Leadership Final

ANA safe staffing statement

"Inadequate nurse staffing levels by experienced RNs are linked to higher rates of patient falls, infections, medication errors and even death. As a result of massive reductions in nursing budgets, combined with the challenges presented by a growing nursing shortage, fewer nurses work longer hours and care for sicker patients. This situation compromises care and contributes to the nursing shortage by creating an environment that drives nurses from the bedside."

diversion program

(also called intervention or peer assistance programs). A diversion program is generally a voluntary, confidential program for nurses whose practice may be impaired due to chemical dependency or mental illness. The goal of a diversion program is to protect the public by early identification of impaired nurses and by providing these nurses access to appropriate intervention programs and treatment services.

common staffing and scheduling options in health care

- 8-10 or 12 hour shifts - premium pay for weekend work - part time staffing pool for weekend shifts and holidays - cyclical staffing, which allows long-term knowledge of future work schedules because a set staffing pattern is repeated every few weeks - job sharing - allowing nurses to exchange hours of work among themselves - flextime, a system that allows employees to select the time schedules that best meet their personal needs while still meeting work responsibilities - staff self-scheduling - shift bidding, which allows nurses to bid for shifts rather than requiring mandatory overtime - closed unit staffing, occurs when the staff members on a unit make a commitment to cover all absences and needed extra help themselves in return for not being pulled from the unit in times of low census.

STEEEP defined

- Effectiveness. Relates to providing care processes and achieving outcomes as supported by scientific evidence. - Efficiency. Relates to maximizing the quality of a comparable unit of health care delivered or unit of health benefit achieved for a given unit of health care resources used. - Equity. Relates to providing health care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care. - Patient centeredness. Relates to meeting patients' needs and preferences and providing education and support. - Safety. Relates to actual or potential bodily harm. - Timeliness. Relates to obtaining needed care while minimizing delays.

decentralized staffing: limitations

- can result in more special pleading and arbitrary treatment of employees - may not be cost effective for org since staffing needs are not viewed holistically - more time consuming for unit manager - risk of unequal treatment of employees - could be viewed as granting rewards or punishments thru scheduling - harder to ensure adequate staffing thru/out org

criteria to meet when handling understaffing issues

- decisions made must meet state and federal labor laws and organizational policies - staff must not be demoralized or excessively fatigued by frequent or extended overtime requests - short and long term solutions must be met - patient care must not be jeopardized

mandatory overtime

- employees are forced to work additional shifts, often under threat of patient abandonment - although mandatory overtime is neither efficient nor effective in the long term, it has an even more devastating short term impact in terms of staff perceptions of a lack of control and its subsequent impact on mood, motivation, and productivity

generational diversity and consideration for staffing

- generation: year of birth - silent generation: 1925-1942 - baby boomer: 1943-1960s - generation x: 1960s-1980 - Generation Y (millennial): 1980-1996 - generation z: 1996-2015

decentralized staffing: strengths

- manager retains greater control over unit staffing - staff are able to take requests directly to their manager - provides greater autonomy and flexibility for individual staff member -> decreased attrition - manager understands needs of staff and unit intimately -> inc likelihood that sound staffing decisions will be made - staff feels more in control of work environment because they can take things directly to manager

leadership roles and management functions in staffing and scheduling

- provide adequate staff - ethically accountable - aware of fluctuating needs of the unit - be innovative in addressing staffing difficulties - encourage diversity - maintain fiscal accountability to the organization

centralized staffing: strengths

- provides organization-wide view of staffing needs, which encourages optimal utilization of staffing resources - staffing policies tend to be employed more consistently and impartially - more cost effective than decentralized staffing - feeds the middle level manager to complete other management functions - generally fairer to all employees because policies tend to be employed more consistently and impartially - allows for the most efficient (cost-effective) use of resources because the more units that can be considered together, the easier it is to deal with variations in patient census and staffing needs

LPNs CANNOT

-Admission assessment -IV push meds -Nursing dx -Teaching -Complex skills -Care for pts with acute conditions -Care for unstable pts

hot stove rule explained

1. All employees must be forewarned that if they touch the hot stove (break a rule), they will be burned (punished or disciplined). They must know the rule beforehand and be aware of the punishment. 2. If the person touches the stove (breaks a rule), there will be immediate consequences (getting burned). All discipline should be administered immediately after rules are broken. 3. If the person touches the stove again, he or she will again be burned. Therefore, there is consistency; each time the rule is broken, there are immediate and consistent consequences. 4. If any other person touches the hot stove, he or she also will get burned. Discipline must be impartial, and everyone must be treated in the same manner when the rule is broken.

leadership roles in delegation

1. Assures that organizational guidelines regarding delegation are current, reflecting best practices 2. Functions as a role model, supporter, and resource person in delegating tasks to subordinates 3. Encourages followers to use delegation as a time management strategy and team-building tool 4. Assists followers in identifying situations appropriate for delegation 5. Communicates clearly when delegating tasks 6. Maintains patient safety as a minimum criterion in determining the most appropriate person to carry out a delegated task 7. Plans ahead and delegates proactively, rather than waiting until time urgency is present and crisis responses are required 8. Conveys a feeling of confidence and encouragement to the individual who has taken on a delegated task 9. Is an informed and active participant in the development of local, state, and national guidelines for nursing assistive personnel (NAP) scope of practice 10. Is sensitive to how cultural phenomena affect transcultural delegation 11. Uses delegation as a means for stretching and empowering workers to learn new skills and be successful 12. Works to establish a culture of mutual trust, teamwork, and open communication so that delegation becomes a strategy that health-care workers feel comfortable using to achieve organizational, patient, and personal goals

before negotiation

1. Be prepared mentally by having done your homework. 2. Determine the incentives of the person you will be negotiating with. 3. Determine your starting point, trade-offs, and bottom line. 4. Look for hidden agendas, both your own and the parties with whom you are negotiating.

TQM principles

1. Create a constancy of purpose for the improvement of products and service. 2. Adopt a philosophy of continual improvement. 3. Focus on improving processes not on inspection of product. 4. End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier. 5. Improve constantly every process for planning, production, and service. 6. Institute job training and retraining. 7. Develop the leadership in the organization. 8. Drive out fear by encouraging employees to participate actively in the process. 9. Foster interdepartmental cooperation and break down barriers between departments. 10. Eliminate slogans, exhortations, and targets for the workforce. 11. Focus on quality and not just quantity; eliminate quota systems if they are in place. 12. Promote teamwork rather than individual accomplishments. Eliminate the annual rating or merit system. 13. Educate/train employees to maximize personal development. 14. Charge all employees with carrying out the total quality management package.

manager roles in conflict resolution

1. Creates a work environment that minimizes the antecedent conditions for conflict 2. Uses appropriately legitimate authority in a competing approach when a quick or unpopular decision needs to be made 3. Facilitates conflict resolution among team members when appropriate 4. Accepts mutual responsibility for reaching predetermined supraordinate goals 5. Establishes a workplace culture that has zero tolerance for incivility, bullying, mobbing, and workplace violence 6. Obtains needed unit resources through effective negotiation strategies 7. Compromises unit needs only when the need is not critical to unit functioning and when higher management gives up something of equal value 8. Is adequately prepared to negotiate for unit resources, including the advance determination of a bottom line and possible trade-offs 9. Addresses the need for closure and follow-up to negotiation 10. Pursues alternative dispute resolution when conflicts cannot be resolved using traditional conflict management strategies

manager roles in delegation

1. Creates job descriptions and scope of practice statements for all personnel, including NAP, that conform to national, state, and professional recommendations for ensuring safe patient care 2. Is knowledgeable regarding legal liabilities of subordinate supervision 3. Assesses accurately subordinates' capabilities and motivation when delegating 4. Delegates a level of authority necessary to complete delegated tasks 5. Shares accountability for delegated tasks 6. Attempts consciously to see the subordinate's perspective to reduce the likelihood of resistance in delegation 7. Develops and implements a periodic review process for all delegated tasks 8. Avoids overburdening subordinates by giving them permission to refuse delegated tasks 9. Counsels and/or disciplines employees appropriately when they fail to carry out appropriately delegated tasks 10. Provides recognition or reward as appropriate for the completion of delegated tasks 11. Provides formal education and training opportunities on delegation principles for staff

medication reconciliation steps

1. Develop a list of current medications. 2. Develop a list of medications to be prescribed. 3. Compare the medications on the two lists. 4. Make clinical decisions based on the comparison. 5. Communicate the new list to appropriate caregivers and to the patient.

manager roles in dealing with problem employees

1. Discusses clearly all written rules and policies with subordinates, explains the rationale for the existence of the rules and policies, and encourages questions 2. Identifies clearly the performance expectations for all employees and confronts employees when those expectations are not met 3. Uses formal authority as judiciously as possible so that subordinates have the opportunity to invoke self-discipline 4. Uses formal authority to administer discipline using a progressive model when employees continue to fail to meet expected standards of achievement 5. Investigates thoroughly the situation before employee discipline is administered 6. Consults with either a supervisor or the Human Resources department before dismissing an employee 7. Maintains clear, objective, and comprehensive written records regarding the problem employee's behavior and attempts to counsel 8. Uses organizational transfers appropriately 9. Seeks out and completes extensive education about psychological impairment and chemical abuse in the work setting; provides these same opportunities to staff 10. Acts as a resource to chemically or psychologically impaired employees regarding professional services or agencies that provide counseling and support services 11. Collects and records adequate objective data when suspicious of employee chemical impairment 12. Focuses employee confrontations on performance deficits and not on the cause of the underlying problem or addiction 13. Works with the rule breaker, psychologically or chemically impaired, and/or marginal employee to develop a remedial plan for action; ensures that the employee understands the performance expectations of the organization and the consequences of not meeting these expectations

leadership roles in quality control

1. Encourages followers to be actively involved in the quality control process 2. Communicates expected standards of care to subordinates clearly 3. Encourages the setting of high standards to maximize quality instead of setting minimum safety standards 4. Embraces and champions quality improvement (QI) as an ongoing process 5. Uses control as a method of determining why goals were not met 6. Is active in communicating quality control findings and their implications to other health professionals and consumers 7. Acts as a role model for followers in accepting responsibility and accountability for nursing actions 8. Uses established professional standards and ethical codes as a guide for practice excellence 9. Distinguishes between clinical standards and resource utilization standards, ensuring that patients receive at least minimally acceptable levels of quality care 10. Supports/actively participates in research efforts to identify and measure nursing-sensitive patient outcomes 11. Creates a work culture that deemphasizes blame for errors and focuses instead on addressing factors that lead to and cause near misses, medical errors, and adverse events 12. Encourages the use of Six Sigma as the benchmark for QI goals 13. Establishes benchmarks that mirror those of best performing organizations and that drive a goal of continuous quality improvement 14. Seeks transparency in sharing and translating quality data with consumers

