LM #3
As a new manager, you are shocked to learn that your unit is still using heparin in heparin locks. You are aware of evidence related to this practice and want to change this practice as quickly as possible on your unit. You are in which stage of Lewin's stages of change? a. Unfreezing b. Experiencing the change c. Moving d. Refreezing
ANS: A Although you may be at a higher level of change in relation to your individual practice and knowledge of the use of change, in this situation, you are recognizing the need for change in relation to practice on the unit that you are managing. This phase is the initial phase in first-order change and will involve listening to staff to see if they perceive a similar problem.
The nurse manager frequently interacts with staff and other hospice facility employees. Communication is purposeful because the manager assesses current issues, such as specific satisfactions and dissatisfactions with the newly implemented computerized documentation system. Informally, the manager gathers available staff members to address similar learning needs. Many times, staff members are found coaching other staff about improving use of the new system. According to Senge (1990), the activities demonstrated in this example are: a. Dialogue, team learning. b. Resilience, personal mastery. c. Shared vision, systems thinking. d. Mental models, teachable moments.
ANS: A Building shared vision occurs when leaders involve all members in moving personal visions of the future into a consolidated vision common to members and leaders.
To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. This learning approach is an example of which change management approach? a. Linear b. First-order c. Facilitative d. Integrative
ANS: A In the second stage, the moving or changing stage of Lewin's first-order, planned change process, planned interventions and strategies are executed to support the implementation of the change. One commonly used method is educating staff about the need for the change.
Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." After speaking with Elizabeth a few days later you discover that she is now fine with the change but is concerned that other areas of the organization might resist the change because of perceptions related to patient safety and cost. She suggests that it is important to bring pharmacy on board as they have had previous concerns about the use of heparin. In relation to change theory, this is indicative of: a. Systems level thinking. b. Linear thinking. c. Interprofessional collaboration. d. First-order change.
ANS: A Senge's complexity theory, Bevan's Seven Change Factors, and general systems theory all highlight connectivity and the idea that changes are not isolated events.
Complex change situations require that the change leader promote ongoing visioning among staff members. One strategy is to: a. Consciously evaluate invisible mental models. b. Allow for individual outcomes. c. Encourage cooperative activities. d. Operate between order and disorder.
ANS: A Senge's theory on change suggests that each individual or organization bases activities on a set of assumptions, or a set of beliefs, or mental pictures about the way that the world should work. When these invisible models are uncovered and consciously evaluated, it is possible to determine their influences on work accomplishment.
Planning is a process designed to achieve goals in dynamic, competitive environments. As a new manager, what is the first step you will undertake to develop a strategic plan of action for a congestive heart failure program? a. Search the environment to determine changes that may affect the organization. b. Appraise the organization's strengths and weaknesses. c. Identify the major opportunities for and threats to the organization. d. Identify and evaluate the various strategies available to the organization.
ANS: A Assessment of the external environment is the first step in the strategic planning process.
The state of being emotionally impelled, demonstrated by a sense of passion and dedication to a project or event, describes: a. commitment. b. control. c. willingness to cooperate. d. communication.
ANS: A Commitment is described as having a sense of passion and commitment to a project without necessarily having a need to control.
Hospital Magnet® decides against creating a separate department to lead and monitor quality activities because: a. total organizational involvement is critical to QI. b. data generated by a single, separate department are generally flawed. c. monitoring and commitment to QI can come only from senior-level managers. d. staff resent suggestions for improvement that originate outside of their unit.
ANS: A Decentralized approaches are effective in developing unit-level solutions, as well as commitment to strategies and implementation of changes.
The chief nursing officer has to write a strategic plan. The most difficult stage in the strategic planning process is: a. assessment of the external and internal environment. b. review of mission statement, goals, and objectives. c. identification of strategies. d. implementation of strategies
ANS: A Determination of strengths, weaknesses, opportunities, and threats requires openness to what is being said and observed and is critical to setting the stage for relevant responses in the latter phases of strategic planning.
The clinic nurse understands that the advantages of planning include: a. assisting staff in critical thinking and improving decisions. b. orienting people to react instead of act. c. forcing managers to be cost-efficient and cost-effective. d. focusing on activities, not results.
ANS: A Effective planning means that everyone in the organization manages his own work and sees how it relates to organizational goals. Being proactive means "aggressive planning" that ensures that decisions are improved and are oriented toward organizational goals.
Through the QI process, the need to transform and change the admissions process across administrative and patient care units is identified. In this particular situation, what method of data organization will be most effective? a. Flowchart b. Histogram c. Narrative d. Line graphs
ANS: A Flowcharts are useful in identifying and visualizing sequential steps, such as the admissions process.
The mediator noticed that tension was still evident between the nurse manager and staff members. He informed the chief nursing officer that to begin team building, it would be important that everyone: a. work together in a respectful, civil manner. b. use avoidance techniques when confronted with a conflict. c. develop a personal friendship with each other. d. socialize frequently outside of work.
ANS: A For team building to occur, team members need to be able to listen actively and respect one another's opinions, while feeling comfortable in openly expressing their own.
Which of the following represents an effective goal statement? a. Involve patients and families in planning health care. b. To revise clinical guidelines for incontinence care from evidence within 6 months. c. Patients and families are partners first in care planning. d. To acquire $4 million in additional funding within 12 months to support clinical education programs for dementia.
ANS: A Goal statements formalize targets for an organization. Objectives include the word to and an action word, and specify dates for attainment. Mission statements convey values and beliefs of the organization.
A nursing unit is interested in refining its self-medication processes. In beginning this process, the team is interested in how frequently errors occur with different patients. To assist with visualizing this question, which organizational tool is most appropriate? a. Histogram b. Flowchart c. Fishbone diagram d. Pareto chart
ANS: A Histograms are bar graphs that are useful in outlining and identifying frequency.
