unit 4 lesson 11

Tips to increase the effectiveness of handoffs

1. Established that dialogue will be limited to that which will improve care to individuals. · Avoid negative discussions of family, visitors, individuals. · Avoid socialization. · Avoid criticizing staff, personnel, ect. 2. Relate to the priorities of care for the individual. · Frequency of vital signs. · Changes in condition. · Physician/NP/PA involvement. · Last PRN medication dose, time. · Risk status for falls and pressure injuries. 3. Report what has been done or needs to be addressed to prepare for transition. · Teaching, referrals, individual/family involvement. · Individual/families understanding of condition, home care. · This handoff, also known as shift report, transfer report, or sign over, is utilized at: · change of shift on a unit. · Transfer to another care facility. · Discharge to a community agency. · Effective handoffs support the transition of critical information and specifically identify high risk and clinically unstable Individuals. Unfortunately, the literature describes adverse events and safety risk occurring when the handoff process is compromised, and complete, and/or missing. · All healthcare facilities have a format/process for handoffs; however, the quality and accuracy of the handoff are primarily dependent on the involved clinicians. Nurses engaged in handoffs can increase the accuracy and clarity of the dialogue. The usual data, name, room, age, medical diagnosis, medicines, and treatment will also be presented.

ethical codes

Ethical standards of behavior require a clear understanding of the multidimensional aspects of an ethical dilemma, including intangible human factors that make each situation unique (personal and cultural values or resources). When a dilemma cannot be resolved through interpersonal negotiation, and Ethics Committee composed of biomedical experts review the case and makes recommendations. Of particular importance to the nurse patient relationship or ethical directives related to the nurse's primary commitment to the following: · patient welfare. · Patient autonomy. · Recognition individual is unique and worthy of respect. · Truth telling and advocacy.

Document and report disruptive behaviors

· A crucial aspect of sustaining quality care is the ability to confront a team member whose behaviors violate accepted norms. Studies show that reporting a colleague to an authority figure without talking the objectionable behavior over with him or her is not effective in restoring harmony. Yet surveys showed that the vast majority of physicians and nurses are reluctant to either confront or report. If your attempts to directly discuss behavior with the involved person failed to achieve behavior change, then you need to follow the agencies process and report the problem. In handling disruptive behavior occurrences, documentation is a key step. Hopefully, the agency has no blame process, but remember that when pushed, many people will retaliate. Be aware! · Some agencies may hold communication training sessions after the offences have been documented.

Interdisciplinary rounds and team meetings.

· A huddle is a brief, informal gathering of the team to decide on a course of action. Huddles reinforced the existing plan of care or informed team members of changes to the plan. A team huddle can be called by any team member. · Callouts and timeouts allow staff to stop and review. As mentioned earlier, TJC mandates that staff working in surgery have a time-out in which all team members review the details of the surgery about to take place to prevent wrong patient, wrong site surgeries. · May increase communication (collaboration) and positively affect patient outcomes · ex. Daily discharge multidisciplinary rounds have been correlated with decreased length of hospital stay. · Interdisciplinary team meetings: daily or weekly meetings to explore common goals/concerns/options, smooth problems before they escalate into conflicts, or provide support. · Clinical teaching rounds: lower on the scale - where a physician once weekly teaches nurses, which has the goal of encouraging physician communication with nursing staff. · Huddles- informal gathering to decide on a course of action. Reinforce existing plan. · Callouts and Time-outs - allow staff to stop and review. TJC mandates this in surgery prior to surgery to prevent wrong patient, wrong site surgeries.

Huddle

· Ad-hoc (informal) meeting to: · Re-establish situational awareness. · Reinforce plans already in place. · Assess the need to adjust the plan. · Can be called by any team member. · During (Middle) · Huddles are held more frequently than team meetings, sometimes daily. · Typically last no more than 7-10 min · Conveyed spontaneously in a convenient location with team members standing rather than sitting close to the site of action. · To stay informed, make on-the-spot decisions, be able to move ahead quickly in rapidly changing circumstances.

Ethical codes

· All legitimate professions have standards of conduct. A code of ethics for nurses provides a broad conceptual framework outlining the principled behaviors and value beliefs expected of professional nurses and delivering health care to individuals, families, and communities. Embodied in ethical codes are nursing score values. Written codes are found in most nations. An international code of ethics was adopted by ICN in 1953 and revised in 2012. This code identifies 4 fundamental nursing responsibilities as being to promote health, prevent illness, restore health, and alleviate suffering. Moreover, the code says each nurse has the responsibility to maintain a clinical practice that promotes ethical behavior, while sustaining collaborative, respectful relationships with coworkers. Among the many elements of the code, those addressing communication state we need to ensure that each patient receives accurate, sufficient communication in a timely manner and she maintained confidentiality. · Professional nurses Regardless of setting, or expected to follow ethical guidelines in their practice. The American Nurses Association code of ethics for nurses with interpretive statements establishes principled guidelines designed to protect the integrity of patients related to their care, health, safety, and rights.

Nurse practice roles

· An empowering aspect of the nurse role is the opportunity to evolve roles, change specialties of care, move into advanced roles, or take on new administrative roles. Nurses must put forth the value of nurses as skilled healthcare providers. Evolved scope of practice and professional standards serve as the foundation for practice accountability and decision authority in contemporary nursing practice.

Social learning theory

· Bandura's work provides a useful framework for examining the role of a nurse. Bandura said that learning takes place in a social environment, in the nurses' case in the clinical setting. Learners aspire to be like, to identify with, those who hold positions to which they themselves aspire. Students are motivated to pay attention to a role model's behavior, to imitate it after cognitively processing observed behavior. They internalize their observations and then reproduce it. Bandura suggested this occurs in four stages: attention, retention, reproduction, and motivation. Reinforcement adds to motivation. · Framework for examining the role of the nurse. · Learning takes place in a social environment - nurse - clinical setting. · Learners aspire to hold positions to which they aspire. Students pay attention to role model's behavior and imitate it. (internalize observations and reproduce it). · Bandura suggests 4 stages: attention, retention, reproduction, and motivation.