management roles in quality control

1. Establishes clear-cut, measurable standards of care and determines the most appropriate method for measuring if those standards have been met, in conjunction with other personnel in the organization 2. Selects and uses process, outcome, and structure audits appropriately as quality control tools 3. Collects and accesses appropriate sources of information in data gathering for quality control activities 4. Determines discrepancies between care provided and unit standards and uses critical event analysis or root cause analysis to determine why standards were not met 5. Uses quality control findings in determining needed areas of staff education or coaching 6. Keeps abreast of current government, accrediting body, and licensing regulations that affect quality control 7. Participates actively in state and national benchmarking and "best practices" initiatives 8. Assesses continually the unit or organizational environment to identify and categorize errors that are occurring and proactively reworks the processes that led to the errors 9. Establishes an environment where research evidence and clinical guidelines based on best practices drive clinical decision making and patient care 10. Is accountable to insurers, patients, providers, and legislative and regulatory bodies for quality outcomes 11. Establishes Lean Six Sigma methodology as a goal for every aspect of QI 12. Complies with external regulatory requirements and data collection related to QI efforts 13. Coordinates efforts to become a high-reliability organization

criteria for delegation to UAP

1. Frequently recur in the daily care of a client or group of clients 2. Are performed according to an established (standardized) sequence of steps 3. Involve little or no modification from one client-care situation to another 4. May be performed with a predictable outcome 5. Do not inherently involve ongoing assessment, interpretation, or decision making which cannot be logically separated from the procedure(s) itself 6. Do not endanger the health or well-being of clients 7. Are allowed by agency policy/procedures

leadership roles in staffing and scheduling

1. Identifies creative and flexible staffing methods to meet the needs of patients, staff, and the organization 2. Is knowledgeable regarding contemporary methods and tools used in staffing and scheduling 3. Assumes a responsibility toward staffing that builds trust and encourages a team approach 4. Role models the use of evidence in making appropriate staffing and scheduling decisions 5. Is alert to extraneous factors that have an impact on unit and organizational staffing 6. Is ethically accountable to patients and employees for adequate and safe staffing 7. Encourages diversity of thought, gender, age, and culture in nursing staffing 8. Proactively plans for staffing shortages so that patient care goals will be met 9. Communicates work schedules as well as scheduling policies clearly and effectively to staff 10. Assesses if and how workforce intergenerational values impact staffing needs and responds accordingly

leadership roles in conflict resolution

1. Is self-aware and conscientiously works to resolve intrapersonal conflict 2. Addresses conflict as soon as it is perceived and before it becomes felt or manifest 3. Immediately confronts and intervenes when incivility, bullying, and mobbing occur 4. Seeks a win-win solution to conflict whenever feasible 5. Lessens the perceptual differences that exist between conflicting parties and broadens the parties' understanding about the problems 6. Assists subordinates in identifying alternative conflict resolutions 7. Recognizes and accepts individual differences in team members 8. Uses assertive communication skills to increase persuasiveness and foster open communication 9. Role models honest and collaborative negotiation efforts 10. Encourages consensus building when group support is needed to resolve conflicts

during negotiation

1. Maintain composure. 2. Ask for what you want assertively. 3. Role model good communication skills (speaking and listening), assertiveness, and flexibility. 4. Be patient and take a break if either party becomes angry or tired during the negotiation. 5. Avoid using destructive negotiation techniques, but be prepared to counter them if they are used against you.

management roles in staffing and scheduling

1. Provides adequate staffing to meet patient care needs according to the philosophy of the organization and evidence-based needs 2. Uses organizational goals and patient classification tools to minimize understaffing and overstaffing as patient census and acuity fluctuate 3. Schedules staff in a fiscally responsible manner 4. Periodically examines the unit standard of productivity to determine if changes are needed 5. Ascertains that scheduling policies are not in violation of state and national labor laws, organizational policies, or union contracts 6. Assumes accountability for quality and fiscal control of staffing 7. Evaluates scheduling and staffing procedures and policies on a regular basis 8. Develops and implements fair and uniform scheduling policies and communicates these clearly to all staff 9. Selects acuity-based staffing tools that reduce subjectivity and promote objectivity in patient acuity determinations

leadership roles in dealing with problem employees

1. Recognizes and reinforces the intrinsic self-worth of each employee and the role of successful work performance in maintaining a positive self-image 2. Encourages employees to be self-disciplined in conforming to established rules and regulations 3. Understands group norms and is able to work within those norms to mold group behavior 4. Assists employees to identify with organizational goals, thus increasing the likelihood that the standards of conduct deemed acceptable by the organization will be accepted by its employees 5. Is self-aware regarding the power and responsibility inherent in having formal authority to set rules and discipline employees 6. Serves in the role of coach in performance deficiency coaching or problem-centered coaching 7. Assures that the rights and the responsibilities of both the manager and the employee are considered in addressing worker grievances 8. Is self-aware regarding values, biases, and beliefs about psychological and chemical abuse 9. Uses active listening as a support tool in working with chemically and psychologically impaired subordinates but recognizes own limitations in counseling and refers impaired employees to outside experts for appropriate counseling 10. Examines the work environment for stressors that contribute to substance abuse and eliminates those stressors whenever possible 11. Keeps patient safety first and foremost when considering how best to intervene with problem employees 12. Recognizes that all employees have intrinsic worth and assists them in reaching their maximal potential

after negotiation

1. Restate what has been agreed on, both verbally and in writing. 2. Recognize and thank all participants for their contributions to a successful negotiation.

driving forces for the development of effective staffing

1. Staffing can make—or break—the relationship between finance and nursing. Although acuity systems have furthered accountability, patient acuity remains a subjective measure. 2. Staffing can blow a budget. Nursing accounts for most of an acute care facility's total payroll. 3. Staffing affects the cost of care. The costs of mortality, readmission, and compromised safety—in both human and monetary terms—are high. Staffing can play a role in reducing the incidence, and thus the cost, of each. 4. Staffing affects the quality of care. Studies have shown a correlation between optimum nurse staffing levels and optimal clinical outcomes. 5. Staffing matters to nursing. For nurses, staffing is everything. It determines patient care; their own physical, emotional, and mental well-being; the nature of their workplace; and whether they'll choose to stay in the profession.

quality control as a systematic process

1. The criterion or standard is determined. Not only must standards exist, leader-managers must also see that subordinates know and understand the standards 2. Information is collected to determine if the standard has been met. The resulting discrepancy or congruency gives managers information with which they can make a judgment about the quality or appropriateness of the nursing care 3. Educational or corrective action is taken if the criterion has not been met. If standards are consistently unmet or met only partially, frequent reevaluation is indicated. quality control measures need to be ongoing, not put forth simply in response to a problem

ANA recommendations to maintain sufficient staffing

1. The formation of nurse-driven staffing committees to create staffing plans that reflect the needs of the patient population and match the skills and experience of the staff. 2. Legislators mandate specific nurse-to-patient ratios in legislation or regulation. 3. Facilities are required to disclose staffing levels to the public and/or a regulatory body.

hallmarks of effective quality control programs

1. There must be support from top-level administration. 2. There must be a commitment by the organization in terms of fiscal and human resources. 3. Quality goals reflect search for excellence rather than minimums. 4. Process is ongoing (continuous).

successful delegation is influenced by

1.Effective communication 2.Collaborative work relationships 3.Role clarity of the delegatee. 4.Level of competence and knowledge of the delegatee Putting it together in a nutshell, successful delegation depends of a few things

org staffing and scheduling policies

1.Staffing cycle 2.Sick leave 3.Vacations and days off requests 4.Holidays 5.Call-offs for low census 6.Shift reassignment 7.On-call pay 8.Tardiness and absenteeism 9.Trading days 10.Transferring out 11.Mandatory overtime

termination conference

1.State the facts of the case and the reason for termination. 2.Explain the termination process. 3.Ask for the employee's input and respond calmly and openly. 4.End the meeting on a positive note, if possible. ● The grievance procedure is essentially a statement of wrongdoing or a procedure to follow when one believes that a wrong has been committed. All employees should have the right to file grievances about disciplinary action that they believe has been arbitrary or unfair in some way.

disciplinary conference

1.State the problem clearly. 2.Ask the employee why there has been no improvement. 3.Explain the disciplinary action to be taken. 4.Describe the expected behavioral change. 5.Get agreement to and acceptance of the plan. When coaching is unsuccessful in modifying problem behavior, the manager must take more aggressive steps and use more formal measures, such as a disciplinary conference. After thoroughly investigating an employee's offenses, managers must confront the employee with their findings. This occurs in the form of a disciplinary conference. The following steps are generally part of the disciplinary conference.

four common steps in progressive discipline

1.Verbal admonishment (informal discipline/reprimand) 2.Written admonishment (formal discipline; list specific rule and consequence and place in file) 3.Suspension from work without pay 4.Dismissal ● •When using progressive discipline, for all but the most serious infractions, the slate should be wiped clean at the conclusion of a predesignated period.

transfers

A lateral transfer describes one staff person moving to another unit, to a position with a similar scope of responsibilities, within the same organization. A downward transfer occurs when someone takes a position within the organization that is below his or her previous level. It may be in a nurse's interest to consider a downward transfer because it can increase the chances of long-term career success. These accommodating transfers generally allow someone to receive a similar salary but with a reduction in energy expenditure. Finally, there is the inappropriate transfer. Some managers solve unit personnel problems by transferring problem employees to another unsuspecting department. Such transfers are harmful in many ways.

barriers to communication explained

Ability of sender: how much the sender understand the message they are trying to send. Is there a language barrier that is preventing the sender from getting the content to the receiver or preventing the receiver from decoding the content as the sender intended. Content: it may include technicalities and jargon that is not understood by the receiver Method of communication: including non-verbal communication Skills and attitude of the receiver is the receiver open to the content or does the receiver have the knowledge base to understand the content being relayed. Organizational factors: such as the hierarchical structure of the organization, the communication channels that need to be used to communicate. Cultural attitudes: for example, is it within the sender or receiver's culture that men are not supposed to listen to women. Are the terminologies being used offensive to the other party? Noise: any interference with makes the message difficult to receive. Noise may be the internal or external climates existing during transmission. Perceptions, prejudices and stereotypes: preconceived perceptions or stereotypes of management or an individual in general. Is the receiver willing to listen to the sender, or anyone else? Inappropriate target for message: Is the message going to the correct person? Technical capabilities: Is the sender having technical difficulties sending the message or the receiver having issues retrieving the messages due to technical difficulties?

quantitative vs qualitative conflicts

Although quantitative and qualitative conflicts produce distress at the time they occur, they can lead to growth, energy, and creativity by generating new ideas and solutions. A person may be totally overwhelmed in one conflict situation yet can handle several simultaneous conflicts later. The difference is in the quality or significance of that conflict to the person experiencing it. The ability to understand and deal with conflict appropriately is a critical leadership skill.

audits

Audits are presented as tools for assessing quality. systematic and official examination of a record, process, structure, environment, or account to evaluate performance. Auditing in health-care organizations provides managers with a means of applying the control process to determine the quality of services rendered. Auditing can occur retrospectively, concurrently, or prospectively.

manifestations of workplace bullying

Backstabbing Swearing/yelling/shouting Making threats Calling names Invading personal space Threatening gestures Constant eye contact Withholding information/controlling communication Refusing to help Finding fault Ethnic or racial jokes or slurs Sabotage Unreasonable workloads/unfair assignments Betraying confidence or gossiping Humiliation Social isolation/exclusion Physical harm Exclusion and silence Eye rolling or other demeaning nonverbal behaviors Innuendo Cyberbullying

conflict process model: perceived conflict

Based on limited knowledge Affected by prior experiences Each party has its own perceptions Assuming how the other is perceiving it second stage: perceived conflict. Perceived or substantive conflict is intellectualized and often involves issues and roles. The person recognizes it logically and impersonally as occurring but does not feel emotionally involved in it. Sometimes, conflict can be resolved at this stage before it is internalized or felt. In an environment characterized by open communication and mutual support, many conflicts can be resolved simply by pointing out that a potential or actual problem exists.

summative task vs critical indicator

Both types of PCSs are generally filled out prior to each shift, although the summative task type typically has more items to fill out than the critical incident or criterion type.