Which of the following would not be a characteristic of an effective team nurse leader? a. An autocratic perspective b. Excellent communication skills c. Awareness of everyone's abilities d. A genuine interest in team members
ANS: A In ineffective teams, leadership tends to be autocratic and rigid, and the team's communication style may be overly stiff and formal. Members tend to be uncomfortable with conflict or disagreement, avoiding and suppressing it rather than using it as a catalyst for change. When criticism is offered, it may be destructive, personal, and hurtful rather than constructive and problem-centered. Team members may begin to hide their feelings of resentment or disagreement, sensing that they are "dangerous." This creates the potential for later eruptions and discord.
Hospital ABCD is a Magnet® hospital. One reason this designation has been applied to Hospital ABCD because it: a. facilitates active staff participation in decision making related to quality nursing care. b. has implemented a graduate nurse orientation program. c. espouses commitment to excellence in patient care. d. is establishing career ladders for nurses.
ANS: A Magnet® hospitals are particularly successful in implementing excellence in patient care through use of standards, evidence, and participatory decision making in quality improvement. Organizations that cannot pursue Magnet® status can implement strategies such as career ladders.
To meet the social and human needs of a target market, it is critical to: a. assess the needs and priorities of the target market. b. revise the organization's mission statement to reflect external needs. c. assess the internal culture and needs. d. develop highly sophisticated media.
ANS: A Marketing emphasizes the identification and meeting of human and social needs, which can only be known through assessment of the needs of the consumer (as opposed to the needs of the organization).
A nursing-led classification system that has led to greater reliability and standardization in data utilized for QI processes is: a. NANDA. b. AHRQ. c. NIOSH. d. nursing process.
ANS: A NANDA has been developed by nurses and uses standardized terminology that enables study of health problems across populations, settings, and caregivers.
Northwestern Hospital has decided to implement peer review. As a clinical leader in the Emergency Department, you have overall responsibility for ensuring that this is in place by next month. The most important step in this process is to: a. provide an educational session for staff on peer review. b. revise the mission statement, objectives, and performance standards. c. develop objectives and performance standards with employees. d. implement objectives and performance standards.
ANS: A Once a strategic plan has been developed, the next step is open communication and execution of the specific plan, which, in this instance, is peer review.
An example of an effective patient outcome statement is: a. eighty percent of all patients admitted to the Emergency Department will be seen by a nurse practitioner within 3 hours of presentation in the Emergency Department. b. patients with cardiac diagnoses will be referred to cardiac rehabilitation programs. c. the hospital will reduce costs by 3% through the annual budget process. d. quality is a desired element in patient transactions.
ANS: A Patient outcome statements must be measurable, specific, and patient-centered.
A mediator suggested that the nurse manager and staff members decide on a method to resolve conflicts. It is important to have agreements about how team members will work together because: a. if there are no agreements, each member will make up rules about how to handle disagreements and relationships. b. people are naturally difficult and will not work well together without such agreements. c. people will naturally ask for agreements about how to be together. d. a way to eliminate nonproductive team members must be available.
ANS: A People must agree on the goals and mission with which they are involved. They have to reach some understanding of how they will exist together. Tenets or agreements such as "I will respectfully speak promptly with any team member with whom I have a problem" go a long way to avoid gossiping, backbiting, bickering, and misinterpreting others. Without agreement, people have implicit permission to behave in any manner they choose toward one another, including angry, hostile, hurtful, and acting-out behavior.
From the information presented in this chapter, which of the following statements best defines an accomplished team? Effective teams: a. can create a form of synergism in which the outcome is greater than the sum of the individual performances. b. do not necessarily need goals, objectives, vision, and a clearly stated purpose. c. do not always have effective communication patterns. d. may or may not have a clear plan that is followed and revisited and has an ongoing evaluation scheme.
ANS: A Research on team building over many years has established that high-functioning teams are characterized by synergy that takes the team from a collection of individuals to an outcome that is greater than the sum of the parts.
In determining the relationship between injury-producing falls and proposed preventive measures as part of the QI process, a QI team might turn to which of the following for confirmatory evidence? a. NDNQI b. NANDA c. NIOSH d. AHRQ
ANS: A The National Database of Nursing Quality Indicators is a national, nursing quality measurement program from the American Nurses Association that provides hospitals with unit-level performance reports with comparisons to national averages and rankings.
The reasons cited by nursing administrators for not planning in a systematic manner include: a. lack of understanding of the planning process. b. lack of knowledge regarding the internal and external operations of the organization. c. not enough hours in the day for both day-to-day operations and planning. d. delegation of the task to subordinates.
ANS: A The nurse manager should participate in strategic planning and quality initiatives with the governing body. Lack of knowledge is a common reason for nonparticipation in planning initiatives.
Trust is an important aspect of helping relationships, therapeutic communications, and the positive communications model. Which statement does not involve or define trust? Trust: a. involves decisions to manipulate situations to gain advantage over another. b. is the basis by which leaders facilitate the activities and progress of a team. c. is low among members and leaders in poorly performing teams. d. involves what we say and not necessarily what we do.
ANS: A Trust is high in high-performing teams and involves not consciously taking advantage of others and behaving in a way that inspires trust. It is the basis by which leaders facilitate the activities and progress of a team.
Which of the following are examples of application of the Leadership Rounding Tool? (Select all that apply.) a. "What is working well for you during bedside reporting?" b. "What has not worked for you today?" c. "Is there someone on your team who deserves special recognition for her efforts in the implementation?" d. "Did you have a good vacation?"
ANS: A, B, C, D The Leadership Rounding Tool suggests establishing and maintaining rapport and asking what is working well, what was a barrier, and who should be recognized, as well as answering tough questions.
Examples of sentinel events include: (Select all that apply.) a. forceps left in an abdominal cavity. b. patient fall, with injury. c. short staffing. d. administration of morphine overdose. e. death of patient related to postpartum hemorrhage.
ANS: A, B, D, E Sentinel events are serious, unexpected occurrences involving death or physical or psychological harm.