Crew resource management-based tools

· CRM is another communication tool similar to SBAR, which was adapted from the field of aviation. This tool provides rules of conduct for communication, especially during handoff care transitions. Just prior to an event, such as surgery, all members of the team stop and summarize what is happening. Each team member has an obligation to voice safety concerns.

Mutual Support: Feedback

· Can be given by any team member at any time. · Essentials of Communication: · Clear & Considerate · Brief & Specific · Timely · Complete & directed towards improvement · A type of mutual support: the ability to anticipate & support team members' needs through accurate knowledge about their responsibilities and workload. · Feedback should be: · Clear - use common language & Considerate - consider a team member's feelings and deliver negative information with fairness & respect (no personal attributes) · Brief - only essential information & Specific - be specific about what behaviors need correcting · Timely - given soon after the target behavior has occurred - verify message received, respond quickly, provide updates · Complete - All relevant info and use standardized communication tools & Directed towards improvement - provide directions for future improvement · Show the hyperlink after discussing the slide. It is inside the title (feedback). It`s the part of the SBAR video where the doctor gives feedback to the med tech (Greg). If short on time simply remind them about it. · Examples of giving feedback: · Cautioning team members about potentially unsafe situations. · "Your patient's b/p appears to be dropping. Do you think we should address this?" · "It looks like you're having some difficulty getting an IV inserted. I have a few minutes and will get a central line set up in case you need one." · Providing necessary information. · "I've brought you the file containing the patient's medical history and old ECGs. I think the patient has a strong family history of hyperlipidemia and heart disease?

Developing a support system

· Collegial relationships are an important determinant of success for professionals. Since lack of support is associated with workplace conflicts, you need to make positive efforts to create a support system network. Don't just passively wait and hope it happens. Integrity, respect for others, dependability, a good sense of humor, and an openness to sharing with others are communication qualities people look for in developing a support system. · Positive reinforcement · Everyone likes to be recognized for their efforts. Simple steps such as saying "thank you" or texting a "job well done" message to colleagues are appreciated. In organizations that have integrated team training and safety initiatives, participation in team activities is integrated into job evaluations. In some agencies come up positive evaluations are tied to bonuses. Other organizations hold formal and informal affairs to recognize and celebrate efforts to improve communication and safety.

Use of two challenge rule

· Communication interventions are shown to improve safe communication. These are best practices. For example, when there is conflicting information or a concern about a potential safety breech, nurses use the "two-challenge rule." The nurse states his or her concern twice. This is theoretically enough cause to stop the action for a reassessment.

· Technology

· Competency in use of technology is a QSEN goal. Technology permits swift transactions, universal access, and levels of portability unanticipated 20 years ago. Defining aspects of caring and patient communication are supported, not led, by technology. Nurses are more responsible than ever to devise communication strategies that preserve the caring aspects of nursing. · Defining aspects of caring and patient communication are supported, not led, by technology.

Professional nursing role competencies

· Competency is defined as a set of capabilities, skills, attitude, and experience. In addition to development of technical nursing skills, technology, and communication skills, collaborative skills are needed to become a positive force in team-based healthcare. Nurse competencies have been defined by professional organizations, including QSEN, state boards of nursing licensure, and the government. Competencies include physical mastery of nursing skills and cognitive knowledge and attitudes needed to provide patient-centered care.

Theoretical constructs related to the nurse role

· Criteria that are characteristic of a profession were initially developed by Flexner more than a century ago. A nurse's professional relationships and work environment play a big part in satisfaction. Job dissatisfaction contributes to high turnover rates at a time when there is a worldwide nursing shortage. Even in developed countries, new graduates leave their jobs and even their profession in high numbers. Job attrition is cited as running between 15% and greater than 60% in various countries, are cited by numerous articles. Could creating a supportive workplace with open communication and respect promote better retention?

Mutual Support: Feedback

· Critical Language- The ability to get everyone to stop and listen is essential for safe care. These words convey urgency and help avoid the natural tendency to speak indirectly and differentially. · Critical Language: (conveys urgency) · "I'm Concerned", "I'm Uncomfortable", "This is Unsafe", "I'm Scared" (CUS) · Means: "We have a serious problem, stop and listen to me." (direct conversation) · Common signal words: "danger," "warning," & caution" · Other signal phrases: · "I would like some clarity about... · Would you like some assistance? · If safety issue not addressed? - take a stronger course of action. - Utilize supervisor or chain of command. · If the person acknowledges your concern, but still does not follow your request, utilize your chain of command reporting the issue to your immediate supervisor.

TeamSTEPPS Tools & Strategies.

· Cross-Monitoring - harm error reduction strategy. · Feedback - info for improving team performance. · Advocacy & Assertion - advocate for patient, assert corrective action in a firm & respectful manner. · Two-challenge rule: Empowers all team members to "stop the line" as if they sense or discover an essential safety breach. When an initial assertive statement is ignored, team member assertively voices a concern two times (1st as a question, 2nd with support for your concern)to ensure that it has been heard. Team member being challenged much acknowledge concern heard. If safety issue not addressed? - take a stronger course of action. - Utilize supervisor or chain of command. · CUS - providers are taught key phrases (critical language) understood by all team members to mean, "Stop. We may have a problem." Ex."I need some CLARITY. I am UNCERTAIN. I have a SAFETY concern."

