Unit 17 Leadership and Care Management

transformational leadership

A leadership style that focuses on change and innovation through effective communication and team building. Engagement, empowerment, and accountability are critical to team effectiveness.

principle of ends

Act so that you treat humanity, both in your own person and in that of another, always as an end and never merely as a means

Evaluation.

It is a mistake to think that evaluation occurs at the end of an activity. It is ongoing. Once you assess a patient's needs and begin therapies directed at a specific problem area, immediately evaluate whether therapies are effective and the patient's response. The process of evaluation compares actual patient outcomes with expected outcomes.

Authority

Right to act in areas in which an individual has been given and accepts responsibility.

Magnet Recognition

The Magnet Recognition Program is based on five model components—transformational leadership; structural empowerment; exemplary professional practice, new knowledge, innovation, and improvements; and empirical quality results. A Magnet hospital empowers a nursing team to make changes and be innovative. Professional nurse councils at the organizational and unit level are one way to create an empowerment model.

Time Management.

These skills involve learning how, where, and when to use your time. Because you have a limited amount of time with patients, it is essential to remain goal oriented. For example, you are caring for two patients on a busy surgical nursing unit. One had surgery the day before, and the other will be discharged the next day. Clearly the first patient's goals center on restoring physiological function impaired as a result of the stress of surgery. The second patient's goals center on adequate preparation to assume self-care at home. Delegation of tasks is another way to help improve time management. One useful time-management skill involves making a priority to-do list. If possible, complete the activities started with one patient before moving on to the next.

Accountability

individuals being answerable for their actions

four core concepts for patient-centered care

(1) respect and dignity, ensuring that the care provided is given on the basis of a patient's and family's knowledge, values, beliefs, and cultural backgrounds; (2) information sharing, meaning that health care providers communicate and share information so patients and families receive timely, complete, and accurate information to effectively participate in care and decision making; (3) participation, whereby patients and families are encouraged and supported in participating in care and decision-making; (4) collaboration, demonstrated by the health care leaders collaborating with patients and families in policy and program development, implementation, and evaluation and patients who are fully engaged in their health care

5. Staff education.

A nurse manager is responsible for making learning opportunities available so staff members remain competent in their practice and empowered in their decision making. This involves planning in-service programs, sending staff to continuing education classes and professional conferences, and having staff present case studies or evidence-based practice issues during staff meetings.

Building a Nursing Team.

A strong nursing team works together to achieve the best outcomes for patients. Effective team development requires team building and training, trust, communication, and a workplace that facilitates collaboration. Building an empowered nursing team begins with the nurse executive, who is often a vice president or director of nursing. The executive's position within an organization is critical in uniting the strategic direction of an organization

categorical imperative

Always act in such a way that you can also resolve that the maxim of your action should become a universal law

Knowledge Building

As an accountable nurse, you are responsible for lifelong learning and maintaining competency. You need to maintain and continually improve your knowledge and skills. Lifelong learning allows you to continuously provide safe, effective, quality care.

Delegation 1

Asking a staff member to obtain an ordered specimen while you attend to a patient's pain medication request effectively prevents a delay in the patient gaining pain relief and accomplishes two tasks related to the patient. Never delegate a task that you dislike doing or would not do yourself because this creates negative feelings and poor working relationships. For example, if you are in the room when a patient asks to be placed on a bedpan and there are no urgent care issues, you assist the patient rather than leave the room to find the nurse assistant. You are accountable for the delegated task. You do not delegate the steps of the nursing process of assessment, diagnosis, planning, and evaluation because these steps require nursing judgment. Patient teaching is also the responsibility of an RN and should not be delegated. Do not give the NAP sole responsibility for the care of patients. You are always responsible for the assessment of a patient's ongoing status; but, if a patient is stable, you delegate vital sign monitoring to the NAP.

Delegation 2

Assess the patient and determine a plan of care before identifying which tasks someone else is able to perform. When directing the NAP, determine how much supervision is necessary. Is it the first time the NAP performed the task? Does the patient present a complicating factor that makes the RN's assistance necessary? Does the NAP have prior experience with a particular type of patient in addition to having received training on the skill? The final responsibility is to evaluate whether the NAP performed the task properly and whether the desired outcomes were met. Efficient delegation requires constant communication (i.e., sending clear messages and listening so all participants understand expectations regarding patient care). The NAP needs to have the chance to ask questions and have your expectations made clear. Clarification of patients' specific needs is always necessary. When a NAP performs a task correctly and does a good job, it is important to provide praise and recognition. If a staff member's performance is not satisfactory, give constructive and appropriate feedback. Giving feedback in private is the professional way and preserves the staff member's dignity.