A clinic nurse developed objectives for a diabetic education program. The characteristics of well-written objectives include that they should be what? (Select all that apply.) a. Achievable b. Understandable and specific c. People-oriented d. Manager-oriented e. Means-oriented f. Measurable
ANS: A, B, F The S.M.A.R.T. acronym describes the attributes of objectives: specific, measurable, agreed-upon, reasonable (achievable), and time-bound.
Mobilizing others to accomplish extraordinary things requires what leadership behaviors? (Select all that apply.) a. Celebrating the successes of others b. Demonstrating exceptional technical skills c. Imagining possibilities d. Establishing a sense of "being in this together"
ANS: A, C, D Leaders who inspire teams to accomplish extraordinary things or to display synergy model the way, inspire shared vision, challenge the status quo, and encourage the heart by celebration of success.
Based on Elizabeth's insights and suggestions, you involve pharmacy, only to discover that the change in practice involves practice committees, a medical practice committee, and concerns from administration about potential costs and safety of the proposed change to the IV protocols. The change process at this point is: a. Linear. b. Nonlinear. c. Sabotaged. d. Neutralized.
ANS: B Complex change involves nonlinear processes and a variety of strategies to negotiate influences on change. Complexity theories alter the traditional systems thinking approach by asserting that system behavior is unpredictable. This theory views change as emergent, nonlinear, and highly influenced by all individuals and subsystems in an organization
An example of one strategy used to improve participation in the change process by staff fitting the behavioral description of innovators and early adopters is to: a. Repeat the benefits of the change. b. Share change experiences early in the process. c. Initiate frequent interactions among staff. d. Provide select information to the staff.
ANS: B Connecting innovators and early adopters to new ideas and with new peers keeps them at the cutting edge.
To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. Staff nurses who gain information on current IV therapy practices are engaging in which phase of Rogers' decision-making process? a. Persuasion b. Knowledge c. Confirmation d. Decision
ANS: B Rogers' innovation-decision process involves five stages for change in individuals, the first of which is knowledge.
When goals/outcomes are somewhat unclear in early preparation for a complex change, the manager and the change management team develop several acceptable goals/outcomes. This change in management approach is termed: a. Unfreezing. b. Nonlinear. c. Cybernetic. d. Linear.
ANS: B While Lewin's theory was designed to describe planned or first-order changes, many scholars think the theory is too simplistic to address how unplanned or second-order change occurs. In complex situations with an uncertain change environment, a nonlinear approach that involves flexibility improves overall outcomes. Linear change is appropriate to stable, less complex, and more predictable situations
In assessing the internal environment, the strategic planning team at Pacific Hospital discovers that 90% of staff members have no idea what the current mission statement means. This is most likely related to: a. the level of abstraction inherent in mission statements. b. development of the statement by the administration team with no other staff involvement. c. outdated goals and objectives contained in the mission statement. d. failure to provide action statements within the mission statement.
ANS: B A mission statement reflects the beliefs of the organization in relation to those it serves and services it provides, and it communicates the direction of an organization. Covey (1990) believes that the process of developing the mission statement is vital to an organization's success and should involve everyone.
With the rise of violence in the psychiatric department, the nurse manager decides that she should work with the risk manager in violence prevention. The nurse manager should: a. request all staff to accept new risk management practices. b. hold staff accountable for safe practices. c. document inappropriate behavior. d. hire more police security.
ANS: B Active involvement of staff in risk management activities is key to prevention of adverse events. Nursing has a primary role in leadership in optimizing patient outcomes, preventing patient care issues, and mitigating adverse events. Accountability for safety can be one aspect of performance evaluations.
By following a shared leadership model, the nurse manager believes that staff members will learn to function synergistically. Some teams function synergistically because members: a. do not volunteer unwanted information. b. actively listen to each other. c. listen to the person who believes he or she is an expert. d. do not speak unless they are absolutely sure they are correct in their views.
ANS: B Active listening in a group creates synergy in that team members really hear one another's ideas and share in decision making.
Assessment of the needs of the consumer or client (in developing a strategic marketing plan) focuses on: a. present needs only. b. present and future needs. c. the development of surveys. d. secondary analysis of existing data.
ANS: B Assessment of needs takes into account needs of the consumer now and for the future, using a variety of data-gathering techniques. Future orientation aids in anticipating how marketing and programs will need to shift to meet those needs.
Healthcare organization X is committed to improving patient outcomes and, as part of the QI process, examines its executive structure and organizational design. This approach recognizes: a. the importance of decentralized structure in QA. b. that structure influences nurse burnout and participation in quality improvement initiatives. c. the need to ensure sufficient supervisory staff to respond in a corrective manner when mistakes occur. d. that a narrow hierarchy ensures accountability for errors and outcomes.
ANS: B Common organizational characteristics of Magnet® hospitals include structure factors (e.g., decentralized organizational structure, participative management style, and influential nurse executives) and process factors (e.g., professional autonomy and decision making, ongoing professional development/education, active quality improvement initiatives). ANCC Magnet® designated hospitals and other high-reliability organizations in the United States and Europe generally have lower burnout rates, higher levels of job satisfaction, and provide higher levels of quality care resulting in greater levels of patient satisfaction.
A new RN staff member asks you about the difference between QA and QI. You explain the difference by giving an example of QI. a. "Last year, the management team established new outcomes that addressed issues such as medication errors." b. "At a staff meeting last year, two of our staff commented on the number of recent falls and asked, 'What can we do about it?'" c. "A process audit was done recently to determine how much time was being spent on patient documentation." d. "Errors are reported on our new computerized forms, and I follow up with staff to make sure that they understand the seriousness of their error."
ANS: B In QI, followers invest in the process by continually asking "What makes this indicator important to measure?" "What has been done to improve it?" "What can I do to improve it?"