Debriefing

· Debriefing occurs after a surgery or critical incident. It is a callback or review meeting during which each team member has an opportunity to voice problems that arose, to identify what went well, and to suggest changes that can be made. · Debriefing: · Talk it over afterwards (while event is still fresh) · - Do well? Challenges? Changes for next time? · Debrief - informal information exchange session designed to improve team performance and effectiveness; after action review.

· The PhD-prepared a nurse researcher

· Doctoral research degree programs in nursing have grown substantially in developed countries. These nurses are prepared to conduct original research, to be primary investigators seeking substantial grants, working not only in university settings but also in many healthcare corporations. · These nurses are prepared to conduct original research, to be primary investigators seeking substantial grants, working not only in university settings but also in many healthcare corporations.

Team leadership

· Effective team leaders: · Organize the team. · Identify & articulate clear goals. · Assign tasks & responsibilities. · Monitor & modify plan; communicate changes. · Review team performance; provide feedback. · Manage & allocate resources. · Facilitate information sharing. · Encourage team members to assist one another. · Facilitate conflict resolution. · Model effective teamwork. · Effective leaders use different leadership techniques (briefs, huddles, and debriefs) to communicate with their team and effectively manage their resources.

Experiential learning

· Experiential learning is defined as an active participation in learning scenarios, with self -reflection to analyze learning components. Contemporary healthcare education depends on experiential learning for developing both technical care skills and communication proficiency. Its competency-based goal is to provide students with knowledge, skills, and attitudes needed to effectively collaborate and improve the quality of healthcare. Students use case study analysis, role play, exercise activities, computer simulations, standardized patient models, ect. The most vital part of the experiential learning process is the final activity of reflection analysis to recap what was learned and strategize about how to correct the mistakes made. · Contemporary healthcare education depends on experiential learning for developing both technical care skills and communication proficiency. · Its competency-based goal is to provide students with the knowledge, skills, and attitudes needed to effectively collaborate and improve the quality of healthcare. · The most vital part of the experiential learning process is the final activity of reflection analysis to recap what was learned and strategize about how to correct mistakes made.

Patient-centered care...

· Focus on fully partnering with patient to provide care that incorporates his or her values and preferences to give safe, caring, compassionate effective care. · To do so requires us to communicate preferences to other health team members · Knowledge. Integrate understanding of arts, sciences, including communication, to apply nursing process. · Skills. Use communication skills in intake clinical interview to ask about patient preferences, to develop care plan, to communicate these to others. Use communication tools. · Attitudes. Value patient expertise and input.

Teamwork and collaboration...

· For teamwork we need mutual respect, open communication, and shared decision making with all team members. · Knowledge. Know scope of practice. Analyze differences in communication styles. · Skills. Adapt own style to the needs of The Team in the current situation. Communicate openly, share in decision making, resolve potential conflicts. · Attitudes. Respect contributions of every team member.

Criticize constructively

· Giving constructive criticism and receiving criticism is difficult for most people. When a supervisor gives constructive criticism, some type of response from the person receiving it is indicated. Initially, it is crucial that the conflict problem be clearly defined and acknowledged. To help handle constructive criticism, nurses can do the following: · schedule a time when you work calm. · Request that supervisory meetings be in a place that allows privacy. · Defuse personal anxiety. · Listen carefully to the criticism and then paraphrase it. · Acknowledge that you take suggestions for improvement seriously. · Discuss the facts of the situation but avoid becoming defensive. · Develop a plan for dealing with similar situations; become proactive rather than reactive. · Maintain open dialogue.

· Leadership

· Hesburgh's description of leadership, and its relationship to caring, still holds true: the mystique of leadership, be it educational, political, religious, commercial, or whatever, it's next to impossible to describe, but wherever it exists, morale flourishes, people pull together toward common goals, spirits soar, order is maintained, not as an end in itself, but as a means to move forward together. Such leadership always has a moral as well as intellectual dimension; it requires courage as well as wisdom; it does not simply know, it cares.

Briefing

· In team situations, such as in the operating room, the team may use another sort of standardized format: a briefing. The leader (the surgeon, in this case) presents a brief overview of the procedure about to happen, identifies roles and responsibilities, plans for the unexpected, and increases each team member's awareness of the situation. The leader asks anyone who sees a potential problem to speak up. In this manner, the leader "gives permission" for every team member to speak up. This can include the patient also, as many patients will not speak unless specifically invited to do so. A debriefing is usually led by someone other than the leader. It occurs toward the end of a procedure and is a recap or summary as to what went well or what might be changed. This is similar to the feedback nurses ask patients to do after they have presented some educational health teaching, which verifies that the patient understood the material. · Before · Similar to a preflight checklist used in aviation · A short session prior to start to discuss: · Team formation · Assign roles · Establish expectations & climate · Anticipate outcomes and likely contingencies · Briefs serve to: · Clarify who will lead the team so others know to who to look for guidance · Open lines of communication so everyone can contribute; discuss protocols, responsibilities, and expected behaviors to avoid miscommunication. · Prepare team for flow of procedure, contingency plans, and how to resolve unusual circumstances. · By delineating expectations, disruptive or unexpected behaviors should be reduced.

Interdisciplinary education

· Interdisciplinary education is defined as educational occasions when two or more professions learn from and about each other to improve collaboration and the quality of care. Introducing interdisciplinary coursework early in the curriculum helps students to understand nursing roles and communication across other professionals. It gives some insight into the "mind set" of other professionals and encourages a pattern of collaboration. Cultivating interdependence between health professionals required for quality care and an era of cost containment is noted as being critical to success in meeting National Health goals. Students gain first hand understanding of the professional values held by other disciplines. In clinical scenarios, the decision making process with team approaches is more complex than with single discipline methods, acknowledging and respecting the unique expected behaviors and skill sets of each health discipline fosters understanding. Frequent communication is essential to good results. · Examples of shared interdisciplinary electives include ethics, death and dying, culture, quality improvement, genomics, emergency preparedness, gerontology, health policy, and legal issues. Clinical simulation Courses open to students from multiple health disciplines provide unique opportunities for students in the healthcare profession to work together in the clinical management of complex disease health conditions.