Ch 17: staffing/scheduling

Ch 17: staffing/scheduling

CPG examle

Clinical Pathway for Total Hip Replacement is clinical guideline (multidisciplinary plan outline) of the optimal sequencing and timing of interventions for a patient recovering from a total hip arthroplasty.

minimum criteria for safe staffing

Decisions made must meet state and federal labor laws and organizational policies. Staff must not be demoralized or excessively fatigued by frequent or extended overtime requests. Long-term as well as short-term solutions must be sought. Patient care must not be jeopardized.

changes in job performance of chemically impaired nurse

Difficulty meeting schedules and deadlines Illogical or sloppy charting High frequency of medication errors or errors in judgment affecting patient care Frequently volunteers to be medication nurse Has a high number of assigned patients who complain that their pain medication is ineffective in relieving their pain Consistently meeting work performance requirements at minimal levels or doing the minimum amount of work necessary Judgment errors Sleeping or dozing on duty Complaints from other staff members about the quality and quantity of the employee's work Disappears from the work area for long periods of time or may spend long periods of time in the bathroom or around the medication cart

how to make quality control proactive

Effective leaders ensure that quality control is proactive by pushing standards to maximal levels and by eliminating problems in the early stages before productivity or quality is compromised.

verbal admonishment

Generally, the first step of the progressive disciplinary process is an informal reprimand or verbal admonishment. This reprimand includes an informal meeting between the employee and the manager to discuss the broken rule or performance deficiency. The manager suggests ways in which the employee's behavior might be altered to keep the rule from being broken again. Often, an informal reprimand is all that is needed for behavior modification.

JCAHO national pt safety goals

Goals focus on problems in healthcare safety and how to solve them To augment the core measures and promote specific improvements in patient safety,

high reliability organizations (HROs)

HROs are organizations that perform well (minimal catastrophic error) despite high levels of complexity and the existence of multiple risk factors that encourage error.

arbitration

If the differences cannot be settled through a formal grievance process, the matter may finally be resolved in a process known as arbitration. In arbitration, both sides agree on the selection of a professional mediator who will review the grievance, complete fact finding, and interview witnesses before coming to a decision.

conflict process model: manifest conflict

If there isn't resolution then there's manifestation of emotions/negative behaviors In the fourth stage, manifest conflict, also called overt conflict, action is taken. The action may be to withdraw, compete, debate, or seek conflict resolution. Individuals are uncomfortable with or reluctant to address conflict for many reasons. These include fear of retaliation, fear of ridicule, fear of alienating others, a sense that they do not have the right to speak up, and past negative experiences with conflict situations. Indeed, people often learn patterns of dealing with manifest conflict early in their lives, and family background and experiences often directly affect how conflict is dealt with in adulthood. Gender also may play a role on how we respond to conflict. Historically, men were socialized to respond aggressively to conflict, whereas women were more likely taught to try to avoid conflicts or to pacify them.

computer aided error analysis (CEA) and root cause analysis (RCA)

If vital signs were not taken frequently enough to satisfy the standard, the manager would need to obtain further information regarding why the standard was not met and counsel employees as needed. This is often done using computer-aided error analysis (CEA) or through root cause analysis (RCA).

report cards

In response to the demand for objective measures of quality, many health plans, health-care providers, employer purchasing groups, consumer information organizations, and state governments have begun to formulate health-care quality report cards.

changes in personality or behavior of chemically impaired nurse

Increased irritability with patients and colleagues, often followed by extreme calm Social isolation; eats alone, avoids unit social functions Extreme and rapid mood swings Euphoric recall of events or elaborate excuses for behaviors Unusually strong interest in narcotics or the narcotic cabinet Sudden dramatic change in personal grooming or any other area Forgetfulness ranging from simple short-term memory loss to blackouts Change in physical appearance, which may include weight loss, flushed face, red or bleary eyes, unsteady gait, slurred speech, tremors, restlessness, diaphoresis, bruises and cigarette burns, jaundice, and ascites Extreme defensiveness regarding medication errors

changes in attendance in chemically impaired nurse

Increasingly absent from work without adequate explanation or notification; most frequent absence on a Monday or Friday Long lunch hours Excessive use of sick leave or requests for sick leave after days off Frequent calling in to request compensatory time Arriving at work early or staying late for no apparent reason Consistent lateness Frequent disappearances from the unit without explanation

confrontation

Many times, team members inappropriately expect the manager to solve their interpersonal conflicts. Managers instead can urge subordinates to attempt to handle their own problems by using face-to-face communication to resolve conflicts, as e-mails, answering machine messages, and notes are too impersonal for interpersonal conflicts that can have significant conflict aftermath.

intrinsic motivation

Motivated by an internal drive to do or be something

motivation

Motivated by an internal drive to do or be something. people who know how to achieve results are motivated by the satisfaction they get from their success Motivation enhanced by the job environment or external rewards •Motivation may be defined as the force within the individual that influences or directs behavior. •Because motivation comes from within a person, managers cannot directly motivate subordinates. •Leaders can create environments that maximizes human development and create emotional engagement to the organization. •Emotional Engagement is one's commitment to organizational goals

extrinsic motivation

Motivation enhanced by the job environment or external rewards

conflict process model: conflict resolution

Mutually agree on solution Constructive way to handle conflict Resolved or suppressed If suppressed - only dominant party is dedicated to fulfilling resolution, defeated party may or may not

formula for calculating nursing care hours per patient day

NCH/PPD = nursing hours worked in 24 hours/patient census

conflict process model: felt conflict

Negative feelings from the parties Situation becomes internalized and emotionalized The third stage, felt conflict, occurs when the conflict becomes emotionalized. Felt emotions include hostility, fear, mistrust, and anger. It is also referred to as affective conflict. It is possible to perceive conflict and not feel it (e.g., no emotion is attached to the conflict and the person views it only as a problem to be solved). A person also can feel the conflict but not perceive the problem (e.g., he or she feels conflict is present but may be unaware of its roots).

common tasks delegated to UAP

Noninvasive and nonsterile treatments Collecting, reporting, and documenting data including, but not limited to, vital signs, height, weight, intake and output, and capillary blood and urine tests Ambulation, positioning, turning Transportation of a client within a facility Personal hygiene, elimination, including vaginal irrigations and cleansing enemas Feeding, cutting up of food, placing of meal trays Socialization activities Activities of daily living

types of workplace violence

Nurse-to-nurse violence (horizontal violence, lateral violence) Patient-to-nurse violence (including visitors) Organization-to-nurse violence (vertical down violence) External perpetrators (strangers, criminal intent) Third-party violence (other health professionals/family members and significant others as well as other health-care workers) Impact of mass trauma or natural disasters on nurses (e.g., terrorism, wars, earthquakes, tornadoes, to name a few) Nurse-to-patient violence Personal violence (e.g., domestic violence, family violence, interpersonal violence)

ombudspersons

Ombudspersons generally hold an official title as such within an organization. Their function is to investigate grievances filed by one party against another and to ensure that individuals involved in conflicts understand their rights as well as the process that should be used to report and resolve the conflict.

conflict process model: conflict aftermath

Pos or negative Resolved or not If not resolved leads to more conflict later The final stage in the conflict process is conflict aftermath. There is always conflict aftermath—positive or negative. If the conflict is managed well, people involved in the conflict will believe that their position was given a fair hearing. If the conflict is managed poorly, the conflict issues frequently remain and may return later to cause more conflict

supervising

Providing guidance and direction, oversight, evaluation and follow-up

controlling phase of management process

Quality Control and Quality Improvement are types of ongoing controlling efforts used to maintain quality of services to clients •Performance is measured against predetermined standards. •Action is taken to correct discrepancies between these standards and actual performance.

patient acuity tool

RNs can assess patient's risk level to help create equitable, quantifiable assignments

what is conflict

Results from real or perceived differences in mutually exclusive goals, values, ideas, attitudes, beliefs, backgrounds, feelings, or actions. Intrapersonal: w/in individ Interpersonal: b/t 2 or more individ Intergroup conflict: b/t 2 or more groups Pos or neg Healthy or unhealthy generally defined as the internal or external discord that results from differences in ideas, values, or feelings between two or more people created when there are differences in economic and professional values and when there is competition among professionals. Scarce resources, restructuring, and poorly defined role expectations also are frequent sources of conflict in organizations. Openly acknowledging that conflict is a naturally occurring and expected phenomenon in organizations reflects a tremendous shift from how sociologists viewed conflict a century ago. The current sociological view is that organizational conflict should be neither avoided nor encouraged but managed. The leader's role is to create a work environment where conflict may be used as a conduit for growth, innovation, and productivity. When organizational conflict becomes dysfunctional, the manager must recognize it in its early stages and actively intervene so that subordinates' motivation and organizational productivity are not adversely affected.

relationship b/t org conflict and effectiveness

Should be viewed as neither good or bad Growth or destructive depending on how it's handled Platform to deal with differences constructively A certain amount is good Constructive conflict creates creativity - develop new ideas Destructive conflict - hinders work performance too little conflict: org stasis too much conflict: reduced org effectiveness w/eventual immobilization of employees

six sigma approach

Sigma is a statistical measurement that reflects how well a product or process is performing. Higher sigma values indicate better performance.

3rd party consultation

Sometimes, managers can be used as a neutral party to help others resolve conflicts constructively. This should be done only if all parties are motivated to solve the problem and if no differences exist in the status or power of the parties involved. If the conflict involves multiple parties and highly charged emotions, the manager may find outside experts helpful for facilitating communication and bringing issues to the forefront.

structure change

Sometimes, managers need to intervene in unit conflict by transferring or discharging people. Other structure changes may be moving a department under another manager, adding an ombudsman, or putting a grievance procedure in place. Often, increasing the boundaries of authority for one member of the conflict will act as an effective structure change to resolve unit conflict. Changing titles and creating policies are also effective techniques.