Responsibility

Carrying out duties associated with a particular role.

Decision Making

Decentralization is a component of the hierarchical level of decision making found in health care institutions. Higher degrees of decentralization take the decision making down to the lower levels of the health care institution and have less supervision of the decision-making process. Working in a decentralized structure has the potential for greater collaborative effort, increased competency of staff, increased staff motivation, and ultimately a greater sense of accomplishment. To make shared decision making work, managers need to know how to move it down to the lowest level possible. Team members need to be kept well informed. They also need to be given the opportunity by managers to participate in problem-solving activities related to direct patient care and unit activities.

3. Interprofessional rounding.

During rounding members of the team meet and share patient information, answer questions asked by other team members, discuss the patient's clinical progress and plans for discharge, and focus all team members on the same patient goals. Interprofessional rounding helps decrease medical errors, decrease patient readmission rates, impact patient satisfaction, and improve quality of care.

Organizational Skills.

Effective use of time means doing the right things, whereas efficient use of time means doing things right. Learn to become efficient by combining various nursing activities (i.e., doing more than one thing at a time). For example, during medication administration or while obtaining a specimen, combine therapeutic communication, teaching interventions, and assessment and evaluation. A well-organized nurse approaches any planned procedure by having all of the necessary equipment available and making sure that the patient is prepared. Keep the work area organized and complete preliminary steps before asking co-workers for assistance. In another example a patient is waiting to visit family, and a chest x-ray film is a routine order from 2 days earlier. The patient's condition has stabilized, and the x-ray technician is willing to return later to shoot the film. In this case attending to the patient's hygiene and comfort so family members can visit is more of a priority.

empowered

Gave legal authority to or enabled an individual or group; promoted self-actualization of an individual or group.

Paternalism

Healthcare professionals make decisions about diagnosis, therapy, and prognosis for the patient. Based upon the health care professional's belief about what is in the best interest of the patient, he/she chooses to reveal or withhold patient information in these three important arenas. This principle is heavily laden as an application of power over the patient. Example: Patient has repeatedly voiced fear over receiving a diagnosis of lung cancer, as he believes this is a death sentence. His primary care physician decides not to reveal the diagnosis to the patient after he says he would kill himself if he had lung cancer.

Staff Involvement.

If the staff learns to value the pursuit of knowledge and the contributions of co-workers, better patient care is an outcome. Healthy work environments have nurses who are skilled in communication, true collaboration among health care team members in decision making, appropriate levels of staffing to meet patient needs, meaningful recognition of nurses, and a nurse leader engaged in authentic leadership.

Deontology

Immanuel Kant; This theory judges the morality of an action based on the action's adherence to rules. Whether an action is ethical depends on the intentions behind the decisions rather than the outcomes that result. Example: Individuals would examine their intentions to determine the ethics of their actions. For example, we have begun not to use restraints on older people for their safety and to think of other measures. We do this because restraining someone against his or her will could not be considered a universal law.

The TEEAMS approach

In this approach the nurse manager spends TIME on the unit with the staff sharing ideas, EMPOWERS the staff, is ENTHUSIASTIC about seeking opportunities to enhance the team, shows APPRECIATION and recognizes team members for a job well done, MANAGES the team and holds team members accountable, and provides SUPPORT in the stressful health care environment.

2. Interprofessional collaboration among nurses and health care providers.

Interprofessional collaboration involves bringing representatives of various disciplines together to work with patients and families to deliver quality care. Interprofessional collaboration involves all professions bringing different points of view to the table. The nurse plays a unique role within the team and is often viewed as the team leader because it is the nurse who takes on the responsibilities of coordination of communication and patient care. Competencies needed for effective interpersonal collaboration include: • Work with individuals of other professions to maintain a climate of mutual respect and shared values. • Use the knowledge of one's own role and those of other professions to appropriately assess and address the health care needs of patients and populations served. • Communicate with patients, families, communities, and other health care professionals in a responsive and responsible manner that supports patient-centered care and a team approach to the maintenance of health and treatment of disease.

4. Staff communication.

It is difficult to make sure that all staff members receive the same message (i.e., the correct message). Staff quickly become uneasy and distrusting if they fail to hear about planned changes on their work unit. For example, many managers distribute biweekly or monthly newsletters of ongoing unit or agency activities. Minutes of committee meetings are usually in an accessible location for all staff to read or are sent to individuals via email. Staff meetings, email, inter-committee communication.

