs to know. • Use simple language so that the message is clear. Keep paragraphs to less than three or four sentences. • Review the message and revise as needed. Almost all important communication requires several drafts. Always reread the written communication before sending it. Look for areas that might be misunderstood. Pay attention to tone. Have all of the key points been made? • Use spelling and grammar checks to be sure that the communication looks professional. Remember that your document is a direct reflection of you, and even the most important message will likely be ignored if the communication is perceived as unprofessional.

Communication Modes/Written

• Written communication. Written messages (including memos, reports, e-mail, and texting, which will be discussed later in this chapter) allow for documentation. They may, however, be open to various interpretations and generally consume more managerial time. Most managers are required to do a considerable amount of this type of communication and therefore need to be able to write clearly.

Communication Modes/Face to Face

•Face-to-face communication. Oral communication is rapid but may result in fewer people receiving the information than necessary. Managers communicate verbally upward and downward and formally and informally. They also communicate verbally in formal meetings, with people in peer work groups, and when making formal presentations.

Organizational Communication Strategies

• Leader-managers must assess organizational communication. Who communicates with whom in the organization? Is the communication timely? Does communication within the formal organization concur with formal lines of authority? Are there conflicts or disagreements about communication? What modes of communication are used? • Leader-managers must understand the organization's structure and recognize who will be affected by decisions. Both formal and informal communication networks need to be considered. Formal communication networks follow the formal line of authority in the organization's hierarchy. Informal communication networks occur among people at the same or different levels of the organizational hierarchy but do not represent formal lines of authority or responsibility. • Communication is not a one-way channel. If other departments or disciplines will be affected by a message, the leader-manager must consult with those areas for feedback before the communication occurs. • Communication must be clear, simple, and precise. This requires the sender to adjust their language as necessary to the target audience. • Senders should seek feedback regarding whether their communication was accurately received. One way to do this is to ask the receiver to repeat the communication or instructions. In addition, the sender should continue follow-up communication in an effort to determine if the communication is being acted upon. The sender is responsible for ensuring that the message is understood. •Multiplecommunicationmethodsshouldbeused,whenpossible,ifamessageisimportant. Using a variety of communication methods in combination increases the likelihood that everyone in the organization who needs to hear the message actually will hear it. • Managers should not overwhelm subordinates with unnecessary information. Information is formal, impersonal, and unaffected by emotions, values, expectations, and perceptions. Communication, on the other hand, involves perception and feeling. It does not depend on information and may represent shared experiences. In contrast to information sharing, superiors must continually communicate with subordinates.

What nursing interventions are essential to reduce the risk of infection?

• Maintaining sterile technique when changing the central venous line dressing • Always performing hand hygiene before manipulating or accessing the line ports • Wearing clean gloves prior to accessing the line port • Performing a 15- to 30-second "hub scrub" using chlorhexidine or alcohol and friction in a twisting motion on the access hub (reduces biofilm on the hub that may contain pathogens)

Communication Modes/non-verbal

• Nonverbal communication. Nonverbal communication includes facial expression, body movements, and gestures and is commonly referred to as body language. Nonverbal communication is considered more reliable than verbal communication because it conveys the emotional part of the message. There is significant danger, however, in misinterpreting nonverbal messages if they are not assessed in context with the verbal message. Nonverbal communication occurs any time managers are seen (e.g., messages are transmitted to subordinates every time the manager communicates verbally or just w

The ANA's tenets characteristic of all nursing care

• Nursing practice is individualized. • Nurses coordinate care by establishing partnerships. • Caring is central to the practice of the registered nurse. • Registered nurses use the nursing process to plan and provide individualized care to their health care consumers. • A strong link exists between the professional work environment and the registered nurse's ability to provide quality health care and achieve optimal outcomes.

The Standards of Professional Performance describe expectations for behavioral competencies:

• Practices ethically • Attains knowledge and competence that reflects current nursing practice • Integrates evidence and research findings into practice • Communicates effectively in all areas of practice • Demonstrates leadership in the professional practice setting and the profession • Collaborates with health care consumers, families, and others in the conduct of nursing practice • Evaluates her or his own practice • Utilizes appropriate resources to plan and provide nursing services that are safe, effective, and financially responsible • Practices in an environmentally safe and healthy manner

When under attack by an aggressive person, an assertive person can do several things:

• Reflect. Reflect the speaker's message back to him or her. Focus on the affective components of the aggressor's message. This helps the aggressor to evaluate whether the intensity of his or her feelings is appropriate to the specific situation or event. For example, assume that an employee enters a manager's office and begins complaining about a newly posted staff schedule. The employee is obviously angry and defensive. The manager might use reflection by stating, "I understand that you are very upset about your schedule. This is an important issue, and we need to talk about it." • Repeat the assertive message. Repeated assertions focus on the message's objective content. They are especially effective when the aggressor overgeneralizes or seems fixated on a repetitive line of thinking. For example, if a manager requests that an angry employee step into his or her office to discuss a problem, and the employee continues his or her tirade in the hallway, the manager might say, "I am willing to discuss this issue with you in my office. The hallway is not the appropriate place for this discussion." • Point out the implicit assumptions. This involves listening closely and letting the aggressor know that you have heard him or her. In these situations, managers might repeat major points or identify key assumptions to show that they are following the employee's line of reasoning. • Restate the message by using assertive language. Rephrasing the aggressor's language will defuse the emotion. Paraphrasing helps the aggressor to focus more on the cognitive part of the message. The manager might use restating by changing a "you" message to an "I" message. • Question. When the aggressor uses nonverbal clues to be aggressive, the assertive person can put this behavior in the form of a question as an effective means of helping the other person become aware of an unwarranted reaction. For example, the desperate, angry employee may imply threats about quitting or transferring to another unit. The manager could appropriately confront the employee about his or her implied threat to see if it is real or simply a reflection of the employee's frustration.

Communication Modes/Telephone

• Telephone communication. A telephone call is rapid and allows the receiver to clarify the message at the time it is given. It does not, however, allow the receipt of nonverbal messages for either the sender or receiver of the message. Accents may be difficult to understand as well in a multicultural workforce. Because managers today use the telephone so much, it has become an important communication tool, but it does have limits as an effective communication device.

What are maximal barrier precautions?

• These are implemented during central venous line insertion: • For the primary provider, this means strict compliance with wearing a cap, mask, sterile gown, and sterile gloves. The cap should cover all hair, and the mask should cover the nose and mouth tightly. The nurse should also wear a cap and mask. • For the patient, this means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion. If a full-size drape is not available, two drapes may be applied to cover the patient or the operating room may be consulted to determine how to procure full-size sterile drapes, because these are routinely used in surgical settings. • Nurses should be empowered to enforce use of a central line checklist to be sure all processes related to central line placement are properly executed for every line placed.

Nursing Interventions for Catheterization

• Using strict aseptic technique during insertion of the smallest catheter possible • Securing the catheter to prevent movement • Frequently inspecting urine color, odor, and consistency • Performing meticulous daily perineal care with soap and water • Maintaining a closed system • Following the manufacturer's instructions when using the catheter port to obtain urine specimens