Interdisciplinary education...

· It gives some insight into the "mind set" of other professionals and encourages a pattern of collaboration. · Cultivating interdependence between health professionals required for quality care in an era of cost containment is noted as being critical to success in meeting national health goals. Students gain firsthand understanding of the professional values held by other disciplines. · In clinical scenarios, the decision-making process with team approaches is more complex than with single discipline methods, acknowledging and respecting the unique expected behaviors and skill sets of each health discipline fosters understanding. Frequent communication is essential to good results. · Examples of shared interdisciplinary electives include ethics, death and dying, culture, quality improvement, genomics, emergency preparedness, gerontology, health policy, and legal issues. Also, clinical simulation courses.

Flexner's criteria

· Members share a common identity, values, attitudes, and behaviors. · A distinctive specialized substantial body of knowledge exists. · Education is extensive, with both theory and practice components. · Unique service contributions are made to society. · Acceptance of personal responsibility in discharging services to the public. · Governance and autonomy over policies that govern activities of profession members. · A code of ethics that members acknowledge and incorporate in their actions.

Patient safety outcomes

· Mortality rates have decreased using this tool in the surgical area. Staff identify adverse events that were avoided due to the information communicated during the briefing. The majority of reported errors have been found to stem from poor teamwork and poor communication. An effective team has clear, accurate communication understood by all. All team members work together to promote a climate of patient safety. To improve interdisciplinary health team collaboration and communication, it is recommended that physicians and nurses jointly share communication training and team building sessions to develop an "us" rather than "them" work philosophy. When clashes occur, differences need to be settled. · Ideally, the healthcare team would provide the patient with more resources, allowing for greater flexibility, promote a "learning from each other" climate, and promote collective creativity in problem solving. Use of standardized communication tools fosters collaborative practice by creating shared communication expectations. Obstacles to effective teamwork include a lack of time, a culture of autonomy, heavy workloads, and the different terminologies and communication styles held by each discipline. Building and redundancy cuts errors but takes extra time, which can be irritating. · To improve interdisciplinary health team collaboration and communication, it is recommended that physicians and nurses jointly share communication training and team-building sessions to develop an "us" rather than "them" work philosophy. · Use of standardized communication tools fosters collaborative practice by creating shared communication expectations. · Building in redundancy cuts errors but takes extra time which can be irritating.

· Nurse managers.

· Most often a midlevel administrative position, these managers provide leadership for staff on hospital units. Administrative duties include work schedules, job goals, and evaluations. Their communication skills and transformative leadership styles have been shown to increase job satisfaction of staff nurses and decrease their stress. Effective managers provide support to team members and use their position to create better working conditions, thus increasing staff retention. · Administrative duties include work schedules, job goals, and evaluations. · Their communication skills and transformative leadership styles have been shown to increase job satisfaction of staff nurses and decrease their stress. · Effective managers provide support to team members and use their position to create better working conditions, thus increasing staff retention.

TeamSTEPPS Model

· One prominent safety model is team strategies and tools to enhance performance and patient safety (TeamSTEPPS). This program emphasizes improving patient outcomes by improving communication using evidence-based techniques. Communication skills include briefing and debriefing, conveying respect, clarifying team leadership, cross monitoring, situational monitoring feedback, assertion in a climate valuing everyone's input, and the use of standardized communication formats, such as SBAR and the comprehensive unit based safety program (CUSP). Creating A-Team culture means each member is committed to: · open communication with frequent, timely feedback; · protecting others from work overload; · and asking for and offering assistance. · AHRQ's CUSP was designed to implement teamwork and communication. It is a multifaceted strategy to help create a culture of safety; urging health care workers to use communication tools. CUSP incorporate team training with strategies to translate research into staff's and evidence-based practice. · TeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety.

Chain of Command

· Order of authority & power in an organization that is had and passed down from top management to every employee at every level. · Instructions flow downward along the chain of command and accountability flows upward. · Whenever you work for an organization, you automatically become a part of a system that has norms for acceptable behavior. · Each organizational system defines its own chain of command and rules about social processes in professional communication. · the more clear cut the chain of command, the more effective the decision making process and greater the efficiency. · Staff nurse --> charge nurse --> unit manager --> director of nursing · Do not sidestep the chain. · Even though your idea may be excellent, failure to understand the chain of command or an unwillingness to form the positive alliances needed to accomplish your objective dilutes the impact of your idea or objective. · Ex. If the charge nurse has been defined as your first line of contact, then it is not in your best interest to seek out other staff personnel for questions without also checking with the charge nurse. (I.E. Clinical Instructor & other student nurses, staff personnel) · Although sidestepping identified chain of command and going to a higher or more tangential (lateral) resource in the hierarchy may appear less threatening initially, the benefits of such action may not resolve the difficulty. (The person who can do something about your problems does not get your request and consequently, does not act on it.) · Furthermore, the trust needed for serious discussion becomes limited.

Clinical simulations

· Problem-based learning scenarios provide innovative opportunities for students to analyze and find solutions in a safe, controlled environment. Clinical simulation is a preferred learning strategy because it allows interdisciplinary students to give close attention to all aspects of the clinical environment and to actively problem-solve solutions from a collaborative team perspective. Students construct and develop "live" understanding of interdisciplinary health team functioning through shared reflection on their actions and interactions with each other in collectively meeting identified patient centered goals. · Problem-based learning scenarios provide innovative opportunities for students to analyze and find solutions in a safe, controlled environment. · Clinical simulation is a preferred learning strategy because it allows interdisciplinary students to give close attention to all aspects of the clinical environment and to actively problem-solve solutions from a collaborative team perspective. · Students construct and develop "live" understanding of interdisciplinary health team functioning through shared reflection on their actions and interactions with each other in collectively meeting identified patient-centered goals.