QI steps

Step 1 est what standard is; recognize gaps b/t standard and performance Step 2 determine what data needs to be collected that is relevant to that standard that's being measured; how it's going to be measured/collected Step 3 evaluate gaps b/t standard and performance; what education or corrective action is needed; put actions to work

quality improvement vs quality assurance

The difference between the two concepts is that QA models target currently existing quality; QI models target ongoing and continually improving quality.

quality gap

The difference in performance between top-performing health-care organizations and the national average

termination/dismissal

The last step in progressive discipline is involuntary termination or dismissal. Many people terminate their employment voluntarily before reaching this step, but the manager cannot count on this happening. Termination should always be the last resort when dealing with poor performance. However, if the manager has given repeated warnings and rule breaking or policy violations continue, then the employee should be dismissed. Although this is difficult and traumatic for the employee, the manager, and the unit, the cost in terms of managerial and employee time and unit morale of keeping such an employee is enormous.

the message

The message is the verbal and/or nonverbal information from the sender. In effective communication, the messages are complete, clear, concise, organized, timely, and expressed in a manner that the receiver can understand. The message must be appropriate for the situation and for the developmental level of the person receiving the message.

conflict management goals

The optimal goal in conflict is a win-win solution for all involved the leader-manager's goal is to manage the conflict in a way that lessens the perceptual differences that exist between the involved parties. A leader recognizes which conflict management or resolution strategy is most appropriate for each situation.

written admonishment

The second step is a formal reprimand or written admonishment. If rule breaking recurs after verbal admonishment, the manager again meets with the employee and issues a written warning about the behaviors that must be corrected. This written warning is very specific about what rules or policies have been violated, the potential consequences if behavior is not altered to meet organizational expectations, and the plan of action that the employee is expected to take to achieve expected change.

Suspension

The third step in progressive discipline is usually a suspension from work, either with or without pay. If the employee continues the undesired behavior despite verbal and written warnings, the manager should remove the employee from his or her job for a brief time, generally a few days to several weeks. Such a suspension gives the employee the opportunity to reflect on the behavior and to plan how he or she might modify the behavior in the future.

arbitration

There are times, however, when mediators are unable to help conflicted parties come to agreement. When this occurs, formal arbitration may be used. Unlike mediation, which seeks to help conflicted parties come together to reach a decision themselves, arbitration is a binding conflict resolution process in which the facts of the case are heard by an individual who makes a final decision for the parties in conflict.

quality measurement tools

There is more than one way to measure quality: •The measure and tool may consider/audit a Process. •The measure and tool may consider/audit an Outcome. •The measure and tool may consider/audit a Structure.

soothing one party

This is a temporary solution that should be used in a crisis when there is no time to handle the conflict effectively or when the parties are so enraged that immediate conflict resolution is unlikely. Waiting a few days allows most individuals to deal with their intense feelings and to be more objective about the issues. Regardless of how the parties are soothed, the manager must address the underlying problem later or this technique will become ineffective.

behavior change

This is reserved for serious cases of dysfunctional conflict. Educational modes, training development, or sensitivity training can be used to solve conflict by developing self-awareness and behavior change in the involved parties.

JCAHO pt safety topics

To find numerous resources on patient safety arranged by topics

systematic quality control and quality improvement processes

We use a variety of systematic processes to measure quality. •FOCUS PDCA •PICO •Model for Improvement and PDSA as noted in QSEN module No matter the process, there are 3 basic principles (pg.622-623) 1.Identify the standards as previously discussed, and/or benchmarking 2.Collect information to determine if standard is being met (what to collect, how to collect, analyzing) 3.Educate or correct if standard is not being met and reevaluate

how do standards help to minimize the complexities of quality health care measurement

We use standardized language when we develop nursing diagnosis. -Example: NANDA language We use quality standards developed by national health care organizations -Examples: American Nurses Association, National Quality Forum, AHRQ, Joint Commission

responsibility charting

When ambiguity results from unclear or new roles, it is often necessary to have the parties come together to delineate the function and responsibility of roles. If areas of joint responsibility exist, the manager must clearly define such areas as ultimate responsibility, approval mechanisms, support services, and responsibility for informing. This is a useful technique for elementary jurisdictional conflicts. An example of a potential jurisdictional conflict might arise between the house supervisor and unit manager in staffing or between an in-service educator and unit manager in determining and planning unit educational needs or programs.

lean manufacturing

a process improvement strategy based on the highly acclaimed Toyota Production System. The focus in Lean Manufacturing is the removal of waste, so that it is possible to produce the right material, in the right amount, at the right time. Define-Measure-Analyze-Improve-Control

quality control

a specific type of controlling—refers to activities that are used to evaluate, monitor, or regulate services rendered to clients.

workload measurement systems

a technique that evaluates work performance as well as necessary resource levels. Therefore, it goes beyond patient diagnosis or acuity level and examines the specific number of care hours needed to meet a given population's care needs. Thus, workload measurement systems typically capture census data, care hours, patient acuity, and patient activities. Although complicated, workload measurement systems do hold promise for more accurately predicting the nursing resources needed to staff hospitals effectively.

bullying

abusive conduct usually verbal, gossip, ostracize, intimidate, horizontal or lateral repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators. repeated, unwanted, harmful actions intended to humiliate, offend, and cause distress in the recipient When it occurs between coworkers, it is known as horizontal bullying.

patient classification systems (PCSs)

also known as workload management, or patient acuity tools, groups patients according to specific characteristics that measure acuity of illness in an effort to determine both the number and mix of the staff needed to adequately care for those patients with objective data, organizations can staff according to documented need rather than perceived convenience, decreasing distrust, fostering collaboration, and moving finance and patient management toward a common goal.

Total Quality Management (TQM)

also referred to as continuous quality improvement, is a philosophy developed by Edward Deming. TQM is one of the hallmarks of Japanese management systems. It assumes that production and service focus on the individual and that quality can always be better. Thus, identifying and doing the right things, the right way, the first time, and problem-prevention planning—not inspection and reactive problem solving—lead to quality outcomes. Workers—not a central QA/QI department—do this data collection, thus providing a feedback loop between administrators, workers, and consumers. Any problems encountered are approached in a preventive or proactive mode so that crisis management becomes unnecessary.

the Leapfrog group

an employer-based coalition, develops and maintains a measure set that focuses on hospital quality and safety practices (CPOE initiative) a growing conglomeration of non-health-care Fortune 500 company leaders who are committed to modernizing the current health-care system. to help minimize risks to patients, the standards and expectations of oversight groups, insurers, and professional groups have been raised

The National Hospital Inpatient Quality Measures

are the product of a collaboration on hospital measurement and reporting between the Centers for Medicare & Medicaid Services and the Joint Commission

ch 20 delegation

ch 20 delegation

ch 21 Conflict, Workplace Violence, and Negotiation

ch 21 Conflict, Workplace Violence, and Negotiation

ch 23: Quality Control in Creating a Culture of Patient Safety

ch 23: Quality Control in Creating a Culture of Patient Safety

ch 25: Problem Employees:Rule Breakers, Marginal Employees, and the Chemically or Psychologically Impaired

ch 25: Problem Employees:Rule Breakers, Marginal Employees, and the Chemically or Psychologically Impaired

Communication material

communication material

AHRQ quality indicators (QIs)

comprise four measure areas: inpatient, prevention, patient safety, and pediatric care. The QIs identify quality topics for monitoring and performance improvement.

goal of quality control at minimum

create a culture of patient safety. Optimally, it allows patient health-care goals to be met.

standards of practice

define the scope and dimensions of professional nursing.

sentinel event

defined by JC as a patient safety event (an event, incident, or condition that could have resulted or did result in harm to a patient) that reaches a patient and results in death, permanent harm, or severe temporary harm and intervention required to sustain life

constructive vs destructive conflict

distinction between constructive and destructive conflict lies in how the conflict is managed to produce positive or negative results. Destructive conflict hinders work performance because people refuse to speak to each other or they do not have civilized conversations. Thus, it can bring down the morale of an entire department and reduce productivity and efficiency. Constructive conflict embraces differing ideas and worldviews, in an effort to move the company toward its goals and mission. Thus, it increases productivity, rather than hampers it

failure mode and effects analysis

examine all possible failures in a design—including sequencing of events, actual and potential risk, points of vulnerability, and areas for improvement Using FMEA allows organizations to review multiple components and subsystems so that the causes and effects of failures can be identified.

incivility

form of bullying, not as obvious, teasing, rude, disrespect, sarcasm, eye rolling, touching, yelling, swearing another term used to describe mistreatment or discourtesy to another person. a continuum, with disruptive behaviors, such as eye-rolling and other nonverbal behaviors and sarcastic comments, on one end of the spectrum, and threatening behaviors, such as intimidation and physical violence, on the opposite end.

mobbing

ganging up on one person when employees "gang up" on an individual. The degree of harm a nurse experiences from bullying or mobbing often depends on the frequency, intensity, and duration of the behavior and/or tactic used

GRRRR

greeting: offer greetings and set pos environment respectful listening: listen w/o interrupting and pause to allow others to think review: summarize message to make sure it was heard accurately recommend or request more info: seek additional info as necessary reward: recognize that a collaborative exchange has occurred by offering thanks

interpersonal conflict

happens between two or more people with differing values, goals, and beliefs. can be defined by the focus and source of the conflict. People-focused conflicts are based on emotions and feelings and often are viewed as a personal attack. Issue-focused conflicts are more likely to be resolved by calmer negotiations. informational deficiencies are another source of interpersonal conflict. Communications are not always received, may be misinterpreted, or different conclusions may be drawn based on past experiences. In addition, role incompatibility may be a cause of interpersonal conflict because of differences between the goals and responsibilities assigned to an individual and what the individual would rather be doing

what is quality in health care

health care constructs institute of medicine dimensions of quality care: STEEEP national quality strategy the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge The first is the assertion that quality does not exist unless desired health outcomes are attained. Outcomes are only one indicator of quality. Sometimes, patients receive the best possible care with the information available and poor outcomes occur. for care to be considered high quality, it must be consistent with current professional knowledge. Quality of care is the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.

examples of management controlling functions

include the periodic evaluation of unit philosophy, mission, goals, and objectives; the measurement of individual and group performance against preestablished standards; and the auditing of patient goals and outcomes.