The nurse educator of the pediatric unit determines that vital signs are frequently not being documented when children return from surgery. According to quality improvement (QI), to correct the problem, the educator, in consultation with the patient care manager, would initially do which of the following? a. Talk to the staff individually to determine why this is occurring. b. Call a meeting of all staff to discuss this issue. c. Have a group of staff nurses review the established standards of care for postoperative patients. d. Document which staff members are not recording vital signs and write them up.
ANS: B Leadership must identify safety shortcomings and must locate resources at patient care levels to identify and reduce risks. One method of doing this is to invite all staff into a discussion related to solutions to an identified concern. This approach encourages teamwork.
You are charged with developing a new nursing curriculum and are committed to developing a curriculum that reflects the needs of the profession and of the workplace. To address deficits that may already be present in nursing curricula related to the workplace, you include more content and skills development related to: a. therapeutic communication with patients. b. effective communication in the workplace. c. increased emphasis on sender-receiver dyads. d. generational differences in communication.
ANS: B Nursing programs teach therapeutic communications with patients and their families. Little focus, however, is placed on effective communication in the workplace, although communication is essential to building and maintaining smoothly functioning teams.
The outcome statement "Patients will experience a ten percent reduction in urinary tract infections as a result of enhanced staff training related to catheterization and prompted voiding" is: a. physician-sensitive and nonmeasurable. b. measurable and nursing-sensitive. c. precise, measurable, and physician-sensitive. d. patient care-centered and nonmeasurable.
ANS: B Nursing-sensitive outcomes refer to outcomes that are affected by nursing activity and are precise, measurable, and patient-centered.
A nurse manager wants to decrease the number of medication errors that occur in her department. The manager arranges a meeting with the staff to discuss the issue. The manager conveys a total quality management philosophy by: a. explaining to the staff that disciplinary action will be taken in cases of additional errors. b. recommending that a multidisciplinary team should assess the root cause of errors in medication. c. suggesting that the pharmacy department should explore its role in the problem. d. changing the unit policy to allow a certain number of medication errors per year without penalty.
ANS: B Quality management stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.
Before beginning a continuous quality improvement project, a nurse should determine the minimal safety level of care by referring to the: a. procedure manual. b. nursing care standards. c. litigation rate of unsafe practice. d. job descriptions of the organization.
ANS: B Standards establish the minimal safety level of care. Procedure manuals provide information about how standards are to be achieved.
Shifts such as changes in the percentage of seniors in the population, governmental initiatives in health care, and the influence of income on health status are factors in the __________ environment. a. public b. macro c. competitive d. social
ANS: B The external environment in strategic marketing planning includes the public, competitive, and macro environments. Demographic, social, and political factors are included in the macro environments.
The mediator suggested to the unit staff that a group agreement needed to be made so meetings could become productive. For example, the group agreement, "We will speak supportively," prevents: a. expression of opposing ideas. b. gossip and making negative comments about absent team members. c. efforts to ensure that everyone thinks alike. d. votes that oppose motions.
ANS: B This is an example of a rule that a team can implement to prevent certain negative behaviors such as gossip, backbiting, and bickering that undermine the productivity and functioning of a group.
As a nursing leadership student, you have had the opportunity to develop a palliative care manual that will be utilized by the palliative care network (PCN) in your region for teaching healthcare professionals. The PCN has requested that you provide a prioritized plan of action for marketing the manual on a regional and state basis. What is the first priority? a. Motivate the target market. b. Research the target market. c. Communicate benefits to the target group. d. Package the product.
ANS: B To put a strategic plan into place for marketing, it is necessary to conduct an external assessment.
Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." Which of the following would be the most effective response to Elizabeth? a. "I understand how you feel, but you are going to have to change." b. "It is unfortunate that you feel this way. Others seem quite excited about the new information." c. "It is difficult sometimes to change what we know very well. Sometimes it can be frightening." d. "Perhaps I can arrange some more information sessions for you, so you can see just how important this change is to patient safety."
ANS: C Dialogue can reveal areas where individuals feel inept or overwhelmed, providing the leader with an understanding of what programs need to be developed to increase personal ability to change and what educational initiatives need to be implemented to support change. To promote dialogue, leaders must serve as facilitators, promoting the sharing of ideas, fears, and honest reactions to the change proposal.
You anticipate that your region will soon move towards an e-health record system. You begin to discuss this with your staff and are disappointed that you receive little positive response from the staff about this possibility. One staff member, in particular, seems to sum it up by saying "e-health? Won't happen in my working life! There are too many problems with it, like privacy issues." This response is most likely motivated by: a. Lack of urgency regarding the need to change. b. Lack of evidence to support importance of technology. c. Deficits in education and experience. d. Lack of organizational support for change.
ANS: C For leaders to inspire change, they must have intimate knowledge of what matters to the people they manage. Kotter (2012) characterizes this as establishing a sense of urgency, and this involves overcoming complacency. This is especially hard when there doesn't seem to be any visible crisis, or the crisis seems irrelevant to the people being asked to change (Kotter, 2012).
The clinical coordinator expects the position description of the new wound care specialist to change nurses' responsibilities in caring for clients with skin integrity problems. The best approach to address this need for change, yet to have the best outcomes for clients, staff nurses, and the organization, is to: a. Select one of the change models. b. Use Lewin's model and principles of change. c. Apply both planned and complexity theory approaches. d. Form a task force of nursing staff and wound care specialists.
ANS: C In the second stage, the moving or changing stage of Lewin's theory, planned interventions and strategies, such as education, vision building, and incremental steps towards the change, are executed to support the implementation of the change. This situation potentially also involves complexity theories that recognize that change involves engagement of individuals and subsystems throughout the unit and organization.
As the unit manager on the unit that is leading changes to heparin locks, you find that Elizabeth is very valuable in terms of her observations about other units and her knowledge of organizational processes, and now in discussing the new procedure with others. Elizabeth might be considered an: a. Engager. b. Innovator. c. Informal change agent. d. Informant.
ANS: C Informal change agents are those who do not have formal, positional power but who have credibility through expertise and can model the new way of thinking, or who offer suggestions, ideas, and concerns
Elizabeth is an example of a(n): a. Early adopter. b. Late majority. c. Laggard. d. Resister.