Justice

John Rawls, this principle refers to an equal and fair distribution of resources, based on analysis of benefits and burdens of decision. Justice implies that all citizens have an equal right to the goods distributed, regardless of what they have contributed or who they are. For example, in the US, we all have rights to services from the postal service, firefighters, police, and access to public schools, safe water, and sanitation. Example: A hospital organization wishes to donate low or no-cost pediatric dental services to the community. There are openings for 45 children per month. Justice requires a fair method, that is free from bias, to determine who will receive these services.

Use of Resources.

Never hesitate to have staff help you, especially when there is an opportunity to make a procedure or activity more comfortable and safer for patients. For example, assistance in turning, positioning, and ambulating patients is frequently necessary when patients are unable to move. Having a staff member such as NAP assist with handling equipment and supplies during complicated procedures such as catheter insertion or dressing changes makes procedures more efficient. Consulting with an experienced RN confirms findings and ensures that you take the proper course of action for the patient. A leader knows his or her limitations.

Total patient care

Nursing delivery of care model originally developed during Florence Nightingale's time. In the model a registered nurse (RN) is responsible for all aspects of care for one or more patients. The RN works directly with the patient, family, physician or health care provider, and health care team members. The model typically has a shift-based focus.

Nurse Manager's Leadership Style

Nursing units where nurse managers use transformational leadership styles have a shared vision that leads the unit to work toward the unit goals together, and staff members have job clarity that improves productivity and staff motivation. Transformational leadership practices of the nurse manager also lead to increased staff satisfaction, decreased stress and burnout in staff nurses, increased overall staff feeling of well-being, and staff retention/increased level of patient satisfaction, a lower patient mortality rate, and a lower rate of medication errors. Nurse managers who use these relational leadership styles create a positive work environment by providing support, encouragement, and constructive feedback to staff through open communication.

Case management

Organized system for delivering health care to an individual patient or group of patients across an episode of illness and/or a continuum of care; includes assessment and development of a plan of care, coordination of all services, referral, and follow-up; usually assigned to one professional.

Important elements of the decision-making process are responsibility, autonomy, authority, and accountability

Responsibility reflects ownership. An individual who manages employees distributes responsibility, and the employees have to accept the manager's direction. A manager is responsible for clearly defining an RN's role within a new care delivery model. Each RN on the team is responsible for knowing his or her role and how to perform that role on the busy nursing unit. With clinical autonomy a professional nurse makes independent decisions about patient care (i.e., planning nursing care for a patient within the scope of professional nursing practice). In work autonomy a nurse makes independent decisions about the work of the unit such as scheduling or unit governance. Clear communication and organization of work to allow a nurse to act on nursing decisions using clinical judgment help to promote autonomy. The nurse has the final authority in selecting the best course of action for the patient's care. A nurse has the authority to consult a dietitian to learn why the recommendations on the plan of care were not implemented and to review the established plan with him or her to ensure that the recommended patient teaching is completed. Accountability refers to individuals being answerable for their actions. It means that as a nurse you take responsibility to provide excellent patient care by following standards of practice. You are accountable for what you do (i.e., performing the nursing process, communicating effectively with health care team colleagues, and staying current on nursing practice issues).

Team Communication.

Strategies to improve your communication with health care providers include addressing the colleague by name, having the patient and chart available when discussing patient issues, focusing on the patient problem, and being professional and assertive but not aggressive or confrontational. In a clinic setting it may mean sharing unusual diagnostic findings or conveying important information regarding a patient's source of family support. Part of good communication is clarifying what others are saying and building on the merits of co-workers' ideas. Examples of communication tools that improve communication include briefings or short discussions among team members; group rounds on patients; callouts to share critical information such as vital signs with all team members at the same time; check backs to restate what a person has said to verify understanding of information; the two-challenge rule that allows concerns to be voiced twice, which allows all team members to voice concerns about safety; "CUS" words, which means "I'm Concerned, I'm Uncomfortable, I don't feel this is Safe; and the use of Situation-Background-Assessment-Recommendation (SBAR)

Priority Setting.

Symptom pattern recognition from your assessment database and certain knowledge triggers help you understand which diagnoses require intervention and the associated time frame to intervene effectively. If a patient is experiencing serious physiological or psychological problems, the priority becomes clear. You need to act immediately to stabilize his or her condition. Classify patient problems in three priority levels: • High priority—An immediate threat to a patient's survival or safety such as a physiological episode of obstructed airway, loss of consciousness, or a psychological episode of an anxiety attack. • Intermediate priority—Nonemergency, nonlife-threatening actual or potential needs that a patient and family members are experiencing. Anticipating teaching needs of patients related to a new drug and taking measures to decrease postoperative complications are examples of intermediate priorities. • Low priority—Actual or potential problems that are not directly related to a patient's illness or disease. These problems are often related to developmental needs or long-term health care needs. An example of a low-priority problem is a patient at admission who will eventually be discharged and needs teaching for self-care in the home. For example, a patient who has just completed ambulation down the hall is short of breath. The dietary assistant arrives in the room to deliver a meal tray. Instead of immediately helping the patient with the meal, you position him comfortably in bed, offer basic hygiene measures, and then evaluate his breathlessness. The patient likely becomes more interested in eating.