Professionalism in nursing

· Professional nurses comprise the largest professional group of healthcare providers. They spend more sustained professional time with patients and families than any other hospital care professional. Nursing roles have steadily evolved to include current expectations for nurses to assume leadership roles, to provide primary care, and to act as first line providers in implementing health care reform initiatives. · Spend more time with patients/families than any other HC professional · Nursing roles have steadily evolved to include current expectations for nurses to assume leadership roles, to provide primary care, and to act as first-line providers in implementing healthcare reform initiatives.

· Role clarity

· Professional role clarity is an essential quality for working with healthcare teams. If nurses are not clear about their professional roles, it is difficult for them to communicate their value as health care providers to other professionals. Yet, McKenna et al., study found new graduates still lack knowledge about their role. Role clarity about professional competencies is necessary to support patient safety initiatives that lead to improved client outcomes. Influencing change and making difficult decisions become easier when nurses have a clear vision of their professional role, because they are better able to stimulate confidence in others. · Role clarity is necessary for nurses to: · Communicate their value to other professionals · Support patient safety initiatives · Leading to improved patient outcomes · Stimulate confidence in others · Making it easier to influence change and make difficult decisions.

Organizational climate...

· Promote understanding of the organizational system · whenever you work in an organization, you automatically become a part of a system that has norms for acceptable behavior. Each organizational system defines its own chain of command and rules about social processes in professional communication. Even though your idea may be excellent, failure to understand the chain of command or an unwillingness to form the positive alliances needed to accomplish your objective dilutes the impact. · Although sidestepping the identified chain of command and going to a higher are more tangential resource and the hierarchy may appear less threatening initially, the benefits of such action may not resolve the difficulty. Furthermore, the trust needed for serious discussion becomes limited. Some of the reasons for avoiding positive interactions stem from an internal circular process of faulty thinking. Because communication is viewed as part of a process, the sender and receiver act on the information received, which may or may not represent the reality of the situation. · Promote clear policies. · As mentioned earlier, regulatory bodies are requiring that healthcare organizations have written codes of behavior and internal processes to handle disruptive behaviors. · Ongoing continuing education stressing awareness and safety training is advocated by OSHA. Prevention strategies might include participation in assertiveness training in-services or the TeamSTEPPS program. Educational interventions that increase staff awareness are extremely effective, as are simulations similar to the exercises in this book. It is not enough to offer an educational intervention once. Team training is necessary. Literature recommends periodic reassessment of need and offering reviews of communication skills and conflict management strategies.

Mutual Support: Feedback

· Providing encouragement. · After she worked her first major trauma, she was told by the head trauma nurse that she did a great job and stayed cool and composed under the stress of the situation. · Benefits the team: · Fosters improvement in work performance · Meets the team's & individual's need for growth · Promotes better working relationships · Helps the team set goals for ongoing improvement · CUS · Use of key phrases understood by all team members to mean, "Stop. We may have a problem." · Two-Challenge Rule - voice concern twice · Still not addressed à Chain of Command · A way of advocating for the patient and being assertive as well as providing mutual support. · "CUS" and several other signal phrases have a similar effect on verbal communication. When they are spoken, all team members will understand clearly not only the issue but also the magnitude of the issue. (Just like SBAR is a standard communication format) · First, state your concern. · Then state why you are uncomfortable. · If the conflict is not resolved, state that there is a safety issue. Discuss in what way the concern is related to safety. If the safety issue is not acknowledged, a supervisor should be notified.

TeamSTEPPS with "I Pass the Baton"

· Regarding handoffs, AHRQ's TeamSTEPPS program recommends that all members use the "I PASS the BATON" mnemonic during any transition by staff and patient care. · I= Introduction (introduce yourself and your role). · P= Patient (state patient name, identifiers, age, sex, location). · A= Assessment (present chief complaint, vital signs, symptoms, diagnosis). · S= Situation (current status, level of certainty, recent changes, response to treatment). · S=Safety concerns (critical laboratory reports, allergies, alerts). · B= Background (call morbidities, previous episodes, current medications, family history). · A= Actions (state what actions were taken and why). · T= Timing (level of urgency, explicit timing and priorities). · O= Ownership (state who is responsible). · N= Next (state the plan: what will happen next, any anticipated changes).

Role

· Role is a multidimensional psychosocial concept defined as characteristic behavior patterns and expression of self expected of an individual within a given society. People develop social, work, and professional roles throughout life. Some roles are conferred at birth (ascribed roles), and some are attained through circumstance during a lifetime (acquired roles). Personal ascribe role performance standards reflect social, cultural, gender, and family expectations. Nursing roles have flexibility.

TeamSTEPPS Tools & Strategies

· SBAR: Situation, Background, Assessment, Recommendation- a standardized communication tool with a structured format to create a common language. Used to communicate critical info that requires immediate attention & action concerning a patient's condition. · Call-out: Allows staff to stop & review. Provider calls out critical info so all team members can hear during urgent situations to help anticipate next steps. · Ex. Of an incoming trauma into the ER: Leader: "Airway status?" Resident: "Airway clear" Leader: "Breath sounds?" Resident "Breath sounds decreased on right" Leader: Blood pressure?" Nurse: "BP is 96/62." · Check-back: repeat back what is heard. Using closed-loop communication to ensure that info conveyed by the sender is understood by the receiver as intended. Sender initiates the message, receiver accepts the message & provides feedback, sender double-checks to ensure that the message is received. Ex. Doctor (sender): "Give 25 mg Benadryl IV push." Nurse (receiver): "25 mg Benadryl IV push." Doctor (sender): "That's correct." A way to verify that your comm. message is understood accurately. · Hand-off: checklist to ensure the transfer of info, authority, & responsibility when transferring care - gives receiver an opportunity to ask questions, clarify & confirm information. · Brief - before event- share plan. · Huddle - middle - adhoc - reestablish, reinforce, adjust plan. · Debrief - end - to improve through lessons learned and positive reinforcement. · STEP - tool used to monitor situations in the delivery of healthcare (Status of patient, Team members, Environment, Progress toward goals).