ANS: C Laggards prefer keeping traditions alive ("We have always done it this way") and openly express their resistance to ideas (speaking out against the change). Late majority individuals are openly negative but will engage with new ideas when most others adopt the change.
The oncology clinic manager and the educational coordinator asked nursing staff to complete a brief written survey to assess their attitudes and knowledge related to having used the new infusion equipment for 6 weeks. The stage of change in this situation is: a. Developing awareness. b. Experiencing the change. c. Integrating the change. d. Perceiving awareness.
ANS: C This particular initiative assesses the success with which the change has been integrated into everyday practice after it has been experienced, or the degree to which staff members have accepted using the new infusion equipment.
The home health agency hired an expert in financial management to evaluate and propose a plan for reversing growing expenses and decreasing revenues. The expert is well respected, both personally and professionally, by members living in this small community. To be effective, staff will need to perceive this change agent as: a. Trusted, quiet. b. Flexible, informal. c. Credible, enthusiastic d. Communicative, personable.
ANS: C To influence the decision, the expert must be seen as having knowledge of what matters to the people that they lead and of the change area itself. The expert also must be enthusiastic and communicative and have referent power.
As a nurse manager, you notice that one of your new nurses has provided exceptional care for a patient with especially complex needs. What would be the MOST effective way of recognizing the nurse's performance? a. At the next performance review, note specifically what the nurse did to make the patient comfortable. b. To avoid embarrassing the nurse in front of others, find a way to compliment the nurse in private. c. When the nurse comes out of the room, tell the nurse specifically what you appreciated about the care that was provided. d. Encourage the patient to note the care on the patient feedback form so that the institution can recognize the nurse's efforts.
ANS: C Acknowledgement is most effective when it is specific, timely, given in public, sincere, and on an eye-to-eye basis. The more time that elapses between the event and acknowledgement, the less effective it becomes.
Pacific Hospital's team develops a process to include staff in development of the mission statement. Which of the following statements would indicate that the staff has been able to develop an effective mission statement? a. Pacific Hospital will increase its sustainability by increasing revenue streams within the next 3 years. Revenue streams are important to our hospital and are a driving force in our sustainability in the face of insurer and government funding changes. b. Pacific Hospital has a desire to relate to its community to enable appropriate identification of programming needs by July. c. Pacific Hospital will provide family-centered care to the community of Pacific Rim. It is committed to delivering a full spectrum of services that foster collaborative partnerships among clients, families, and the hospital, and it utilizes evidence-based practice to guide planning and interventions. d. To provide health promotion programs for school-aged children
ANS: C An effective mission statement reflects the values and direction of the organization. Included in the statement are beliefs about individuals, health, practitioners, and the relationship of the organization to practice, research, professionalism, and/or education.
Nurses are valuable partners in marketing strategies because they: a. are more likely than other members of the organization to use marketing tools. b. have a strong background in using evidence to support decisions. c. have close involvement with patients, who are the target group for marketing. d. constitute the largest staff group in most healthcare organizations.
ANS: C As nurses are directly involved with patients who use services and who are the target group for marketing efforts, nurses have excellent insights into patient needs.
To conduct assessment of the internal environment, the strategic planning team for Pacific Hospital: a. invites community members and staff of the hospital to an evening focus group session. b. discusses what it sees as the primary threats and opportunities in demographic shifts affecting the hospital. c. invites all levels of staff to focus groups on the effectiveness of the hospital environment, including information systems and staffing. d. asks the board to provide a summary of major opportunities for the future.
ANS: C Assessment of the internal environment should include all levels of staff and facilitates feedback on effectiveness of strengths and weaknesses of systems and processes within the institution.
A new graduate is asked to serve on the hospital's quality improvement (QI) committee. The nurse understands that the first step in quality improvement is to: a. collect data to determine whether standards are being met. b. implement a plan to correct the problem. c. identify the standard. d. determine whether the findings warrant correction.
ANS: C Before further action (data collection, decision making related to correction, and implementation of a plan) can occur, it is necessary to identify the standards against which data collection and decision making will occur. Institutions may or may not adopt standards that are already established by organizations such as the ANA.
Your institution has identified a recent rise in postsurgical infection rates. As part of your QI analysis, you are interested in determining how your infection rates compare with those of institutions of equivalent size and patient demographics. This is known as: a. quality assurance. b. sentinel data. c. benchmarking. d. statistical analysis.
ANS: C Benchmarking is a widespread search to identify the best performance against which to measure practices and processes
The mediator asked each staff member to reflect on his or her communication style. Which of the following best describes communication? Communication: a. is a reflection of self-analysis. b. is a result of thoughtful consideration. c. consists of thoughts, ideas, opinions, emotions, and feelings. d. focuses on the sender of the message.
ANS: C Communication involves both senders and receivers and may or may not be a reflection of self-analysis and thoughtful consideration. It always, however, involves thoughts, ideas, opinions, emotions, and feelings.
Patient perceptions are useful in: a. determining disciplinary actions in QI. b. establishing the competitive advantage of QI decisions. c. providing one source of data for QI initiatives. d. establishing blame for poor-quality care.
ANS: C Customers define quality and patient dissatisfaction as useful indicators of which areas are of greatest concern to patients and of what matters then to nurses and organizations. Patient perceptions guide areas of inquiry; however, they do not establish what disciplinary decisions will be made.
The chief nursing officer decided that the nurse managers need a series of staff-development programs on team building through communication and partnerships. She understood that the nurse managers needed to build confidence in ways of handling various situations. The greatest deterrent to confidence is: a. lack of clarity in the mission. b. lack of control of the environment. c. fear that one can't handle the consequences. d. fear that the boss will not like one's work.
ANS: C Fear of not being able to manage consequences undermines confidence and a sense of competency.
