NUR 444 - Exam #3

What did the death of a college student in 1984 due to a drug interaction lead to?

Limit on the number of hours that a resident could be on duty.

What Cannot Be Delegated

Aspects of the nursing process Performing an assessment Formulating a nursing diagnosis Developing and updating a plan of care Evaluating the patient progress Communicating with health-care providers Implementing orders from health-care providers Providing teaching to patient and/or family Evaluating patient status and triage

Peer Review

Assessing, monitoring, and making judgments about the quality of nursing care provided by a peer Fosters accountability and supports self-regulation

Differentiate between patient assignment and patient supervision.

Assignment focuses on distribution of work among qualified staff and complexity of care. Supervision involves guidance, monitoring, evaluation, and follow-up at both patient and management levels.

5 Approaches to Managing Conflict: Collaboration

Best strategy to use in conflict management because it involves a shared approach to resolving conflict. Shared goals are identified, and a commitment to working together is implemented by those involved. Collaborating is time consuming, but it results in the best chance of a resolution.

Review and understand that staff need to be aware and have a clear understanding of policies and procedures and how staff can assist and what can be delegated appropriately.

Breaking Down Barriers - Nurse leaders and managers must - Hold all staff accountable to principles addressed in the job description. - Provide periodic feedback related to the delegation process. - Focus efforts on creating a supportive environment that promotes effective communication and teamwork. - Identify strategies to improve the delegation process. Nurses and UAPs need continued support and education related to delegation techniques and communication for safe and effective management of care in acute care settings. A team approach is necessary to reach desired patient outcomes and can be improved with effective communication and delegation practices. Nurse leaders and managers should consider including education regarding communication and roles and responsibilities related to delegation during new-hire orientation and annually. In addition, using a care delivery model that builds relationships between RNs and UAPs can improve communication techniques, delegation practice, and patient outcomes.

Flow Chart

Clarifies complex processes and provides a basis for designing new processes.

Review the Institute for Healthcare Improvement 100,000 lives campaign and the interventions that would apply to this campaign.

Medication reconciliation to prevent adverse drug events is an intervention of the 100,000 Lives Campaign. Timely preoperative antibiotic administration is an intervention of the 100,000 Lives Campaign. Implementation of the "Central Line Bundle" is an intervention of the 100,000 Lives Campaign.

The nurse manager is having a staff meeting to improve patient outcomes in terms of delegation of care. Staffing includes three registered nurses (RNs), three licensed vocational nurses (LVNs), three certified nurse's aides (CNAs), and two administrative medical support staff. Which observation if noted by the nurse manager would indicate a concern relative to effective delegation?

Delegator-Related Barriers - Overdelegation—occurs when: The workload is more than the delegate can accomplish in the allotted time frame. The RN feels uncomfortable performing a certain task.) - Underdelegation—occurs when: There is failure to transfer authority for a task or to provide clear direction to the delegate because the RN fears losing control or authority, feels insecure, believes he or she can accomplish the task quicker, or is inexperienced. - Lacking willingness to do the task - Lacking skill or comfort with the skill required for the task Delegate-Related Barriers - Feeling overworked or perception of an unfair assignment - Feeling physically unable to do the work - Lack of guidelines that address who can delegate and what tasks can be delegated - Lack of policies that protect nurses from inappropriate assignments and delegation of inappropriate nursing activities or responsibilities - Poor staffing levels - Absence of processes for validation of competencies for delegation - Establishment of guidelines, policies, and procedures that support the delegation - Inclusion of delegation in the job descriptions of all nursing personnel

Ben Kolb

Died from a "drug mix-up" during a minor surgery.

Betsey Lehman

Died from a chemo overdose.

Josie King

Died from acute dehydration.

Review what would be appropriate as a nurse manager is preparing to do a performance appraisal for the staff nurses annual review?

Documents progress throughout the rating cycle and keep the notes up to date. Schedule the meeting in a private quiet area without interruption. Provide feedback throughout the rating cycle and provide clear communication for the expectations, and performance. A discussion for professional growth is essential during a performance appraisal!

The nurse leader is aware that in creating a culture of safety on the unit they would need to encourage and welcome a discussion of errors between staff members

Embedded within a culture of safety is a just culture, or a culture that is fair to those who make an error. A just culture improves patient safety because it encourages nurses to learn from each other's mistakes and to report all errors and near misses without fear of repercussion.

