Time Management and Delegation in Nursing, Exams of Nursing

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NURS 265 MANEGEMENT EXAM FINAL STUDY GUIDE A GRADED

2023-

Terms :

Advocacy The protection and support of another's rights. Based on respect for an individual to make personal choices and recognizes the right of a person to choose what happens. The nurse acts as an advocate for patients by providing the necessary information needed (through teaching and education) to make a decision about health care needs. Code of Ethics (^) A set of principles, established by a profession to guide the individual practitioner. It guides our conduct. Change Agent A person skilled in the theory and implementation of planned change. The change agent must be skillful in facilitating the change and is active in each stage of the change process. Communication An enabling process that allows info to be transferred. It allows ideas to be translated into actions. The exchange of meaning between and among individuals through a shared system - includes verbal and nonverbal. Conflict Internal or external discord. Results from differences in ideas, values, or feelings. Reasons include: Scarce resources and poorly defined role expectations.

Critical Thinking: Similar to "reflective thinking". Related to evaluation; Has a broader scope than decision-making or problem solving in that it includes reasoning and creative analysis, involves higher-order reasoning and evaluation; it has both a cognitive and affective component. It includes: insight, intuition, empathy, and the willingness to take action. Delegation (^) Getting work done through others; directing the performance of one or more people to accomplish goals Ethical Dilemmas Having to choose between two or more undesirable alternatives Ethics The systematic study of what a person's conduct and actions should be with regard to him/herself, other human beings and the environment. Decision-Making A complex, cognitive process often defined as choosing a particular course of action. To judge or settle. The final step of the problem- solving process. Problem solving Systematic process that focuses on analyzing a difficult situation. It is part of decision making. The time and energy needed to correct this problem are not warranted. Case Management A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communication and available resources. This promotes quality and cost- effective outcomes. It is the latest work design proposed to meet patient needs. Intuitive Decision- Making Model Intuition used in decision-making; this was not valued much in the past. There has been recent interest in this model; however, intuition can be overpowered by emotions.

Leader Person who influences and guides direction, opinion, and course of action. A job title alone does not make a person a leader. Manager The person who brings things about, and has responsibility to the company; "conducts" through coercion Leadership (^) The process of moving a group in some direction through mostly non-coercive means. A way of behaving. An interpersonal ability to cause others to respond; Involves empowering beliefs and teaching others to tap their full capabilities by shifting the beliefs that have been limiting to them. It increases productivity by maximizing work force effectiveness. Management Problem-oriented process that is needed whenever 2 or more individuals work together toward a common goal. It emphasizes control of hours, costs, salaries, overtime, use of sick leave, inventory and supplies. Transformationa l Leaders Visionalry, able to empower others and raise each other to higher levels. Transformational leadership is "an interactive relationship, based on trust, that positively impacts both the leader and the follower" A high-performing transformational leader demonstrates a strong commitment to the profession and the organization and is willing to tackle obstacles using learning, self- confidence and shows a sense of being in control. Legal Decision Making Protects the pt and the nurse. Laws and legislation define the scope of acceptable practice and protect individual rights Malpractice Part of the negligence law that relates to lack of skill or misconduct by professional persons

Negligence (^) Conduct which falls below the standard of care established by law for the protection of others - involves an unreasonable risk of harm to the pt. It is FAILURE to do something that a reasonable prudent person WOULD DO (omission) or DOING something that a reasonably prudent person WOULD NOT do (commission) Transactio n al Leaders Concerned with "day-to-day" operations. Motivation The force within an individual that influences strength or direction or behavior. Managers cannot directly motivate subordinates - managers must create a work environment in which both organizational and individual needs can be met. : Types of motivation include

• positive reinforcement

Argyris Theory Stresses that managerial domination causes workers to become discouraged and passive. Flexibility within the organization and employee participation is stressed. Nurse Practice Act Laws est in each state to regulate the practice of nursing. They are broadly worded and vary among jurisdictions but all contain the basic elements. Herzberg's Motivators & Hygiene Theory Frederick Herzberg believed that employees can be motivated by the work itself. You can separate personal motivators from job dissatisfiers; motivators give people a desire to work.

Scientific Managem e nt A set of principles that advocate replacing traditional methods with scientific methods of organizing work. Workers are hired based on technical competence and abilities - workers can view how they "fit" into the organization. Developed by Frederick Taylor, a mechanical engineer, who felt that if workers could be taught the "one best way to accomplish a task", productivity would increase Nursing Process. Facilitates decision making. Used for patient care and for solving leadership and management problems. HOWEVER, a weakness is that it does not require clearly stated objectives. Paradigm A model, theory perception, assumption or frame of reference. The way a person perceives or "sees" the world. Critical thinking is needed to examine this. Paradigm Shift A break with the old way of thinking - Critical thinking is needed to create this shift Patient Bill of Rights A written list that includes the rights and responsibilities of the pt while receiving hospital care. It implies a code of ethics the nurse observes professionally. Procrastination my life Standards of care Minimal level of expertise that may be delivered to the pt. They can be found in the state nurse practice act, professional organizations federal agency guidelines and regulations, hospital policy and procedure manuals, nurse's job descriptions.