ORYX

is a set of performance measures required by The Joint Commission (example DVT care performance measures are reported) This initiative integrated outcomes and other performance measures into the accreditation process with data being publicly reported at a website known as Quality Check all organizations accredited by JC were required to select at least 1 of 60 acceptable performance measurement systems and to begin data collection on specific clinical measures

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, commonly known as Hospital CAHPS or HCAHPS

is a standardized survey instrument for measuring adult patients' perspectives on care they experience during a hospital stay (consumer focused on things like cleanliness of rooms, communication with nurse and practitioner, ability to understand discharge instructions)

the receiver

is the observer, listener, and interpreter of the message. Interpretation is also called decoding. Decoding is impacted by the receiver's past experiences and their current state (internal climate). The receiver uses visual, auditory, and tactile senses to help decode the message. Decoding is also impacted by the receiver's external climate. The receiver decodes the message and, based on their interpretation of the message they received, encodes a message and responds to the sender.

delegation

is to a different scope of practice with additional training RN delegates IV push meds to LPN who has extra certification in IV med admin getting work done through others or as directing the performance of one or more people to accomplish organizational goals.

the conflict process model

latent conflict (also called antecedent conditions) -> perceived conflict -> felt conflict -> manifest conflict -> conflict resolution or management -> conflict aftermath Provides framework to look at conflict and explain how it occurs and how to minimize or resolve it

retrospective audits

looking back at care delivered at what the outcome structure or process was; look back thru charts to see how long someone receives pain meds after rating pain at a 6 performed after the patient receives the service

prospective audits

looking forward and trying to predict something; looking at numbers to see how to predict making something better going forward attempt to identify how future performance will be affected by current interventions

complying with staffing mandates

many states have imposed mandatory licensed staffing requirements 14 states have addressed nurse staffing in hospital california has imposed legislation to comply with minimum staffing ratios imposed staffing due to patient care being affected

outcome measures/outcome audits

measure the end result of the care delivered (Outcome Audits) are we meeting the outcome? Outcomes can be defined as the result of care. Patient-reported outcome measures (PROMs) attempt to capture whether the services provided actually improved patients' health and sense of well-being determine what results, if any, occurred as a result of specific nursing interventions for patients. These audits assume that the outcome accurately demonstrates the quality of care that was provided. Most experts currently consider outcome measures to be the most valid indicators of quality care, but historical evaluations of hospital care focused on structure and process. In today's era of cost containment, outcome research is needed to determine whether managed care processes, restructuring, and other new clinical practices are producing the desired cost savings without compromising the quality of patient care. There is growing recognition, however, that it is possible to separate the contribution of nursing to the patient's outcome; this recognition of outcomes that are nursing sensitive creates accountability for nurses as professionals and is important in developing nursing as a profession. More nursing-sensitive outcome measures for the acute care setting include patient fall rates, nosocomial infection rates, the prevalence of pressure sores, physical restraint use, and patient satisfaction rates

structure measures/structure audits

measure the environment in which care is delivered (Structure Audits) we aren't meeting the outcome so let's look at why assume that a relationship exists between quality care and appropriate structure. A structure audit includes resource inputs such as the environment in which health care is delivered. It also includes all those elements that exist prior to and separate from the interaction between the patient and the health-care worker. For example, staffing ratios, staffing mix, emergency department wait times, and the availability of fire extinguishers in patient care areas are all structural measures of quality of care. Structural standards, which are often set by licensing and accrediting bodies, ensure a safe and effective environment, but they do not address the actual care provided.

process measures/process audits

measure the way care is delivered (Process Audits) are we meeting that process? measure how nursing care is provided. The audit assumes a connection between the process and the quality of care. Critical pathways and standardized clinical guidelines are examples of efforts to standardize the process of care. They also provide a tool to measure deviations from accepted best practice process standards. tend to be task oriented and focus on whether practice standards are being fulfilled

concurrent audits

occur at the time we're delivering care; evaluated in real time performed while the patient is receiving the service

intergroup conflict

occurs between two or more groups of people, departments, and organizations. An example of intergroup conflict might be two political affiliations with widely differing or contradictory beliefs or nurses experiencing intergroup conflict with family and work issues.

intrapersonal conflict

occurs within the person. It involves an internal struggle to clarify contradictory values or wants. For managers, intrapersonal conflict may result from the multiple areas of responsibility associated with the management role. Managers' responsibilities to the organization, subordinates, consumers, the profession, and themselves sometimes conflict, and that conflict may be internalized. Being self-aware and conscientiously working to resolve intrapersonal conflict as soon as it is first felt is essential to the leader's physical and mental health.

what type of measure/audit is... Our Benchmark: "Less than 5% of patients will develop a surgical site infection"

outcome

organizational standards

outline levels of acceptable practice within the institution each organization develops a policy and procedures manual that outlines its specific standards. These standards may minimize or maximize in terms of the quality of service expected. Such standards of practice allow the organization to measure unit and individual performance more objectively.

during controlling phase

performance is measured against predetermined standards, and action is taken to correct discrepancies between these standards and actual performance. Controlling, then, should not be viewed as a means of determining success or failure but as a way to learn and grow, both personally and professionally.

Maslow's hierarchy of needs

physiologic/basic needs security/safety social/love esteem self-actualization

standards

predetermined level of excellence that serves as a guide for practice. They are predetermined, established by an authority, and communicated to and accepted by the people affected by them objective, measurable, and achievable

best negotiating practices

prepare exchange bargain conclude execute repeat 70% listening 30% talking

what type of measure/audit is... A clinical practice guideline (CPG): Antibiotic must be given one hour prior to surgery and antibiotic must be stopped within a set time after surgery to decrease surgical site infections

process

prospective payment system

providers are paid a fixed amount per patient admission regardless of the actual cost to provide the care

standardized nursing language

provides a consistent terminology for nurses to describe and document their assessments, interventions, and the outcomes of their actions.

centralized staffing: limitations

provides less flexibility for the worker and may not account for a specific worker's desires or special needs - managers may be less responsive to personnel budget control in scheduling and staffing matters

clinical practice guidelines (CPGs)

reflect evidence-based practice (EBP); that is, they should be based on cutting-edge research and best practices. •CPGs provide diagnosis-based step-by-step interventions for providers to follow in an effort to promote quality care. provide diagnosis-based, step-by-step interventions for providers to follow to promote high-quality care while controlling resource utilization and costs developed following an extensive review of the literature and suggest what interventions, in what order, will likely lead to the best possible patient outcomes.

nurse hazing

repeated actions to intend cause distress horizontal: coworkers

summative task type

requires the nurse to note the frequency of occurrence of specific activities, treatments, and procedures for each patient. For example, a summative task-type PCS might ask the nurse whether a patient required nursing time for teaching, elimination, or hygiene

5 rights to delegation

right task: One that is delegable for a specific patient right circumstance: Appropriate patient setting, available resources, and other relevant factors considered right person: Right person is delegating the right task to the right person to be performed on the right person. right direction/communication: Clear, concise description of the task, including its objective, limits, and expectations right supervision/evaluation: Appropriate monitoring, evaluation, intervention, as needed, and feedback

STEEEP

safe timely effective efficient equitable patient centered care

IHI model for improvement

setting aims: Determine which specific outcomes you are trying to change. The aim should be time-specific and measurable; it should also define the specific population of patients or other system that will be affected. est measures: Identify appropriate measures to track your success. Teams use quantitative measures to determine if a specific change actually leads to an improvement. selecting changes: Identify changes that you will test. Ideas for change may come from those who work in the system or from the experience of others who have successfully improved. testing changes: Testing a change in the real work setting — by planning it, doing it, studying the results, and acting on what is learned

conflict process model: latent conflict

situations that exist before conflict manifests itself The first stage in the conflict process, latent conflict, implies the existence of antecedent conditions such as short staffing and rapid change. In this stage, conditions are ripe for conflict, although no conflict has actually occurred, and none may ever occur. Much unnecessary conflict could be prevented or reduced if managers examined the organization more closely for antecedent conditions. For example, change and budget cuts almost invariably create conflict. Such events, therefore, should be well thought out so that interventions can be made before the conflicts created by these events escalate.

centralized staffing

staffing decisions are made by a central office or staffing center manager limited to making minor adjustments and providing input manager communicates special staffing needs and helps with sudden changes in staffing/acuity manager still responsible for making sure adequate personnel are available to meet needs of org

what type of measure/audit is... How many RN's are available to administer antibiotics to decrease surgical site infections? Was the antibiotic on the unit or still in pharmacy?

structure

diversion

taking pts pain meds and giving them NS instead and pocketing the med

medication reconciliation

the process of comparing the medications a patient is taking (or should be taking) with newly ordered medications This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

benchmarking

the process of measuring products, practices, and services against best performing organizations—as a tool for identifying desired standards of organizational performance. organizations can determine how and why their performance differs from exemplar organizations and use the exemplar organizations as role models for standard development and performance improvement.

JC core measures

to better standardize its valid, reliable, and evidence-based data sets. Hospitals that choose not to participate in the Core Measures initiative receive a reduction in their Medicare Annual Payment. The four areas initially targeted for Core Measures implementation were acute myocardial infarction, pneumonia, heart failure, and the surgical care improvement project Acute myocardial infarction Children's asthma care Emergency department Hospital outpatient department Hospital-based inpatient psychiatric services Immunization Perinatal care Stroke Venous thromboembolism

causes of unit conflict

unclear expectations, poor communication, lack of clear jurisdiction, incompatibilities or disagreements based on differences of temperament or attitudes, individual or group conflicts of interest, and operational or staffing changes. In addition, not only does diversity in gender, age, and culture influence conflict resolution, it may also create conflict itself. This occurs as a result of communication difficulties, including language and literacy issues and a growing recognition that some factors are beyond assimilation.

decentralized staffing

unit managers make scheduling decisions unit manager is responsible for covering all absences, reducing staff during periods of decreased census, adding staff during high census or acuity, prepping monthly unity schedules, prepping holiday and vacation schedules

critical indicator PCS

uses broad indicators such as bathing, diet, intravenous fluids and medications, and positioning to categorize patient care activities.

mediation

which uses a neutral third party, is a confidential, legally nonbinding process designed to help bring the parties together to devise a solution to the conflict. As such, the mediator does not take sides and has no vested interest in the outcome. Instead, the mediator asks questions to clarify the issues at hand (fact finding), listens to both parties, meets with parties privately as necessary, and helps to identify solutions both parties can live with.

types of communication

§In the organization, the formal channels of communication are vertical (upward and or downward communication), horizontal communication, and diagonal communication. This type of formal communication is done according to a set of predetermined rules and policies, and is based on chains of command or hierarchy within the organization. § §The sender chooses a mode or a medium to send the message. You may use verbal, non-verbal, or written modes to send the message. §At the organizational level, written communication allows for documentation, so you may have what we call a paper trail if needed. §Face-to-face communication is a commonly used mode and allows for both verbal and nonverbal communication. §Written communication include things like discharge instructions or pamphlets about smoking cessation. Choosethe most appropriate way to communicate with your team.

content

§The content of communication describes the actual subject matter, words, gestures, and substance of the message. It is the message that everyone may hear or see.

the sender

§begins the conversation to deliver a message (content) to another person. The sender, sometimes called the source or the encoder, uses verbal and nonverbal methods to transmit the message. The sender arranges or encodes the message in a way that would help the receiver understand and interpret the message. The message is impacted by internal and external climate impacting the sender. The internal climate include the sender's values, feelings, temperament, and any ensuing stressors, whereas the external climate include things like the weather, temperature, organizational factors like power and status in the organization. The sender must be attentive to what the receiver may hear and how the intended message is not communicated.

feedback

§validates that the receiver received the message and understood it as the sender intended. Feedback may be written, verbal, nonverbal, or a combination. The sender must verify the message has been received as it was intended, to avoid confusion.

the LPN will

•1. Contribute to the nursing assessment by collecting, reporting and recording objective and subjective data in an accurate and timely manner. •2. Participate in the development of the plan of care/action in consultation with a Registered Nurse. •3. Participate in the assisting and giving of safe direct care. •4. Participate in establishing and maintaining a therapeutic nurse/client relationship. •5. Seek resources for patients/clients with cultural, physical or language barriers. •6. Contribute to the evaluation of the responses of individuals or groups to nursing interventions and participate in revising the plan of care where appropriate. •7. Communicate accurately in writing and orally with recipients of nursing care and other professionals.