Explain how a corrective action plan can be used to improve staff performance. Review the four levels and define.

First: An informal, verbal reprimand is given. Second: A written reprimand is given. Third: Violation occurs a third time and/or there is no improvement. Fourth: Violation continues to occur after multiple reprimands or employee fails to improve performance to the level of standard of performance.

Stage Two (Culture of Safety):

Good safety performance becomes an organizational goal Safety is perceived by leadership and management as important, but safety performance is addressed in terms of goals rather than as part of the strategic plan and culture of the organization.

Eight-stage model (Kotter) of creating change

Most helpful for rapidly changing and learning organizations.

Which elements should be included in nurse leaders' and managers' responses in handling conflict in the clinical care setting? Nurse leaders and managers need to mediate when interpersonal or intergroup conflict occurs to avoid negative effects on nursing care and patient outcomes. Elements that should be explored include the following:

Mutual respect: Those involved in the conflict may need a reminder to be respectful and focus on the issue and not the other person. Needs versus wants: The nurse leader and manager must help those involved differentiate between what they need and what they want. Compassion and empathy: Those involved in the conflict may need assistance understanding each other and hearing the other person's position. Staying in the "I": The nurse leader and manager reminds those involved to focus on "I" statements and avoid using "you" statements and avoid blaming.

Innovative decision process (Roger)

Helpful when attempting to implement technological changes.

The nurse manager is discussing an error that occurred with a nurse and is using the person approach to human error. Review and define human error.

Human errors can be viewed from two perspectives: the person approach and the systems approach The person approach focuses on unsafe acts of health-care professionals and errors as the result of human behaviors, such as inattention, forgetfulness, negligence, and incompetence. The systems approach, however, acknowledges that errors happen because humans are not perfect.

Factors related to the classification of human factors

Human factors—include staffing levels, staff education and competency, and staffing shortages​

Fishbone Diagram

Illustrates the many possible causes of an error and the relationships among those causes.

Review appropriate and inappropriate types of questions for an RN interview.

Inappropriate: money, marital status, children, age, where you live, politics, religion, sexual orientation, gender preferences (ask how they would like to be addressed), disabilities, arrest record, military status, U.S. citizenship. Although information related to the applicant's age, marital status, and medical information may be needed for payroll, benefits, and insurance purposes, the nurse leader and manager should not inquire about this information during the interview. Such information can be obtained after the employee is hired.

Facilitating communication between management and staff will lead to?

Increased collaboration.

5 Approaches to Managing Conflict: Competing

Individuals pursue their own needs, desires, or goals at the expense of others. The competitor wants to win and is not cooperative. This strategy is power driven and can result in aggression.

Which activities should only be performed by an RN even if LPN(s), or UAP(s) are available?

Initiation of blood transfusions Tracheostomy care Vital signs on a new patient to be admitted Insertion of a foley

Near Miss

Is a potential error that was discovered before it was carried out​.

Review the five standard operating protocols of the World Health Organization that have been implemented globally.

1. Medication accuracy at transitions in care 2. Correct procedure at the correct body site 3. Use of concentrated injectable medicines 4. Communication during patient care handovers 5. Health-care-associated infections

Review the process for developing a corrective action plan for a nursing staff member. What is the primary focus of a corrective action plan?

A progressive process used to improve poor performance in which deficiencies and substandard performance are addressed immediately to avoid escalation of the behavior. The nurse leader and manager must first determine the reason for the substandard performance: Is it the result of a lack of knowledge, skill, or experience, or did the employee violate policy or procedure? Next, the nurse leader and manager should address the behavior with a progressive corrective action plan according to the organization's policy and procedure; the plan may include a verbal reprimand, a written reprimand, suspension with or without pay, and termination. Corrective action should include constructive feedback to improve behavior or performance, rather than destructive feedback, which does not encourage the employee to succeed and can be detrimental to their development. Once poor performance is addressed and the employee meets the conditions of the corrective action plan, the incident should not be held against the employee unless the behavior is repeated. However, if the employee repeats the behavior, and continued efforts to assist them in meeting the minimum standards of performance are not successful, termination may be necessary.