The nurse manager is concerned about the negative ratings her unit has received on patient satisfaction surveys. The first step in addressing this issue from the point of view of quality improvement is to: a. assemble a team. b. establish a benchmark. c. identify a clinical activity for review. d. establish outcomes.
ANS: C In theory, all aspects of clinical activity could be improved through the QI process. However, QI efforts should be concentrated on changes to patient care that will have the greatest effect.
Team Member A and Team Member B engage in heated disagreements on a frequent basis in team meetings. Their behavior is characterized by insistence on their points of view and refusal to back down or to negotiate alternative solutions once their ideas have been expressed. This behavior is characteristic of: a. autocratic leadership. b. constructive conflict. c. dualism. d. creativity.
ANS: C Our society tends to be dualistic in nature. Dualism means that most situations are viewed as right or wrong, black or white. Answers to questions are often reduced to "yes" or "no." As a result, we sometimes forget a broad spectrum of possibilities actually exists. Exercising creativity and exploring numerous possibilities are important. This allows the team to operate at its optimal level.
The chief executive officer asks the nurse manager of the telemetry unit to justify the disproportionately high number of registered nurses on the telemetry unit. The nurse manager explains that nursing research has validated which statement about a low nurse-to-patient ratio? The low ratio: a. promotes teamwork among healthcare providers. b. increases adverse events. c. improves patient outcomes. d. contributes to duplication of services.
ANS: C Studies related to staffing and patient outcomes suggest that patient outcomes are improved with a low nurse-to-patient ratio and especially with a low registered nurse-to-patient ratio.
The nurse manager used a mediator to help resolve conflicts on the unit. During the mediation process, the nurse manager saw signs of potential team building. One key concept of an effective team is: a. conflict. b. task clarity. c. commitment. d. a designated leader
ANS: C Team building involves moving toward a common vision, which requires commitment. Conflict and clarification of tasks are components in the development of this commitment.
The SBAR system of communications is one of the most used communication systems in health care because: a. it deals with all aspects of communications in patient care except communication with the physician. b. the nurse is on the same communication level as administration. c. it honors a familiar, structured transfer of information among health professionals. d. it honors an unstructured transfer of information.
ANS: C The SBAR system was developed by professionals in the California Kaiser Permanente System and involves direct, respectful communication skills among professionals with the aim of quality patient care.
A private ambulance clinic established a few streets away from Pacific Hospital markets its services as quality-based within caring relationships. The clinic is part of the __________ environment. a. public b. macro c. competitive d. social
ANS: C The competitive environment includes factors and elements that compete for resources with another organization. These elements may include those in public and macro environments.
At the beginning of the strategic planning processes, Pacific Hospital learns that nursing staff members are uncomfortable with utilizing evidence-based practice, and that staff perceives that only limited resources are available to support translation of evidence into their usual practice. Because this issue has been identified, the management team determines that a plan of action is required to address the issue. Who should be involved at this point? a. Nursing unit managers b. Staff nurses c. All staff d. Administration
ANS: C The first phase in planning is conducting an assessment of the external and internal environments. Assessment of the internal environment should include all levels of staff and facilitates feedback on effectiveness of strengths and weaknesses of systems and processes within the institution.
From your observation of planning activities in the organization, you have noticed that planning and decision making occur at various levels of the organization. The nurse manager has overall responsibility for which of the following? a. Sending out postcards b. Organizing a telephone follow-up c. Monitoring ongoing activities and projects d. Listing the patient population
ANS: C The nurse manager should articulate organizational decision making for the criteria model adopted by the organization and monitor ongoing implementation of the plan.
A nurse is explaining the pediatric unit's quality improvement (QI) program to a newly employed nurse. Which of the following would the nurse include as the primary purpose of QI programs? a. Evaluation of staff members' performances b. Determination of the appropriateness of standards c. Improvement in patient outcomes d. Preparation for accreditation of the organization by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
ANS: C The primary purpose of QI is improvement of patient outcomes, which relates to prevention of error, quality patient care, and patient satisfaction.
After staff meetings lately, Sharon, the head nurse, observes her staff in small groups, having animated discussions that end abruptly when she approaches. Sharon reflects on this observation and realizes that: a. two very outspoken members tend to dominate discussions in meetings. b. this behavior is indicative of a high level of communication among her staff. c. staff members are very committed to the team and have strong opinions. d. ongoing discussion outside of meetings is conducive to creativity.
ANS: C When team communication is dominated by a few members, leaving others uninvolved or bored, disagreement is not expressed openly. As a result, team members "stuff" their feelings and wait until after meetings to voice their opinions.
The executive team at Hospital XYZ develops a polished strategic plan that includes a mission statement, goals, and objectives. The executive team involves the marketing team, so that the plan can be communicated internally and externally. After 2 years, no significant progress has been made toward any of the goals. What has been omitted in the plan? a. Planning b. Marketing c. Integrated financial planning d. Customer focus
ANS: C Without the inclusion of a business plan with the strategic plan and integration of financial planning and allocation of resources execution of the strategic plan can become paralyzed, even with the most effective communication of the strategic plan itself.
An example of one strategy to improve participation in the change process by staff fitting the behavioral descriptions of laggards, early majority, late majority, and rejecters is to: a. Encourage teamwork. b. Transfer to a different unit. c. Require attendance at staff meetings. d. Delegate the roles and tasks of change.
ANS: D According to Rogers's work, the individual's decision-making actions pass through five sequential stages. The decision to not accept the new idea may occur at any stage. However, peer change agents and formal change managers can facilitate movement through these stages by encouraging the use of the idea and providing information about its benefits and disadvantages.
Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that "what she has been doing all these years means that she is incompetent and doesn't care about her patients." Your response to her indicates that: a. Elizabeth will never adopt the change. b. Elizabeth is insecure in her practice. c. Elizabeth requires more information about the practice. d. Change involves emotions.
ANS: D Change, whether proactively initiated at the point of change or imposed from external sources, affects people. Responses to all or part of the change process by individuals and groups may vary from full acceptance and willing participation to outright rejection or even rebellion. It is critical to be able to "read" people and to recognize that communication should involve people's emotions and feelings.