Components of Situation Monitoring

· STEP · A tool for monitoring situations in the delivery of health care. · Status of Patient - history, VS, Meds, PE, POC, Psych issues · Team Members - fatigue, workload, task performance, skills, stress · Environment - facility info, administrative info, HR, Triage acuity, equip · Progress toward goals - status of team's patient(s), established goals of team, tasks/actions of team, plan still appropriate? · Cross-Monitoring · A human error reduction strategy that involves: · Monitoring actions of others · Providing safety net · Ensuring mistakes/oversights caught quickly & easily · "Watching each other's back" · Cross-monitoring is used by fellow team members to help maintain situation awareness and prevent errors. · Commonly referred to as "watching each other's back," it is the action of monitoring the behavior of other team members by providing feedback and keeping track of fellow team members' behaviors to ensure that procedures are being followed appropriately. · It allows team members to self-correct their actions if necessary. · Cross-monitoring is not a way to "spy" on other team members; rather, it is a way to provide a safety net or error-prevention mechanism for the team, ensuring that mistakes or oversights are caught early. · When all members of the team trust the intentions of their fellow team members, a strong sense of team orientation and a high degree of psychological safety results.

TeamSTEPPS Key Principles

· Team Structure - a multi-team system working together effectively to ensure patient safety · Includes core and contingency teams; also patient, coordinating team, ancillary and support services, & administration · Communication - structured process by which information is clearly and accurately exchanged among team members. (i.e. SBAR) · Leadership - ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources. · Situational Monitoring - process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team function. · Mutual Support - ability to anticipate and support team members' needs through accurate knowledge about their responsibilities and workload.

Interdisciplinary rounds and team meetings

· Team training is 1 tool used to increase collaboration between physicians and nurses. The use of teams is a concept that has been around for years within the medical and nursing professions. For example, medicine has used medical rounds to share information among physicians. Contemporary health care teams use "Interdisciplinary rounds" to increase communication among the whole team-physicians, pharmacists, therapists, nurses, and dietitians. This strategy may increase communication and positively affect patient outcome. For example, daily discharge multidisciplinary rounds have been correlated with decreased length of hospital stay. Some magnet hospitals use hourly rounding by the nurse and nurse assistant to ensure patient status is assessed. · Interdisciplinary "team" meetings can be held daily or weekly to explore common goals, concerns, and options; smooth problems before they escalate into conflicts; or provide support. There are also clinical teaching rounds, where once a week, a physician teaches nurses, with the goal of encouraging physician communication with the nursing staff.

Organizational climate

· The ANA position statement on "incivility, bullying and workplace violence" mandates that nurses and employers work to create a climate of respect using evidence based strategies including building and accountability, negotiation, respect, and trust. The literature mentions specific strategies including the following: · Zero tolerance policy for disrespect. · Continuing education programs to raise awareness and teach conflict intervention skills. · Accountability follow-up. · Creating a corporate climate conveying respect for all workers. · Promote opportunities for interdisciplinary communication · creating opportunities for interdisciplinary groups to get together is a highly effective strategy for enhancing collaboration and communication. Ideas include collaborative rounds, huddles, team briefings and debriefings, and committees to discuss problems. Some studies associate daily team rounds and joint decision making with shorter hospital stay and lower hospital charges. · Interdisciplinary groups are a highly effective strategy for enhancing collaboration and communication. Some studies associate daily team rounds and joint decision making with shorter hospital stay and lower hospital charges. i.e. collaborative rounds, team briefings, committees to discuss problems.

TeamSTEPPS

· The Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD) have developed TeamSTEPPS®, a teamwork system that offers a powerful solution to improving collaboration and communication within your institution. Teamwork has been found to be one of the key initiatives within patient safety that can transform the culture within health care. Patient safety experts agree that communication and other teamwork skills are essential to the delivery of quality health care and to preventing and mitigating medical errors and patient injury and harm. · TeamSTEPPS is an evidence-based program aimed at optimizing performance among teams of health care professionals, enabling them to respond quickly and effectively to whatever situations arise. This curriculum was developed by a panel of experts, incorporating more than 25 years of scientific research that has been conducted on teams and team performance.

· The doctor of nursing practice

· The Doctor of Nursing practice (DNP) is a terminal practice degree for professional nurses. It is a nonresearch clinical doctorate. The complexity of the nation's health care environment served as a major impetus for promoting transitions to practice doctorates, as did the need to position nursing professionally on a par with other major health professions, all of which offer practice-focused doctorates. The curriculum combines advanced nursing practice skill proficiency with a solid foundation in the clinical sciences, evidence based practice methods, system leadership, information technology skills, health policy, and interdisciplinary collaboration. Think of the role as promoting implementation of research evidence developed by nurse researchers and many others. · Nation's complex healthcare environment promoted it as well as the need to place nurses on same level as other practice-focused doctorates. · The curriculum combines advanced nursing practice skill proficiency with a solid foundation in the clinical sciences, evidence-based practice methods, system leadership, information technology skills, health policy, and interdisciplinary collaboration.