Understand what is appropriate to delegate to a new nurse who is newly assigned to a new unit by an experienced RN such as:

Admitting a new patient to the unit who is scheduled for elective surgery in the morning Inserting a Foley catheter Performing a pain assessment in order to administer PRN pain medication.

What elements are critical for a nurse to consider with regard to using delegation on med-surg units?

All nurses should be aware of their respective state practice act because it defines their scope of practice. Assessment of patient acuity and complexity is a critical factor in planning effective delegation. Knowledge of both the number and type of staff is a critical factor in planning for delegation.

5 Approaches to Managing Conflict: Compromise

An effective conflict management strategy. When compromising, everyone gives something up, and everyone gets something they want in return. However, to be effective, those involved must be on an even playing field.

Which characteristics are attributed to emerging change theories?

Are cyclical rather than linear and require organizations to react with speed and flexibility Are based on a systems approach to change and innovation that results in a comprehensive view and a realization that systems are complex Include new theories based on complexity science, which recognizes that the world is in continual motion and that a change in one area can result in numerous changes in other areas

Unsafe Act

Occurs in the presence of a potential hazard, sometimes as the result of a violation, not an error​.

Adverse Event or Patient Safety Event​

Occurs when an injury to a patient is caused by medical management rather than the patient's underlying condition​.

As a nurse manager who is assigned to investigate medication errors that occur on two separate shifts. Who would the nurse manager involve as a part of the investigation?

Once a QI activity is identified, nurse leaders and managers form an interprofessional team to implement the QI process. Nurses at all levels may be part of an intraprofessional or interprofessional team to explore the problem identified. The team should be made up of members representing those involved with the problem.

Review the following task and identify which task can be delegated to an LPN/LVN. Which task can be delegated from an LPN/LVN to a UAP?

Oral hygiene Feeding a patient with dysphagia Collecting a urine specimen Obtaining daily weight

Review Benner's Novice to Expert Model. What would the nurse manager expect to see from these new graduates as they begin their orientation on a nursing unit?

Orienting - Nurse leaders and managers must: Be dedicated to providing a proper orientation for new staff to enhance retention. Make sure orientation programs bridge the gap between the student nurse clinical setting and the real-world clinical setting through an evidence-based TTP model. Consider the characteristics of the new staff members and select an appropriate preceptor using the novice-to-expert model. Provide regular verbal and written feedback to build confidence and self-esteem.

Describe the nurse leaders role in the change process.

Participant Stakeholders: This information is represented by the framed question, "who" of change. Rationale: This information is represented by the framed question, "why" of change. Timing: This information is represented by the framed question, "when" of change. Technique: This information is represented by the framed question, "how" of change. Change/Innovation: This information is represented by the framed question, "what" of change.

The nurse manager is putting together an interview panel for their unit which is made up of front-line staff and the manager. What are the considerations that would be a priority for a successful interview?

Position/job description Roles of responsibilities for that position

The elements for establishing a culture of safety

Provides blame-free environment in which staff members feel comfortable reporting errors and near misses​ Supports nurses in that it is nonpunitive and ​emphasizes accountability, excellence, honesty, integrity, and mutual respect​

Review the goals related to the National Quality Forum (NQF) for patient safety (Know which does NOT apply)

Reduction of preventable hospital admissions and readmissions Advancement of electronic measurement to capture necessary data for performance measurement Reduction of the incidence of adverse health care-associated conditions Reduction in harm from inappropriate or unnecessary care

Slips, Lapses, and Mistakes​

Refer to actions that do not result in the intended outcome​.

Sentinel Event

Refers to a patient safety event that results in death, permanent harm, or severe temporary harm and intervention required to sustain life ​- automatically reported.

Which behaviors are considered to be common human responses to change?

Resistance to change is common. Many people are not comfortable with change. Various factors can affect a person's ability to handle change and innovation, such as adaptability, comfort with the status quo, perceptions of the benefits of the change, and how threatened a person feels by the change. Effective change agents anticipate human responses to change and include strategies to manage the responses in the plan. - Staff members need time to adjust to the thought of change and time to adjust to the actual change. - Nurse leaders and managers can help staff cope with change by making sure the rationale for the change is clear and allowing staff members to verbalize concerns and express their emotions. - During the change process, nurse leaders and managers can also help staff members cope by ensuring open communication, providing feedback on a regular basis, and empowering them throughout the change process.