Leadership vs Management –

• Some view leadership as a function of management… However, just because someone is a manager, doesn’t necessarily make them a good leader!
• What is “ management ”? – problem oriented process that is needed whenever 2 or more individuals are working toward a common goal; emphasizes salaries, overtime, cost, use of sick leave, etc. DIFFERENCES BETWEEN THE TWO Manager – coercive power (power to punish) Leader – NON coercive influence
• Have an assigned position within an organization
• Plan, organize, direct, motivate, control
• Have a legitimate source of power (due to the delgated authority that accompanies their position)
• They are required to manipulate people, environment, money, time and other resources to achieve the organization’s goals
• They carry out specific functions, duties, responsibilites
• Have greater formal responsibility and accountability for rationality and control
• Direct willing AND UNWILLING subordinates – they are accountable to the organization for their actions and their subordinates actions
• Role models
• Share their information and wisdom willingly
• Often do not have delgated authority
• Obtain power through influence, other means
• Have a wider variety of roles (could be manager, or could be travel nurse, other position)
• Have goals that may or may not reflect those of the organization
• Emphasize interpersonal relationships
• Direct WILLING followers
• May not be part of the formal organization
• Focus on group process, info gathering, feedback and empowering others
• My be undervalued in nursing
• Committed to the profession  leadership will follow You can have good leaders and bad leaders just like you can have bad managers and bad managers…
  • a good rolemodel/leader will be committed to the profession, will show professionalism and will uphold the facility’s policy. Manager – could be good leader or bad leader; Summary of Ideas of Management: (how the manager views the employee/how the employee views the management)
• The workplace should be designed to promote the greatest efficiency of time and energy – should be in convenient place (the pt rooms should be set up so as to facilitate efficiency of care
• A personnel system should be established to hire, train and promote employees based on their technical competencies  workers are viewed on how they fit into an organization; the interviewer will view you on how good of a fit you are to their particular place
• Each employee’s abilities and limitations should be identified so that they can be best matched to the most appropriate job… When Interviewing: Workers are viewed according to how the “fit” into the organization, and how they contribute to the organizational productivity – signs they would look for (is this how the potential employee would approach patient care?): o Chewing gum/overly madeup or heavy perfume o Late for interview o Improper clothing Financial incentives should be used as a reward for work accomplishments

The relashionship between managers and workers should be cooperative and interdependent 

equal sharing of the workload should be promoted! Examining how the managers view their employees is important; for instance, managerial

domination causes workers to become discouraged & passive  Managerial attitudes about

employees (an how these managers will end up treating these employees) is directly corretlated with employee satisfaction and will affect motivation and productivity Ex. Some managers view their employees as lazy – will tend to micromanage (be authoritarian)

• their attitude about the employee shapes their management style
• the manager that believes that most employees do what they need to do most of the time without needing to be told will tend more toward a Laissez-Faire leadership style…
  • Flexibility and employee participation in decision-making should be stressed
  • No one management style will be effective in all situations, at all times and with all people…

Leadership Styles:

1. Authoritarian (autocratic) ▪ Focus: Makes most of the decision alone without input from employees ▪ Control: Maintains strong control over the group ▪ Emphasis is on the difference in status (“I” and “you”) ▪ Communication flows downward; directs others using commands, but accepts no feedback ▪ Criticism is punitive (Inflicting or intended as punishment.) ▪ Motivates others through coercion ▪ Task-oriented ; most effective in a crisis situation  results in well-defined group actions that are predictable ▪ Productivity is usually HIGH, but creativity, self-motivation and autonomy are reduced ▪ Two authoritarian type people working together will lead to power struggles 2. Democratic ▪ Focused on the individual characteristics of subordinates ▪ Control: Less control is maintaned, but there is some control ▪ Emphasis is on effective group functioning: (“we” rather than “I” and “you”) ▪ Communication flows up and down ▪ Criticism is constructive ▪ Motivates through economic and ego awards (positive reinforcement) ▪ People-oriented : effective when cooperation and coordintion between groups are necessary  resuts in decision making involving others ▪ Other are directed through suggestions and guidance ▪ Promotes autonomy and growth in individual workders ▪ Can be frustrating and less effective when decisions must be made in a hurry because many people must be consulted 3. Laissez-Faire ▪ Focus: Provides little to no direction or supervision; referred to as the “let along” leader ▪ Control: Permissive with little or no control ▪ Emphasis is on the group ▪ Communication is upward and downward between members of the group ▪ Criticism – none