barriers to communication

•Ability of sender •Content •Method of communication •Skills and attitude of the receiver •Organizational factors •Cultural attitudes •Noise •Perceptions, prejudices and stereotypes •Inappropriate target for message •Technical capabilities

assigning

•Allocating tasks appropriate to the individual's job description assignment: involves distributing work to a qualified person or persons for implementation of a specific activity or set of activities within their job description

responsibility

•An obligation to accomplish a task

punishment

•An undesirable event that follows unacceptable behavior, which may have negative consequences but can be a powerful motivator for change

rules

•As few rules and regulations as possible should exist in the organization. •All rules, regulations, and policies should be regularly reviewed to see if they should be deleted or modified in some way. •If a rule or regulation is worth having, it should be enforced. When rule breaking is allowed to go unpunished, groups generally adjust to and replicate the low-level performance of the rule breaker. •If a rule is consistently broken, one needs to ask the following: 1.Whose rule is it? 2.Do we still need the rule? •Not disciplining an employee who should be disciplined jeopardizes an organization's morale.

rights and responsibilities in grievance resolution

•Both parties have rights and responsibilities to be heard and to listen. •Employee has not only the right to a positive work environment but also a responsibility to express discontent responsibly. •The manager has a right to expect employees to follow the rules but must make sure employees know and understand the rules.

the complexity defining quality health care

•Centers for Medicare and Medicaid Services (CMS) •Joint Commission- Core Measures, National Patient Safety Goals, ORYX measures •American Nurses Association •National Database for Quality Nursing Indicators (NDQNI)-Nurse-Sensitive Indicators developed by ANA and the National Quality Forum •Agency for Healthcare Research Quality (AHRQ) Patient Safety Indicators •National Hospital Quality Measures. •CAHPS Hospital Survey (HCAHPS) •The Leapfrog Group •CPOE •National Quality Forum- Safe Practices •Your work organizations •Report Cards

strategies to create an environment of self discipline

•Clearly written and communicated rules and regulations •Atmosphere of mutual trust •Judicious use of formal authority •Employee identification with organizationalgoals

elements affecting delegation to a transcultural work team

•Communication •Space •Social organization •Time •Environmental control •Biologic variations Communication: especially dialect, volume, use of touch, and eye contact Space: interpersonal space differs between cultures Social organization: family unit of primary importance in some cultures Time: cultures tend to be past, present, or future oriented Environmental control: cultures often have either internal or external locus of control Biological variations: susceptibility to diseases (e.g., Tay-Sachs) and physiologic differences (e.g., height and skin color)

clear communication and delegation

•Define the task clearly. • •Delineate end results, time frame, and standards. • •Delegate the objective, not the procedure.

PICO model in QI

•Discover an area of concern/interest •Form a focused clinical question using the PICO format •Research best practices •Implement/test a change idea

causes of underdelegating

•Fear that delegation may be interpreted as a lack of ability to do the job completely or correctly •A desire to complete the job •Fear that subordinates will resent delegated work •Lack of experience in the job •Enjoyment of the work •Fear of liability Lean towards maximizing mode perfectionism frequently stems from the individual's false assumption that delegation may be interpreted as a lack of ability on his or her part to do the job correctly or completely. Delegation does not need to limit the individual's control, prestige, and power; rather, delegation can extend their influence and capability by increasing what can be accomplished

models of QI: FOCUS PDA

•Find a process that needs improving; gather and compare data from your organization •Organize a team who knows the process •Clarify current knowledge on the process (standards) •Understand the variance •Select a plan/process for improvement F: ID need O: get peeps together who understand process being evaled C: clarify EBP U: understand why your standard might be different S: plan, do, check, act cycle

confronting the chemically impaired employee

•Gather as much evidence as possible of employee's impairment. •Immediate confrontation is necessary if manager suspects employee may be impaired and thus poses a risk to clients. •Denial of the impairment or use of defense mechanisms should be expected; manager should not nurture or counsel the employee. •The manager should outline the plan for the employee to overcome chemical impairment. •The goal of a diversion program is to protect the public by early identification of impaired nurses and by providing these nurses access to appropriate intervention programs and treatment services.

disciplinary process for unionized employees

•Generally entails more procedural, legalistic safeguards for administering discipline and a well-defined grievance process for employees who believe that they have been disciplined unfairly Another difference between unionized and nonunionized employee discipline lies in the burden of proof, which typically is the responsibility of the employee without union membership but is the responsibility of the manager of the employee who belongs to a union. This means that managers who discipline union employees must keep detailed records regarding misconduct and counseling attempts.

why delegate

•Getting work done through others •Directing to accomplish organizational goals •Giving someone else the authority to complete a task or action on your behalf •Transfer or hand-off to a competent individual,

constructive discipline

•Helps the employee to grow •Is carried out in a supportive, corrective manner •Employee is reassured that punishment is given because of actions and not because of who he or she is as a person. •Primary focus is to assist employees to be self-directed in meeting organizational goals.

strategies for successful delegation

•Identify necessary skill and education levels •Plan ahead •Select and empower capable personnel •Communicate goals clearly •Set deadlines and monitor progress •Be role model and provide guidance •Evaluate performance •Reward accomplishment

driving forces for developing effective nurse staffing: staffing

•Impacts the relationship between nursing and finance •Can blow a budget •Affects cost of care •Affects quality of care •Matters to nursing

chemical impairement

•Impairment resulting from drug or alcohol addiction

discipline

•Involves training or molding the mind or character to bring about desired behaviors •Is often considered a form of punishment but is not quite the same thing as punishment

potential costs of delegation to UAP

•Liability for negligence •Issues for task delegation oJob description oKnowledge base oDemonstrated skills •Accountability for patient outcomes

performance deficiency coaching

•Manager actively brings areas of unacceptable behavior or performance to the attention of the employee and works with him or her to establish a short-term plan to correct deficiencies. This type of coaching may be ongoing or problem centered. Problem-centered coaching is less spontaneous and requires more managerial planning than ongoing coaching. In performance deficiency coaching, the manager actively brings areas of unacceptable behavior or performance to the attention of the employee and works with him or her to establish a plan to correct deficiencies. Because the role of a coach is less threatening than that of an enforcer, the manager becomes a supporter and helper. Performance deficiency coaching helps employees, over time, to improve their performance to the highest level of which they are capable. As such, the development, use, and mastery of performance deficiency coaching should result in improved performance for all.

problem employees

•Managers must be able to distinguish between employees who need progressive discipline and those who are chemically impaired, psychologically impaired, or marginal employees so that the employee can be managed in the most appropriate manner.

motivational theorists

•Maslow—hierarchy of needs •Skinner—operant conditioning/behavior modification •Herzberg—motivator/hygiene theory •Vroom—expectancy model •McClelland—basic needs •Gellerman—"stretching" •McGregor—Theory X and Y

profile of impaired nurse

•May vary greatly • •Typically, behavior changes are seen in the following three areas: •Personality/behavior changes •Job performance changes •Time and attendance changes

the delegate's responsibility

•Must accept only tasks that match their competency •Must maintain competency for delegated responsibility •Must communicate with nurse in charge of patient •Must carryout accepted task correctly and competently

licensed nurse responsibilities

•Must determine when and what to delegate •Must communicate with delegatee •Must be available for guidance and questions •Must follow-up with patient •Must provide feedback to delegatee

reentry guidelines for the recovering nurse

•No psychoactive drug use is tolerated. •The employee should be assigned to day shift for the first year. •The employee should be paired with a successfully recovering nurse whenever possible. •The employee should be willing to consent to random urine screening with toxicology or alcohol screens. •The employee must give evidence of continuing involvement with support groups such as Alcoholics Anonymous or Narcotics Anonymous. Employees should be encouraged to attend meetings several times each week. •The employee should be encouraged to participate in a structured aftercare program. •The employee should be encouraged to seek individual counseling or therapy as needed.

resistance to delegation

•Not seeing subordinate's perspective •Subordinate feels unprepared for responsibility •Resistance to authority •Over-delegation

delegation as a function of professional nursing

•Organizations must have a clearly defined structure where RNs are recognized as the leaders. •Job descriptions must clearly define the roles and responsibilities of all. •Educational programs must be developed to help personnel learn each other's roles and responsibilities •Adequate programs must be developed to foster leadership and delegation.

common sources of org conflict

•Poor communication •Changes to the structure •Inadequately defined organizational structure •Unclear expectations •Scarce resources •Individual behavior •Conflicts in interest •Diversity Communication: est understanding and clarity Changes to structure org may consist of poorly defined roles Overlapping or similar responsibility cause unclear expectations Need specific roles and responsibilities Conflict rises when parties battle for the same resource

causes of overdelegating

•Poor time management •Insecurity in the ability to perform a task •Insensitive to staff workload burdening their subordinates. Some managers overdelegate because they are poor managers of time, spending most of it just trying to get organized. Others overdelegate because they feel insecure in their ability to perform a task.

how to motivate your staff

•Set your staff up for success •Build empowering relationships •Set achievable goals and results •Provide appropriate support •Reinforce desired behaviors •Evaluate the process •Reward results Effective communication is at the helm of staff motivation: you must be able to communicate with your team. Be self aware of your communication strategies (verbal and non-verbal). There can be confusion when the non-verbal does not match the verbal. Master the art of constructive criticism when feedback is required. Set your staff up for success: Hire top performers. people who know how to achieve results are motivated by the satisfaction they get from their success; they want to get that feeling as often as possible. Build empowering relationships that provide them with the experiences they need to develop the skills required to achieve goals. Set achievable goals and results: Once you know a person's goals, values, and skill level, you can work with him or her to develop a plan with achievable goals, and to provide reinforcement and rewards in line with what that person wants. Every employee wants to feel that their job makes a difference. They want to feel as if they matter, as if their efforts matter. Provide appropriate support: Creating a hassle-free working environment. Assess what your staff members need to achieve the goals and behaviors identified. Nurses' experiences with anticipatory guidance helps us anticipate support needs. Reinforce desired behaviors by sharing the good news. Knowing they're performing an action more efficiently motivates staff to continue the behavior and spurs them on to even greater accomplishments. Also, Let them know you trust them. Evaluate the process: When reviewing an experience, we examine goals, actions, support, and reinforcement; then we can decide what to repeat, what to avoid, and what to do differently in the future. It is like doing the evaluation for your plan of care. Reward results: Show your appreciation. When your staff achieves desired goals and results, reward them by giving them what they want. People are motivated to act when they anticipate or participate in getting something they want.

substance misuse

•Substance misuse is usually defined as maladaptive patterns of psychoactive substance abuse indicated by continued use even when faced with recurrent occupational, social, psychological, or physical problems as well as use in dangerous situations.

termination

•Termination should always be the last resort when dealing with poor performance but is necessary for employees who continue to break rules despite repeated warnings. •Termination is always difficult for the employee, manager, and unit; however, the cost in terms of managerial/employee time and unit morale of keeping such an employee is enormous.

continuous quality improvement involves

•The Organization as a Whole •Front-Line staff •Physicians •Respiratory Therapists •Physical Therapists •Ancillary staff •Patients No matter how good a product or service is, there's always room for improvement

accountability

•The act of accepting ownership for the results or lack thereof.

incidence of chemical impairment in nursing

•The chemical impairment rate of health professionals is generally acknowledged as being greater than that of the general public. •The majority of disciplinary actions by licensing boards are related to misconduct resulting from chemical impairment, including the misappropriation of drugs for personal use and the sale of drugs and drug paraphernalia to support the nurse's addiction.