Nursing Care Delivery Models

Team nursing developed in response to the severe nursing shortage following World War II. In team nursing the RN is the leader who leads a team of other RNs, practical nurses, and nursing assistive personnel (NAP) who provide direct patient care. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. Patient- and family-centered care is a model of nursing care in which mutual partnerships among the patient, family, and health care team are formed to plan, implement, and evaluate the nursing and health care delivered. At the center of patient-centered care is the patient or family member as the source of control and full partner in providing care. Total patient care delivery was the original care delivery model developed during Florence Nightingale's time. In this model the RN is responsible for all aspects of care for one or more patients during a shift of care, working directly with patients, families, and health team members. There is a high degree of collaboration among health care team members and is primarily found in critical care areas. Case management is a care-management approach designed to coordinate and link health care services across all levels of care for patients and their families while streamlining costs and maintaining quality. For example, a case manager coordinates a patient's acute care in the hospital and follows up with the patient after discharge, either to home, rehabilitation, or a long-term care setting. Case managers do not provide direct care but instead work with and collaborate with direct-care providers about the care delivered by other staff and health care team members and actively coordinate patient discharge planning.

Clinical Decisions.

The first activity involves a focused but complete assessment of a patient's condition so you know the patient and make accurate clinical judgments about his or her nursing diagnoses and collaborative health problems. Learn a patient's typical patterns of responses and his or her current situation and knowing the patient as an individual. After obtaining a thorough assessment and identifying a patient's diagnoses and problems, you develop a plan of care, implement nursing interventions, and evaluate patient outcomes. The process requires clinical decision making using a critical thinking approach. Learn to attend and listen to the patient, look for any cues (obvious or subtle) that point to a pattern of findings, and direct the assessment to explore the pattern. Never hesitate to ask for assistance.

1. Establishing nursing practice through problem-solving committees or professional shared governance councils.

These groups establish and maintain care standards for nursing practice on their work unit. Participation in shared governance empowers a nurse to make decisions and increases nurses' confidence in decision making and their autonomy. The committees review ongoing clinical care issues, identify problems, apply evidence-based practice in establishing standards of care, develop policy and procedures, resolve patient satisfaction issues, etc. It is important for the committees to focus on patient outcomes rather than only work issues.

Fidelity

This principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It involves an agreement to keep our promises. Fidelity refers to the concept of keeping a commitment and is based upon the virtue of caring. Example: A patient asks the nurse not to reveal the fact that she is dying or give her diagnosis to his family. The nurse asks why she does not want her family advised. The patient explains that her family is very emotional and has stated they would do everything to keep her alive, even if it required long-term mechanical ventilation. The patient has explained multiple times that she does not want mechanical ventilation. The nurse recognizes that keeping of this information in confidence, while supporting the family, is an example of exercising fidelity.

Ethical Relativism

This theory holds that morality is relative to the norms of one's culture; this theory believes there is no "universal truth." Example: An example, often used, is female genital circumcision. One side calls it female genital mutilation. Another group may consider this an appropriate cultural rite of passage. The ethical issue discussed—is this a cultural issue or human rights issue? Since it is performed on girls as young as seven years old, the issue of assent, consent, and culture are prominent in ethical discussions.

Feminist Theory

This theory supports ethical relativism in that it does not support universal acts. Feminist theory requires examination of context of the situation in order to come to a moral conclusion. It asks how an action affects the person, the family, and those depending upon one another (e.g. community). Example: There are two people, who are 16 years of age, who have a new diagnosis of insulin dependent diabetes. Neither can afford the recommended insulin pump. The company will donate one pump per year as a charity option. Ethical relativism might help make a decision on which patient to give the pump to at no cost. Using this theory, one would take into account the patient's culture, lifestyle, motivation, and maturity level before deciding to whom the insulin pump would be best allocated. Additionally, feminist ethics would look at how the parents of the young people are being affected by the disease, and whether a pump would make life easier or more difficult for the family. The family's resources, both financial and emotional, would be taken into account. The context of the situation would be explored.