Errors of Omission

Results when an action that is a standard of care is not taken or omitted​.

Error of Commission

Results when the wrong action is taken or committed​.

5 Approaches to Managing Conflict: Accommodating

Sacrificing one's own needs or goals and trying to satisfy another's desires, needs, or goals. This strategy does not resolve conflict and may result in future conflict.

Stage One (Culture of Safety):

Safety Management is based on rules and regulations The organization sees safety as an external requirement imposed by regulatory bodies, and mere compliance with rules and regulations is considered adequate.

Stage Three (Culture of Safety):

Safety Performance is seen as dynamic and continuously improving Safety performance is viewed by everyone in the organization as dynamic and in need of continuous improvement in this stage. There is a strong emphasis on communication, training, management style, and improving efficiency and effectiveness.

Three stages for establishing a culture of safety

Safety management is based on rules and regulations.​ Good safety performance becomes an organizational goal.​ Safety performance is seen as dynamic and ​continuously improving.

When preparing for your self-assessment for an upcoming performance appraisal the following should be included:

Self-appraisals should contain documentation of the past year's accomplishments. Self-appraisals should contain self-reflection and identification of strengths as well as weaknesses. Feedback from colleagues/peers will help support evidence of self-appraisal by recognizing perceptions of others. Revision of goals based on personal assessment reflects effective use of self-appraisal for it incorporates analysis of presented facts.

Run Chart

Shows trends over time and reflects how processes are operating.

What Can Be Delegated

Specified by state nurse practice acts, regulatory agency guidelines, and institutional policies Examples include Monitoring patients Collecting specimens Documenting data

Identify common human responses to change

Such as: Limiting communication would be seen as a barrier to change. It is important to keep communication open in order to foster adaptive and integrative responses to change. Change initiatives typically fail because of poor coordination, ineffective communication, and lack of staff cooperation. Thoughtful planning and ongoing communication can help overcome barriers to change.

Nursing managers have asked nursing staff to participate in a discussion relative to maintaining a quality workforce within the nursing unit and health-care facility. What methods would help to support this goal?

The pursuit and attainment of excellence help to promote and maintain a quality workforce. Matching competencies and skill sets of employees leads to development of a quality workforce.

Review the five rights of delegation as they relate to delegating effectively.

The right task is assigned to the right person under the right circumstances with the RN providing the right direction/communication and the right supervision. The right circumstances involve knowledge of patient settings; as such, environmental considerations should be taken into account when delegating tasks. Client assessment plays a critical role in the delegation of tasks. It helps to support the five rights of delegation by focusing on all aspects of care by identifying the right patient. Maintaining and providing competent care is a required element of the five rights of delegation, as it focuses on the right person. Giving the right direction or communication is a critical element of the five rights of delegation.

TJC established the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery that became effective July 1, 2004.

The three components of the Universal Protocol are a pre-procedure verification, site marking, and a time-out.

When considering implementing a traditional change theory in clinical practice, what expectations would be evident?

Traditional change theories and models are linear and suggest that change occurs in a sequential manner. For the change to be successful, the organization or unit must progress through each stage. These theories require ongoing work to ensure that goals are met and change is sustained.

360-Degree Feedback

Underscore self more on 360 degree process Is constructive: nurses receive feedback from everyone around them Provides specific opportunities for the employee to use in his or her development plan

The nurse leader is referencing the American Nurses Association's nursing-sensitive quality indicators and knows that structure indicators include which element?

Understand that we no longer look at Staff to patient Ratios The new standard is related Hours of patient care per patient

Histogram

Used to display frequency of events and assist the QI team in recognizing patterns in numerical data.

Force-field model (Lewin)

Useful for problem solving, most situations, and planned change.

5 Approaches to Managing Conflict: Avoidance

Withdrawing or hiding from the conflict. The strategy is not always effective in resolving conflict and just postpones the conflict. Because the conflict is not resolved, it may reappear again later.

Willie King

Wrong leg amputation.

Positions and job descriptions should be

up to date and updated every two years.