McGregor's hot stove rule

•The following four elements must be present to make discipline as fair and growth-producing as possible: 1.Forewarning -Need to know ahead of time what the consequences are going to be 2.Immediate consequences -If you place your hand on a stove there will be immediate consequences 3.Consistency -The consequence needs to be the same every time 4.Impartiality -Doesn't matter who it is, there has to be the same consequence applied

self-discipline

•The process by which rules are internalized and become part of the person's personality •Highest and most effective form of discipline •Self-discipline is possible only if subordinates know the rules and accept them as valid.

authority

•The right to act and empower

formal grievance process

•The steps are generally outlined in union contracts or administrative policies. •It typically entails progressive lodging of complaints up the chain of command. •If differences are not settled in formal grievance process, the dispute generally proceeds to arbitration.

marginal employees

•These employees disrupt unit functioning because the quantity or quality of their work consistently meets only minimal standards. •These employees often make tremendous efforts to meet competencies yet usually manage to meet only minimal standards at best. •Traditional discipline is generally not constructive in modifying their behavior. traditional discipline is generally not constructive in modifying their behavior. This is because marginal employees often make tremendous efforts to meet competencies yet usually manage to meet only minimal standards at best.

late stage chemical dependency

•Tolerance is developed by the employee to the chemical, and the individual needs the chemical in greater amounts and more often to achieve the same effect. •The individual characteristically exhibits high defensiveness. •Employee must continually use the substance even though he or she generally no longer gains pleasure from it. •The manager should not assume the role of counselor or treatment provider or feel the need to diagnose the cause of the chemical addiction. The manager's role is to clearly identify performance expectations for the employee and to confront the employee when those expectations are not met.

destructive discipline

•Use of threats and fear to control behavior •Employee always alert to impending penalty or termination •Arbitrarily administered and either unfair in the application of rules or in the resulting punishment

causes of improperly delegating

•Wrong time, to the wrong person, or for the wrong reason •Beyond the capability of the person, or something the manager should do •Decision making without providing adequate information includes such things as delegating at the wrong time, to the wrong person, or for the wrong reason. It also may include delegating tasks and responsibilities that are beyond the capability of the person to whom they are being delegated or that should be done by someone with greater expertise, training, or authority.

handoff

•transfer of responsibility between caregivers of similar training (RN to RN, LPN to LPN). •Trading work; bartering

key concepts ch 21

■ Conflict can be defined as the internal discord that results from differences in ideas, values, or feelings of two or more people. ■ Because managers have a variety of interpersonal relationships with people with different values, beliefs, backgrounds, and goals, conflict is an expected outcome. ■ The most common sources of organizational conflict are communication problems, organizational structure, and individual behavior within the organization. ■ Conflict theory has changed dramatically during the last 100 years. Currently, conflict is viewed as neither good nor bad because it can produce growth or be destructive, depending on how it is managed. ■ Too little conflict results in organizational stasis, whereas too much conflict reduces the organization's effectiveness and eventually immobilizes its employees. ■ Conflict also has a qualitative component, and the impact of a conflict on any individual varies significantly in terms of how it is perceived and handled. ■ The three categories of conflict are intrapersonal, interpersonal, and intergroup. ■ The first stage in the conflict process is called latent conflict, which implies the existence of antecedent conditions. Latent conflict may proceed to perceived conflict or to felt conflict. Manifest conflict may also ensue. The last stage in the process is conflict aftermath. ■ The optimal goal in conflict resolution is creating a win-win solution for everyone involved. ■ Common conflict resolution strategies include compromise, competing, accommodating, smoothing, avoiding, and collaboration. ■ Bullying is abusive conduct that is threatening, humiliating, or intimidating in nature. ■ Incivility is a term used to describe mistreatment or discourtesy to another person. It occurs on a continuum from disruptive behaviors such as eye-rolling and other nonverbal behaviors and sarcastic comments to threatening behaviors, such as intimidation and physical violence. ■ In mobbing, employees "gang up" on an individual. ■ When bullying, incivility, and mobbing occur in the workplace, it is known as workplace violence. ■ Workplace violence impacts the physical, emotional, and socioeconomic health of employees and threatens patient safety. ■ All organizations should have bullying policies in place with zero tolerance as the expectation. ■ As a negotiator, it is important to win as much as possible, lose as little as possible, and make the other party feel satisfied with the outcome of the negotiation. ■ Because knowledge is power, the more informed the negotiator is, the greater is his or her bargaining power. ■ The leader, although able to recognize and counter negotiation tactics, always strives to achieve an honest, collaborative approach to negotiation. ■ The manager must know his or her bottom line but try never to use it. ■ Closure and follow-up are important parts of the negotiation process. ■ ADR usually involves at least one of the elements of mediation, fact finding, arbitration, and the use of ombudspersons. ■ Seeking consensus, a concord of opinion, although time-consuming, is an effective conflict resolution and negotiation strategy.

key concepts ch 23

■ Controlling is implemented throughout all phases of management. ■ Quality control refers to activities that are used to evaluate, monitor, or regulate services rendered to consumers. ■ A standard is a predetermined baseline condition or level of excellence that constitutes a model to be followed and practiced. ■ Because there is no one set of standards, each organization and profession must set standards and objectives to guide individual practitioners in performing safe and effective care. ■ CPGs provide diagnosis-based, step-by-step interventions for nurses to follow in an effort to promote evidence-based, high-quality care and yet control resource utilization and costs. ■ Benchmarking is the process of measuring products, practices, and services against those of best performing organizations. ■ The difference in performance between top-performing health-care organizations and the national average is called the quality gap. Although the quality gap is typically small in industries such as manufacturing, aviation, and banking, wide variation is more common in health care. ■ CEA and RCA help to identify not only what and how an event happened but also why it happened, with the end goal being to ensure that a preventable negative outcome does not recur. ■ Outcome audits determine what results, if any, followed from specific nursing interventions for patients. ■ Process audits are used to measure the process of care or how the care was carried out. ■ Structure audits monitor the structure or setting in which patient care occurs (such as the finances, nursing service structure, medical records, and environmental structure). ■ There is growing recognition that it is possible to separate the contribution of nursing to the patient's outcome; this recognition of outcomes that are nursing sensitive creates accountability for nurses as professionals and is important in developing nursing as a profession. ■ Standardized nursing languages provide a consistent terminology for nurses to describe and document their assessments, interventions, and the outcomes of their actions. ■ QA models seek to ensure that quality currently exists, whereas QI models assume that the process is ongoing and that quality can always be improved. ■ Quality control in health-care organizations has evolved primarily from external forces and not as a voluntary effort to monitor the quality of services provided. ■ Critics of the PPS argue that although DRGs may have helped to contain rising health-care costs, the associated rapid declines in length of hospital stay and services provided have resulted in declines in quality of care. ■ The JC is the major accrediting body for health-care organizations and programs in the United States. It also administers the ORYX initiative and collects data on core measures to better standardize data collection across acute care hospitals. ■ CMS plays an active role in setting standards for and measuring quality in health care including P4P. ■ HCAHPS survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. It measures recently discharged patients' perceptions of their hospital experience. ■ NCQA, a private nonprofit organization that accredits managed care organizations, also developed the HEDIS to compare quality of care in managed care organizations. ■ Ideally, everyone in an organization should participate in quality control activities. ■ In response to the demand for objective measures of quality, many health plans, health-care providers, employer-purchasing groups, consumer information organizations, and state governments have begun to formulate health-care quality report cards. ■ A plethora of studies across the past two decades suggests that medical errors continue to be rampant in the health-care system. ■ A "just culture" deemphasizes blame for errors and focuses instead on addressing factors that lead to and cause near misses, medical errors, and adverse events. ■ The Leapfrog Group identified four evidence-based standards that they believe will provide the greatest impact on reducing medical errors: CPOE, evidence-based hospital referral, IPS, and the use of The Leapfrog Group Safe Practices scores. ■ The FDA has suggested that a drug bar code system coupled with a computerized order entry system would greatly decrease the risk of medication errors. ■ Historically, the health-care industry has been comfortable with striving for three sigma processes (all data points fall within three standard deviations) in measuring health-care quality; Six Sigma is typically adopted by the highest performing organizations for quality. ■ As direct caregivers, staff nurses are in an excellent position to monitor nursing practice by identifying problems and implementing corrective actions that have the greatest impact on patient care.

key concepts ch 25

■ It is essential that managers can distinguish between employees who need progressive discipline and those who are chemically impaired, psychologically impaired, or marginal employees so that the employee can be managed in the most appropriate manner. ■ Discipline is a necessary and positive tool in promoting subordinate growth. ■ The optimal goal in constructive discipline is assisting employees to behave in a manner that allows them to be self-directed in meeting organizational goals. ■ To ensure fairness, rules should include McGregor's "hot stove" components of forewarning, immediate application, consistency, and impartiality. ■ If a rule or regulation is worth having, it should be enforced. When rule breaking is allowed to go unpunished, groups generally adjust to and replicate the low-level performance of the rule breaker. ■ As few rules and regulations as possible should exist in the organization; all rules, regulations, and policies should be regularly reviewed to see if they should be deleted or modified in some way. ■ Except for the most serious infractions, discipline should be administered in progressive steps, which include verbal admonishment, written admonishment, suspension, and dismissal. ■ In performance deficiency coaching, the manager actively brings areas of unacceptable behavior or performance to the attention of the employee and works with him or her to establish a short-term plan to correct deficiencies. ■ The grievance procedure is essentially a statement of wrongdoing or a procedure to follow when one believes that a wrong has been committed. All employees should have the right to file grievances about disciplinary action that they believe has been arbitrary or unfair in some way. ■ The presence of a union generally entails more procedural, legalistic safeguards for administering discipline and a well-defined grievance process for employees who believe that they have been disciplined unfairly. ■ Because chemical and psychological impairment are diseases, traditional progressive discipline is inappropriate because it cannot result in employee growth. ■ The profile of the impaired nurse may vary greatly, although typically, behavior changes are seen in three areas: personality/behavior changes, job performance changes, and time and attendance changes. ■ Nurses and managers traditionally have been slow to recognize and respond to chemically impaired colleagues. ■ Confronting an employee who is suspected of chemical impairment should always occur before the problem escalates and before patient safety is jeopardized. ■ The manager should not assume the role of counselor or treatment provider or feel the need to diagnose the cause of the chemical addiction. The manager's role is to clearly identify performance expectations for the employee and to confront the employee when those expectations are not met. ■ The goal of a diversion program is to protect the public by early identification of impaired nurses and by providing these nurses access to appropriate intervention programs and treatment services. ■ Strategies for dealing with marginal employees vary with management level, the nature of the health-care organization, and the current prevailing attitude toward passive or active intervention.