Utilitarianism

This theory supports what is best for most people. The value of the act is determined by its usefulness, with the main emphasis on the outcome or consequences. Example: In the US, our system of disaster triage is based upon the concept of utilitarianism. Health care providers triage rapidly, electing to use resources to provide the most care to the greatest number of people, as opposed to expending maximum resources on a single critically ill person who is unlikely to survive.

Patient- and family-centered care

a model of nursing care in which mutual partnerships among the patient, family, and health care team are formed to plan, implement, and evaluate the nursing and health care delivered

Nonmaleficence

avoidance of harm or hurt; core of medical oath and nursing ethics. Example: When this elderly person above received pain medication (an act of beneficence) there are complications that could arise. Practitioners recognize that using a narcotic may cause confusion. When obtaining the consent for her hip surgery, we want to make certain that the patient is alert enough to understand the risks and benefits of the procedure. We must balance the beneficence of providing the medication quickly with the possible maleficence of obtaining a consent when patient does not have the capacity to make the decision for surgery.

Beneficence

compassion; taking positive action to help others; desire to do good; core principle of our patient advocacy. Example: An elderly patient falls at home and has a fractured hip. In the emergency room, the nurse acts to provide pain medication as soon as possible in an act of beneficence.

Autonomy

freedom of choice and responsibility for the choices; agreement to respect another's right to self-determine a course of action; support of independent decision making Example: In clinical situations nurses respect a patient's autonomy, where the patient is allowed the freedom of choice regarding treatment, such as in deciding whether he/she wishes to be intubated during an exacerbation of COPD, or deciding when he/she wishes to forgo further dialysis. If a patient lacks capacity for such a decision and has an advance directive, the person who has the durable power of attorney can make the decision.

Interprofessional collaboration

involves bringing representatives of various disciplines together to work with patients and families to deliver quality care

Provision 8

the nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities

Provision 4

the nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care

Provision 5

the nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth

Provision 1

the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person

Provision 3

the nurse promotes, advocates for, and protects the rights, health, and safety of the patient

Provision 2

the nurse's primary commitment is to the patient, whether an individual, family, group, community, or population

Provision 7

the nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and generation of both nursing and health policy

Provision 6

the nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care

Provision 9

the profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain integrity of profession, and integrate principles of social justice into nursing and health policy

shared governance

these groups establish and maintain care standards for nursing practice on their work unit. Shared governance is a dynamic process that promotes decision making, accountability, and empowerment in staff nurses and enables them to control their nursing practice

delegation

transferring responsibility for the performance of an activity or task while retaining accountability for the outcome

Key Points

• A manager sets a philosophy for a work unit, ensures appropriate staffing, mobilizes staff and institutional resources to achieve objectives, motivates staff members to carry out their work, sets standards of performance, and empowers staff to achieve objectives. • Patient- and family-centered care is composed of the core concepts of respect and dignity, information sharing, participation of family members and collaboration. • A transactional leader develops effective teams on the nursing unit, empowers staff members, communicates effectively with the nursing team, and guides and supports the nursing team in their shared decision making. • An empowered nursing staff has decision-making authority to change how they practice. • Nursing care delivery models vary according to the responsibility and autonomy of the RN in coordinating care delivery and the roles other staff members play in assisting with care. • Critical to the success of decision making is making staff members aware that they have the responsibility, authority, autonomy, and accountability for the care they give and the decisions they make. • A nurse manager encourages shared decision making by establishing nursing practice committees, supporting interprofessional collaboration, setting and implementing quality improvement plans, and maintaining timely staff communication. • Clinical care coordination involves accurate clinical decision making, establishing priorities, efficient organizational skills, appropriate use of resources and time-management skills, and an ongoing evaluation of care activities. • In an enriched professional environment, each member of a nursing team is responsible for open, professional communication. • Effective delegation requires the use of good communication skills. • When done correctly, delegation improves job efficiency, productivity, and job enrichment. • An important responsibility for the nurse who delegates nursing care is evaluation of the staff member's performance and patient outcomes.

Tips on appropriate delegation:

• Assess the knowledge and skills of the delegatee: (e.g., "How do you usually apply the cuff when you measure a blood pressure?") • Match tasks to the delegatee's skills: Know which tasks and skills are in the scope of practice and job description for the team members • Communicate clearly: Always provide clear directions by describing a task, the desired outcome, and the time period; For example, "I'd like you to please help me by getting Mr. Floyd up to ambulate before lunch. Be sure to check his blood pressure before he stands and write your finding on the graphic sheet. OK? Thanks." • Listen attentively: Listen to the NAP's response after you provide directions. • Provide feedback: Always give the NAP feedback regarding performance, regardless of outcome. Let them know of a job well done.