To effectively achieve a change goal/outcome in a change situation, the wound care specialist will: a. Preserve the status quo. b. Diminish facilitators and reinforce barriers. c. Weigh the strength of forces. d. Strengthen facilitating forces.
ANS: D For change to be effective, the facilitators must exceed the force of the barriers; thus, strengthening the facilitating forces would achieve this aim.
As the unit manager, you spend a day performing direct patient care and work with a new system that is designed to capture patient documentation at the bedside. During discussions with staff while giving care, you discover that the number of screens that need to be opened during documentation makes charting more complex and time-consuming than traditional manual charting approaches. On the basis of this feedback, you: a. Assume that the system is doing what it needs to do. b. Provide reassurance to staff that the unit has achieved its goals in implementation of the system. c. Ask some of the staff if they have had similar experiences with the system. d. Consult chart audit data and end user consultation reports to determine if errors and problems are occurring.
ANS: D In Kotter's eight-step change model, removing obstacles means keeping alert for barriers in structure and processes that limit the ability to change and then removing those barriers once they have been found.
Sarah, RN, is one of your most enthusiastic staff members and has been to a workshop on preparing educational materials for patients. On the basis of this workshop, she would like to develop an information Website for patients who are being admitted to the ward. An appropriate response to Sarah's suggestion would be: a. "That is a great suggestion, but we have no resources for such an expensive undertaking right now." b. "Perhaps you can keep that in mind as we redesign our charting system." c. "We have too many seniors as patients, and you know that they don't use technology." d. "There is a great group here that meets to look at technology pilots. Let's see if you can join them and discuss your idea further."
ANS: D Involving Sarah with others who enjoy new ideas and who are able to try out new ideas in pilot projects enables her to remain on the cutting edge and to try out innovative solutions with the least amount of disruption.
Resistance is most likely when change: a. Is not well understood. b. Involves many layers in an organization. c. Involves nonprofessional workers. d. Threatens personal security.
ANS: D Resistance and reluctance commonly occur when personal security is threatened and may involve loss of confidence in abilities or loss of job or financial security.
The wound care nurse decided to involve those to be affected by change early in the change management process. This can positively result in: a. Coordination. b. Resistance. c. Anticipation. d. Participation.
ANS: D Successful change means persistence and advancement of the change, which requires the undivided focus of all team members. Early involvement and participation are critical to capturing the undivided focus of team members.
Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because "the unit has been using heparin for years and there has never been any adverse effects." According to Havelock (1973), this comment may originate from failure in which phase of the six phases of planned change? a. Generating self-renewal b. Choosing the solution c. Diagnosing the problem d. Building a relationship
ANS: D The first phase of this model of planned change involves building a relationship as a basis for later phases, which include diagnosing the problem and choosing the solution. At this point, as a new manager, the relationship may not have yet developed sufficiently with Elizabeth.
A nurse manager is experiencing conflicts between herself and staff members. She had tried to develop a team by using a shared leadership model to empower the staff. Staff members are functioning: a. as a team. b. independently. c. interdependently. d. as a group.
ANS: D A group is a collection of interconnected individuals working together, with a high degree of interdependence, for the same purpose. A team is a unified group that is committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable. The conflict indicates that the staff may not be united in a common purpose.
The staff development educator developed strategies to help nurse managers actively listen. Guidelines for active listening include which of the following? a. Speed up your internal processes so that you can process more data. b. Realize that the first words of the sender are the most important. c. Be prepared to make an effective judgment of the communication sender. d. Cultivate a desire to learn about the other person.
ANS: D Active listening means suspending judgment about what is about to be said and listening to all that is said (and not just the first or last words). It is motivated by a genuine desire to learn about the other person
The unit manager was addressing nursing students in the lounge area and was discussing team leadership and team effectiveness. She stated, "One can agree to disagree with another team member's perspective even when one doesn't necessarily see that perspective as being the correct one." In being creative, what did she mean? a. Championing one's own opinion b. Being compassionate c. Being flexible d. Committing to resolution
ANS: D Caregivers must listen to the other person's perspective, listen to the message accurately, identify differences, and creatively seek resolutions.
A method commonly used in quality assurance to monitor adherence to established standards is: a. a Pareto chart. b. brainstorming. c. patient interviews. d. chart audit.
ANS: D Chart audits are a common method of addressing process standards. Chart audits over time yield trend charts.
As the nurse manager on a rehab unit, you are asked to come to the tub room immediately because two nursing assistants are having a loud disagreement in front of a patient. You ask the nursing assistants to meet you outside and after ensuring that a third nursing assistant is able to care for the patient, you speak with the two nursing assistants. Which of the following would you ask first? a. "How long have you two been working together?" b. "Have you experienced disagreements like this before?" c. "How do you think this patient's perception of her care has been changed?" d. "What happened to bring on this disagreement today?"
ANS: D Conflicts are usually based on attempts to protect a person's self-esteem or to alter perceived inequities in power. When a nurse recognizes upset and reaction, the following steps can be helpful (Sportsman, 2005): Identify the triggering event ("What happened to bring on this disagreement today?"). Discover the historical context for each person. Assess how interdependent each person is on the other. Identify the issues, goals, and resources involved in the situation
In the cardiac intensive care unit, there has been simmering discontent about the new nurse manager, who avoids any discussion about her scheduling and practice decisions. The staff have begun to sort into "different camps" depending on how they feel about the manager or the decisions. Which of the following statements MOST accurately describes this situation? a. The tension that has been generated will result in creative solutions. b. Staff will become a cohesive group that takes a stand against the manager. c. The conflict will result in increased dialogue about practice and scheduling options. d. Patient care may suffer because attention and energy is being diverted toward the unit relationships
ANS: D Destructive conflict polarizes groups, saps group morale, deepens differences in values, and diverts energy from more important activities, such as patient care. Constructive conflict opens up issues of importance, results in solutions to problems, and enables authentic communication.