· Advanced practice nurses

· The IOM mandate to increase the number of professional nurses in advanced practice roles makes a strong statement in health care reform. An advanced practice nurse (APRN) is a licensed skill practitioner holding a minimum of a masters degree and a clinical specialty, with the expert knowledge base, complex decision making skills, and clinical competencies required for expanded specialty practice. Various countries have established many roles for APN's, including nurse practitioners, clinical nurse specialists, certified nurse midwives, nurse anesthetists, ect. Specialized training allows APRNs to diagnose an independently managed care, including prescriptive authority for some, as regulated by each state. In addition to clinical roles, APRNs function in research, educational, and administrative roles. A significant issue yet to be completely resolved is a lack of consistency that has lessened but still exist surrounding role responsibilities and scope of practice of APRNs. · NP: provide first-line health care services across the health-illness continuum in a variety of primary and acute care settings. The collaborate with MDs (depending on state laws), diagnose, treat common conditions and injuries, some have prescriptive authority. · CNM: provide a wide variety of first-line and clinical management of prenatal and gynecologic care to normal, healthy women. Perform uncomplicated delivery of babies & can have prescriptive authority. · CNS: provide care & consultation in a specialty area (i.e. cardiology). Some states have prescriptive authority in psych. Perform indirect nsg roles - staff dev, nursing ed, administration, informatics. · CRNA: administer anesthesia and conscious sedation in more than 1/3 of the hospitals in the U.S.

· Regulation

· The agency for healthcare research and quality (AHRQ)- the agency for healthcare and research quality in the U.S. Department of Health and Human services has taken a leading role in promoting safer health, funding research to compile evidence and develop "best practices" evidence-based care protocols. For years they operated TeamSTEPPS safety and communication training programs, an operation now continued by the American Hospital Association. An amazing number of resources are available on the Internet. Professional standards of practice serve the dual purpose of providing a standardized benchmark for evaluating the quality of their nursing care and offering the consumer a common means of understanding nursing as a professional service relationship. In this way, standards are used to communicate with the public as to what can be expected from professional nurses. The ANA now publishes separate books on standards of practice for each nursing specialty.

Situation Monitoring

· The process of continually scanning & assessing what's going on around you to maintain situation awareness. · Situation Awareness · The state of "knowing what's going on around you." · Shared Mental Model · Result from each team member maintaining situation awareness & ensures that all members are "on the same page." · Situation Monitoring - not static - ongoing, dynamic - Individual Skill - can train and develop it · Situational Awareness - is "knowing what is going on around you." Having everyone aware of the "Big Picture" and thinking ahead to plan & discuss contingencies. (Ongoing dialogue) - Individual Outcome · Shared mental model - shared perceptions (Team Outcome) - to avoid confusion & ensure all working toward same goals. · A continuous process is necessary b/c of the dynamic situations in which teams function. It allows individual team members to maintain their situation awareness and share new and emerging information with other team members to retain a shared mental model.

Scope of practice

· The scope of practice for professional nurses continues to expand to include reimbursable health screening and promotion, risk reduction, and disease prevention strategies. Nurses increasingly provide care as part of interdisciplinary healthcare teams and hospitals and the community. All nurses are expected to advocate for healthcare transformation and to take a leadership role in addressing environmental, social, and economic determinants of health. Nurses are assuming public advocacy roles to inform policymakers, educators, and other health care providers about health related issues. Nurses also provide leadership and coordination in healthcare improvement through education and participation in research. · Expanding to include reimbursable health screening and promotion, risk reduction, and disease prevention strategies. · Nurses increasingly provide care as part of interdisciplinary healthcare teams in hospitals and the community. · All nurses are expected to advocate for healthcare transformation and to take a leadership role in addressing environmental, social, and economic determinants of health. · Nurses are assuming public advocacy roles to inform policy makers, educators, and other healthcare providers about health-related issues. · Nurses also provide leadership and coordination in healthcare improvement through education and participation in research.

Care transitions

· The traditional patient report from one nurse handing over care to another nurse (care transition) needs to be accurate, specific, and clear and allow time for questions to foster a culture of patient safety. Walking to the bedside in use of a checklist are some more recommendations given to foster a more complete report. Using the SBAR format or any other standardized communication format for reports results in a safer environment for your patients, includes patients as active team members, and has been shown not to increase report duration. · Handoff reports (Care Transitions) · The traditional patient report from one nurse handing over care to another nurse. (i.e. shift changes, patient transfers). Best done at the bedside and use of a checklist. · Needs to be accurate, specific, & clear, & allow time for questions to foster a culture of patient safety. · SBAR · "I PASS the BATON" · When a team member is temporarily or permanently relieved of duty, necessary information about the patient might not be communicated. · The handoff strategy is designed to enhance information exchange at critical times such as transitions in care. More important, it maintains continuity of care despite changing caregivers and patients. · Handoffs include the transfer of knowledge and information about the degree of uncertainty (or certainty about diagnoses, etc.), response to treatment, recent changes in condition and circumstances, and the plan (including contingencies). In addition, both authority and responsibility are transferred. Lack of clarity about who is responsible for care and for decision-making has often been a major contributor to medical error (as identified in root cause analyses of sentinel events and poor outcomes).

Patient-centered care

· This competency is defined as empowering the patient/family to be a full partner in providing compassionate, coordinated care. In the KSAs, under knowledge, you are expected to integrate multiple dimensions of care, including communication, to involve the patient and family. In terms of scales, you are expected to elicit patient values and preferences during your initial interview and care plan development and to communicate their preferences to other members of the health care team. In terms of attitudes, you are to value expressions of patient values, as well as their expertise regarding their own health status. In meeting the QSEN competency of providing patient centered care, do you communicate with your patients to engage them in planning care?