key concepts ch 20

■ Professional nursing organizations and regulatory bodies are actively engaged in clarifying the scope of practice for unlicensed workers and delegation parameters for RNs. ■ Delegation is not an option for the manager—it is a necessity. ■ Delegation should be used for assigning routine tasks and tasks for which the manager does not have time. It is also appropriate as a tool for problem solving, changes in the manager's own job emphasis, and building capability in subordinates. ■ In delegation, managers must clearly communicate what they want to be done, including the purpose for doing so. Limitations or qualifications that have been imposed should be delineated. Although the manager should specify the end product desired, it is important that the subordinate has an appropriate degree of autonomy in deciding how the work is to be accomplished. ■ Managers must delegate the authority and the responsibility necessary to complete the task. ■ Most delegation errors could be avoided if the five rights of delegation, identified by the ANA and the NCSBN, were followed. ■ RNs who are asked to assume the role of supervisor and delegator need preparation to assume these leadership tasks. ■ Assuming the role of delegator and supervisor to the NAP increases the scope of liability for the RN. Although the NAP does bear some personal accountability for their actions, this does not negate accountability for the RN who delegated the task(s). ■ The RN always bears the ultimate responsibility for ensuring that the nursing care provided by his or her team members meets or exceeds minimum safety standards. ■ Although the Omnibus Budget Reconciliation Act of 1987 established regulations for the education and certification of "certified nurse's aides" (minimum of 75 hours of theory and practice and successful completion of an examination in both areas), no federal or community standards have been established for training the more broadly defined NAP. ■ When subordinates resist delegation, the delegator must ascertain why the delegated task was not accomplished and take appropriate action to remove these restraining forces. ■ Transcultural sensitivity in delegation is needed to create a productive multicultural work team.

key concepts ch 17

■ The manager has both a fiscal and an ethical duty to plan for adequate staffing to meet patient care needs. ■ In centralized staffing, staffing decisions are made by personnel in a central office or staffing center. In decentralized staffing, each department is responsible for its own staffing. ■ Innovative and creative methods of staffing and scheduling should be explored to avoid understaffing and overstaffing as patient census and acuity fluctuate. ■ Twelve-hour shifts have become commonplace in acute care hospitals even though there continues to be debate about whether extending the length of shifts results in increased judgment errors related to fatigue and increased sick time. ■ Agency nurses and travel nurses, who are typically employed by an external nursing broker, can provide scheduling relief in response to unanticipated increases in census or patient acuity, but their continuous use is expensive and can result in poor continuity of nursing care. ■ Per diem staff, who receive a higher rate of pay, but no benefits, have the flexibility to choose when they want to work. ■ Flextime is a system that allows employees to select the time schedules that best meet their personal needs while still meeting work responsibilities. ■ Self-scheduling allows nurses in a specific unit or department to work together to construct their own schedules rather than have schedules created by management. ■ Workload measurement systems, which typically capture census data, care hours, patient acuity, and patient activities, can evaluate work performance as well as required resource levels. ■ 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 each organization. ■ Mandatory overtime should be a last resort, not standard operating procedure because an institution does not have enough staff. ■ Research suggests that as professional nursing representation in the skill mix increases, patient outcomes generally improve, and adverse incidents decline. ■ California is the only state in the United States that has enacted legislation requiring mandatory staffing ratios in hospitals and long-term care facilities. The answer as to whether mandated ratios have improved care or created new cost burdens for California is still unclear. ■ Those with staffing responsibility must remain cognizant of mandatory staffing ratios and comply with such mandates. ■ Managers should attempt to have a diverse staff who will meet the cultural and language needs of the patient population. ■ Staffing and scheduling policies must not violate labor laws, state or national laws, or union contracts. ■ Fair and uniform staffing and scheduling policies and procedures must be written and communicated to all staff. ■ Existing staffing policies must be examined periodically to determine if they still meet the needs of the staff and the organization.

addressing workplace violence

■Alter unit climate ■Model appropriate behavior ■Provide staff education ■Have ZERO tolerance policy ■Institute safe reporting mechanism

destructive negotiation tactics

■Ambiguous or inappropriate questioning ■Gestures of helplessness ■Intimidation ■Manipulation ■Ridicule ■Flattery ■Aggression

collaborating

■An assertive and cooperative means of conflict resolution whereby all parties set aside their original goals and work together to establish a supraordinate or common priority goal ■True collaboration requires mutual respect; open and honest communication; and equitable, shared decision-making powers. everyone wins Focus on solving problem expand range of possible options achieve win/win outcomes Collaborating is an assertive and cooperative means of conflict resolution that results in a win-win solution. In collaboration, all parties set aside their original goals and work together to establish a supraordinate or priority common goal. In doing so, all parties accept mutual responsibility for reaching the supraordinate goal. Although it is very difficult for people truly to set aside original goals, collaboration cannot occur if this does not happen. For example, a married couple experiencing serious conflict over whether to have a baby may first want to identify whether they share the supraordinate goal of keeping the marriage together. A nurse who is unhappy that he or she did not receive requested days off might meet with his or her supervisor and jointly establish the supraordinate goal that staffing will be adequate to meet patient safety criteria. If the new goal is truly a jointly set goal, each party will perceive that an important goal has been achieved and that the supraordinate goal is most important. In doing so, the focus remains on problem solving and not on defeating the other party. Collaboration is rare when there is a wide difference in power between the groups and individuals involved. Many think of collaboration as a form of cooperation, but this is not an accurate definition. In collaboration, problem solving is a joint effort with no superior-subordinate, order-giving-order-taking relationships. True collaboration requires mutual respect; open and honest communication; and equitable, shared decision-making powers. Collaboration enhances a person's participation in decision making to accomplish mutual goals and therefore is the best method to resolve conflict to achieve long-term benefits. Because it may involve others over whom the manager has no control and because its process is often lengthy, it may not be the best approach for all situations.

smoothing

■An individual attempts to reduce the emotional component of the conflict. downplay the differences Ignoring the elephant in the room Insult to party who sees issues as important Smoothing is used to manage a conflict situation. Smoothing occurs when one party in a conflict attempts to pacify the other party or to focus on agreements rather than differences. In doing so, the emotional component of the conflict is minimized. Managers often use smoothing to get someone to accommodate or cooperate with another party. Although it may be appropriate for minor disagreements, smoothing rarely results in resolution of the actual conflict.

workplace violence

■Bullying ■Incivility ■Mobbing ■Nurse Hazing ■Patient/family violence against nurse ■Nurse violence against patient Verbal abuse is the number-one form of workplace violence against nurses

conflict resolution styles

■Compromising ■Competing ■Cooperating/accommodating ■Smoothing ■Avoiding ■Collaborating

compromising

■Each party gives up something it wants. ■Rewards are divided between parties ■Mutually exclusive situations in play Equal power Goals mutually exclusive no win no lose minimally acceptable to all relationships undamaged In compromising, each party gives up something it wants. Although many see compromise as an optimum conflict resolution strategy, it may result in a lose-lose situation because either or both parties perceive that they have given up more than the other and may therefore feel defeated. For compromising not to result in a lose-lose situation, both parties must be willing to give up something of equal value. Compromising becomes a win-win only when both parties perceive they have won more than the other person. It is important that parties in conflict do not adopt compromise prematurely if collaboration is both possible and feasible.

negotiation closure

■End on a friendly note ■Restate the final decision ■Hide astonishment at your success ■Make the other party feel that he/she also won ■Follow up with a memo

negotiation

■Frequently resembles compromise when used as a conflict negotiation strategy ■Emphasis is on accommodating differences between the parties. Meeting in the middle No win no lose in its most creative form is like collaboration and in its most poorly managed form may resemble a competing approach

seeking consensus

■It is always an appropriate goal in resolving conflicts and in negotiation. ■All parties support, or at least do not oppose, an agreement. ■The greatest challenge in consensus building is time. everyone loses something but everyone agrees upon it means that negotiating parties reach an agreement that all parties can support, even if it does not represent everyone's first priorities. Consensus decision making does not provide complete satisfaction for everyone involved in the negotiation as an initially unanimous decision would, but it does indicate willingness by all parties to accept the agreed-on conditions.

types of alternative dispute resolution

■Mediation: 3rd party helps by seeking facts ■Due process hearings: right to fair trial ■Ombudsperson: investigate grievances and ensure protected rights

competing

■One party pursues what it wants, regardless of the cost to others. win - lose situation zero sum orientation win/lose power struggle The competing approach is used when one party pursues what it wants at the expense of the others (zero sum game). Because only one party typically wins, the competing party seeks to win regardless of the cost to others. These win-lose conflict resolution strategies then typically leave the loser angry, frustrated, and wanting to get even in the future. Managers may use competing when a quick or unpopular decision needs to be made. It is also appropriately used when one party has more information or knowledge about a situation than the other. Competing in the form of resistance is also appropriate when a person needs to resist unsafe patient care policies or procedures, unfair treatment, abuse of power, or ethical concerns.

cooperating/accommodating

■One party sacrifices his or her beliefs and wants to allow the other party to win. selfless Preserve harmony Unassertive Submissive accede to the other party maintain harmony focus on other's needs and mutual relationships Cooperating is the opposite of competing. In the cooperating approach, one party sacrifices his or her beliefs and allows the other party to win. The actual problem is usually not solved in this win-lose situation. Accommodating is another term that may be used for this strategy. The person cooperating or accommodating often expects some type of payback or an accommodation from the winning party in the future. In addition, employees who use accommodation as a primary conflict management strategy may keep track and develop resentment. Cooperating and accommodating are appropriate political strategies if the item in conflict is not of high value to the person doing the accommodating.

avoiding

■Parties are aware of a conflict but choose not to acknowledge it or attempt to resolve it. no acknowledgement No attempt to resolve it withdraw from the situation maintain neutrality In the avoiding approach, the parties involved are aware of a conflict but choose not to acknowledge it or attempt to resolve it. those who actively avoid conflict frequently have low esteem or hold a position of low power. Avoidance may be indicated in trivial disagreements, when the cost of dealing with the conflict exceeds the benefits of solving it, when the problem should be solved by people other than you, when one party is more powerful than the other, or when the problem will solve itself. The greatest problem in using avoidance is that the conflict remains, often only to reemerge later in an even more exaggerated fashion.

negotiation terminology

■The very least for which a person will settle is often referred to as the bottom line. ■Trade-offs are secondary gains, often future-oriented, that may be realized as a result of conflict. ■The manager also must look for and acknowledge hidden agendas—the covert intention of the negotiation.

steps for conflict resolution

■Understand the conflict. ■Communicate with the opposition. ■Brainstorm possible resolutions. ■Use an impartial mediator. ■Explore alternatives. ■Cope with stressful situations and pressure tactics. ■Choose the best resolution.