After an extensive campaign to ensure that the community surrounding Pacific Hospital has been exposed to the emphasis of excellence in clinical care that occurs through the use of evidence, the marketing team finds that the public perception has changed little. This determination is made possible through: a. marketing surveys. b. focus groups. c. informal feedback. d. comparison of data against benchmarks.
ANS: D Developing benchmark data at the beginning of a project enables comparison of later data against the benchmark to determine if a marketing plan has met its objectives.
Benchmarks in the strategic marketing planning process are useful in: a. establishing programs. b. setting targets. c. rewarding employees. d. measuring progress.
ANS: D Establishing benchmarks enables measurement of the interim and final achievements of programs.
Sally (RN) and Melissa (RN) have shared an ongoing conflict since the first day that Melissa worked on the unit. Sally has confided to another colleague that she doesn't even know why the conflict started or what it was about. This is an example of: a. how expectations and objectives need to be made clear in team situations. b. the need to encourage open discussion of disagreements in opinions. c. the importance of involving all staff in discussions in group settings. d. the enduring nature of first impressions.
ANS: D First impressions are lasting and, as Sally indicates to her colleagues, are often an unconscious response.
Which of the following represents a well-written objective? a. Hospital-acquired infections are reduced, and procedures to reduce infections are implemented. b. To increase staff satisfaction and to decrease burnout. c. To increase the health of the community. d. To implement evidence-based practice on nursing units, as evidenced by adoption of evidence-based processes, by June 1.
ANS: D Objectives are specific (begin with word to followed by an action word; specify single result to be achieved; and specify a target date for attainment) and measurable (provide level of accomplishment at the end).
After a year, the staff at Pacific Hospital is frustrated, and implementation of evidence-based practice has gone poorly. In responding to this situation, the strategic planning team at Pacific Hospital: a. recommends that the mission, objectives, and goals of the hospital be reassessed. b. revises the goal statements in the strategic plan. c. consults an external team on preparation of materials on evidence-based practice. d. holds focus groups with staff to determine what kinds of issues, challenges, and obstacles have occurred in implementation.
ANS: D On a consistent basis, the strategic plan is reviewed at all levels to determine whether the execution of goals, objectives, and activities is on target. As stated, a sense of flexibility regarding the objectives is important to consider, and objectives may change as a result of legislation, budget changes, and change in structure or other environmental factors. Involving staff enables development of creative methods to ensure that necessary changes occur.
As a nurse manager, you know that the satisfaction of patients is critical in making QI decisions. You propose to circulate a questionnaire to discharged patients, asking about their experiences on your unit. Your supervisor cautions you to also consider other sources of data for decisions because: a. the return rate on patient questionnaires is frequently low. b. patients are rarely reliable sources about their own hospital experiences. c. hospital experiences are frequently obscured by pain, analgesics, and other factors affecting awareness. d. patients are reliable sources about their own experiences but are limited in their ability to gauge clinical competence of staff.
ANS: D Patients are reliable and motivated sources of their own experience but often do not have sufficient knowledge of clinical procedures to provide feedback about clinical competence.
The nurse manager was upset with the staff nurse and said, "You did not understand what I said." Which element in the communication process was she referring to? a. Feedback between receiver and sender b. A message channel c. A receiver who decodes the message d. A set of barriers that may occur between sender and receiver
ANS: D Problems can occur at any point in communication and result in miscommunication. In this instance, it can be assumed that there was a sender, a receiver, a channel, and feedback. In this scenario, barriers such as distractions, inadequate knowledge, differences in perceptions, and emotions and personality may have resulted in misunderstanding between the manager and the staff nurse.
The nurse gives an inaccurate dose of medication to a patient. After assessment of the patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication understands that: a. the error will result in suspension. b. an incident report is optional for an event that does not result in injury. c. the error will be documented in her personnel file. d. risk management programs are not designed to assign blame.
ANS: D QM stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.
At Hospital Alpha, there has been a 20% increase in instruments and sponges being left in patients during surgery and surgeries on the wrong limbs. These are known as: a. sentinel events. b. medically sensitive events. c. nurse-sensitive events. d. Never Events.
ANS: D The NQF and CMS define Never Events as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a healthcare facility. Examples of Never Events include surgery on the wrong body part, foreign body left in a patient after surgery, mismatched blood transfusion, major medication error, severe pressure ulcer acquired in the hospital, and preventable postoperative deaths.
A community-based pain management program is being planned for your region. As a coordinator of a home care agency, you have been requested to develop a conceptual framework, mission statement, philosophy, and objectives for the program. In what order will you pursue this endeavor? a. Objectives, philosophy, and mission statement b. Philosophy, objectives, and mission statement c. Philosophy, mission statement, and objectives d. Mission statement, philosophy, and objectives
ANS: D The development of the mission statement is the first step in defining the purpose and direction of the organization after an assessment has been completed.
In implementing the strategic plan for effective utilization of evidence to guide nursing practice at Pacific Hospital, the nursing unit managers take the next step, which is the implementation. Implementation most likely would involve: a. revisiting the mission statement and objectives. b. reevaluating external and internal factors affecting evidence-based practice. c. preparing a budget to support implementation. d. developing unit-based objectives related to the plan.
ANS: D The previous planning (assessment of internal and external environments, development of a mission and plan, and allocation of resources) has already been completed. The next step involves adapting the strategic plan to the nursing units.
"I really wish that my supervisor would realize and acknowledge all the things I do well." In nursing, this has been identified as a problem. Which statement is part of the solution? Focus on: a. new staff. b. care assignments with which the individual is not familiar. c. making corrections. d. the strengths of the individual rather than the weaknesses.
ANS: D The research of Rath (2007) included many recommendations, one of which was that focusing on mediocre behaviors and on a person's weaknesses will not lead to excellence. Focusing on weaknesses tends to decrease the appreciation, and thus the acknowledgements.