Role theory

· Using concepts from sociology and social psychology, role theory encompasses socially defined norms, behaviors, and duties that are expected to be performed by an individual in a certain role within our social structure. Individuals who do not conform incur social disapproval. Everyone has multiple roles to fulfill as defined by societies such as cultural roles, gender roles, work roles, social roles, ect. Problems occur when one role comes into conflict with another. · Encompasses socially defined norms, behaviors, and duties expected to be performed by people in certain roles within our social structure. Do not conform - social disapproval. · Everyone has multiple roles defined by society : i.e. cultural, gender, work, social roles. · Problems occur when one role conflicts with another.

TeamSTEPPS: team strategies and tools to enhance performance and patient safety

· When AHRQ adapted the Department of Defense team training program to use in healthcare settings, they gave it the TeamSTEPPS acronym. A main component of this free program is training to use a toolbox of communication strategies. How many times do we say good communication is essential to effective team function? Effective communication skills convey accurate information and provide awareness of your role responsibilities. As a team member, you communicate to keep all others informed and contribute to successful goal achievement. · Teamwork and collaboration are a major focus of both TeamSTEPPS and QSEN. Each team member shares a clear vision of expected outcomes for each patient. TeamSTEPPS creates a transformed health care model. Tools and strategies are provided, which can be used to develop a better system wide communication knowledge, skills, and attitudes. Communication clarity is an important goal, as is the conciseness found on checklists. Experts recommend the use of standardized communication tools such as SBAR, CUS assertive statements ("I am concerned; "I am uncomfortable, this is a safety issue"), followed by the "two-challenge rule" stating your concern twice, check-backs (to verify that your communication message is understood accurately), briefs, debriefs, and huddles. · TeamSTEPPS teachers team members, including nurses, how to increase their competencies in leadership, situation monitoring, and use of mutual support strategies. Examples of leadership competency are clarifying team goals and roles. Competencies for situation monitoring include use of decision making skills in emergency situations and providing corrective feedback. Mutual support skills include assisting others and using communication tools.

Teamwork and collaboration

· With this competency, you are able to function effectively within nursing and on interprofessional teams, to foster open communication, mutual respect, and shared decision making to achieve quality care. A partial example of expected knowledge objectives for this competency might be that you know the various roles and scope of practice for team members and are able to analyze differences and communication style preferences for patient, family, and other members of the health care team. In terms of skill, you are expected to be able to adapt your own style of communicating and to initiate actions to resolve any conflicts. In terms of attitudes, your behavior shows that you value teamwork and different styles of communication. · Function effectively within nursing & interprofessional teams, fostering open communication, mutual respect, & shared decision making to achieve quality patient care. · Knowledge: Know scope of practice. Analyze differences in communication styles: · Describe the nurse's role in team functioning -Coordinator of the team. · Give examples of how nurses have historically communicated (narrative) vs. physician (bullet point). · Skills: Adapt own style to the needs of the team in the current situation. · Follow communication practices (i.e. SBAR, Checklists) that minimize risks associated with hand-offs among providers and across transitions in care. · Attitudes: Value teamwork and different styles of communication. Respect contributions of every team member. · Appreciate the risks associated with hand-offs among providers and across transitions in care. · Welcome suggestions from others regarding alternative forms of communication.

· Direct patient care nurses

· direct patient care nurses are expected to exhibit competent care skills and also show competency in their communication skills. Contemporary professional nursing roles reflected the increasing complexities of health care, globalization, changing patient demographic characteristics and diversity, and the exponential growth of health information technology. · The bedside nurse's role consists of delivery and organization of care for multiple patients. This role includes quality control issues, problem solving, patient education, and coordination of communication among the many health team members. There is a strengthened focus on health promotion/disease prevention, and self-management of chronic disorders also echoes new economic realities and provider availability. For more information, refer to AACN's essentials of baccalaureate nursing document defining core professional role competencies required of contemporary nurses. To deliver high quality, safe, patient centered care, the focus is on collaboration, a hallmark of role competence. We need to know our own role so we can work together smoothly. · An empowering aspect of the nurse role is the opportunity to evolve roles, change specialties of care, move into advanced roles, or take on new administrative roles. · Contemporary professional nursing roles reflect the increasing complexities of healthcare, globalization, changing patient demographic characteristics and diversity, and the exponential growth of health information technology. · To deliver high-quality, safe, patient-centered care, the focus is on collaboration, a hallmark of role competence. We need to know our own role so we can work together smoothly.

· The clinical nurse leader

· leadership is the art of motivating people to act to achieve a common goal. In response to the IOM report, the American Association of colleges of nursing developed the clinical nurse leader model as a masters prepared generalist role to provide leadership at the bedside. The CNL's focus is on quality of care, bridging the gaps between members of the health team. The CNL curriculum prepares students with a baccalaureate degree in another field to become an advanced generalist nurse (masters degree in eligibility for licensure as a registered nurse). Core competencies include clinical leadership skills, environmental management, and clinical outcome management. For CNLs to practice as an APRN in a specific clinical specialty, the CNL must complete further academic preparation.

scope of practice

· scope of practice is defined as the rules, regulations, and boundaries within which a person may practice in a field of health care. Globally, professional practice organizations are issuing practice standards for nursing care that specify clear, comprehensive communication as a requirement.

· Nurse scientist

· the position varies with employing agencies. Often these are joint appointments between academia and healthcare agency. The nurse scientist is a knowledge broker who facilitates knowledge application in understandable terms to patient care. They use science to inform not just clinical practice but policy-making. This cuts down on the former average of 17 years it used to take for scientific evidence to make it into practice changes. · This position varies with the employing agencies. · Often these are joint appointments between academia and healthcare agency. · The nurse scientist is a knowledge broker who facilitates knowledge application in understandable terms to patient care. They use science to inform not just clinical practice but policy-making.