▪ Motivates – by support when requested by the group or individuals; can result in creativity & productivity when all group members are highly motivated… ▪ However, refuses to assume leadership responsibilties that accompany the job and disperses decision making througout the group ▪ No guidance, information or individualized attention  chaotic and can be frustrating resulting in possible group apathy and disinterest ▪ C an be appropriate when problems are poorly defined and brainstorming is needed Examples : Lunch Times –

• Autocratic: assigns specific ppl to specific times regardless of what the employees want
• Democratic: signup sheet w specific times
• Laissez-Faire: doesn’t know who’s going when Policies – mostly autocratic; ex. “no eating in specific areas” Uniforms –
• Policy saying you are changing uniforms – you don’t have a choice, you must wear a uniform
• Policy doesn’t specify what type of uniform, everyone comes in wearing whatever style/color they want – Laz. Faire
• On your unit you can choose from Navy, white or royal blue  democratic

Future Demands –

What type of leader do you want? An integrated leder/manager that is able to incorporate all types of leadership according to the need. \need someone who has both transactional and transformational qualities!

• be well grounded regarding purpose of the organization
• become coaches /mentors
• take risks, (abandon traditional judging of performances)
• Share the goals of the organization: v. important! A good manager/Leader is one that is able to
  • manage daily operations of the unit,
  • displays a vision,
  • activates and empowers others
  • one that is well prepared to deal with the challenges of the changing health care system
  • Agrees with the philosophy of the unit/corporation they are applying to - Transformational Leader : “Visionary”, is able to empower others and is able to carry their unit to the next level, into the future, thinks outside the box. - Transactional Leader : focuses on the day-to-day operations, “task-oriented”; more concrete thinkers;

KEY PLAYERS IN LEADERSHIP & MANAGEMENT: Problem Solving, Decision Making, & Critical

Thinking

• Key in everything we do! Decision Making – choosing a particular course of action;

• it is possible for decision making to occur without full analyisis required in problem solving
• triggered by a problem, but is often handled in a manner that does not focus on eliminating the underlying problem; therefore the decision may or may not solve the problem

o For example: if the person handled a conflict only when it occurred instead of attempting to identify the real problem causing the conflict, only decision-making skills would have been used. Problem Solving – is part of decision making and is a systematic process that focuses on analyzing a difficult situation.

• Always includes a decision making step
• Attempts to identify the root problem in situations before the decision is solved – much time and energy is spent on identifying the real problem Critical Thinking – “reflective thinking”; has a broader scope than decision making and problem solving
• Involves reflecting on the meaning of statements, examining the offered evidence and reasoning and then forming judgments about facts
• More complex than problem solving or decision making  involves higher order reasoning and evaluation;
• Has both a cognitive and affective component
• Looks for patterns and relationships, for example – evaluating a patient’s response to interventions; seeing the correlations between medical diagnosis and what pt problems might be a priority o Validate and organize data o Transfer knowledge from one situation to another o Evaluate according to established criteria – for ex. For peripheral perfusion (distal pulses, cap refill, temp, etc.); for wounds (approximation, drainage, redness, size, granulation tissue, etc.) o Is a key component whether caring for a patient, or when answering a test question! ➢ Basic Level Critical Thinker: ▪ Assumes the instructor/person in authority has all the right answers ▪ Believes that there is a right answer always correct in every situation ➢ Complex Level Critical Thinker ▪ Analyzes the situation described in clinical or on a test question ▪ Determines what a test question is asking (test) or what is happening with a patient (clinical) ▪ Chooses the safest choice for the patient (clincal) or selects the answer that represents the safest nursing judgement answer choice (test) ▪ Accepts that a particular action in one situation may not be the best choice in all situations

TRADITIONAL PROBLEM SOLVING –

• best if there is time to sit down and really think/analyze the situation; less effective if there are time constraints
• Need to go through each step thoroughly
• Nursing Process is a type of Traditional Problem Solving

Steps in Traditional Problem Solving

1. Identify the key problem:
2. Gather data – the info surrounding the problem, what led up to it?
3. Explore alternatives – what are possible solutions to the problem?
4. Evaluate alternatives –
5. Select appropriate solutions – what is the best solution according to critical thinking process
6. Implement this solution
7. Evaluate the results When undergoing the decision making process (when evaluationg the solutions) – things to consider:

o Define Objectives clearly – a decision made without a clear objective in mind or one that is inconsistent with one’s philosophy is likely to be a poor quality decision. Sometimes the problem is identified, but the wrong objectives are set. o Gather Data carefully –gather CLEAR facts! Make sure they are accurate. Ask: what is happening?, why is this happening? What are the causes of the problem? Who is affected by the problem? For example, facts can be misleading if they are presented in an out of context way; make sure the data gathered are factual. Use an evidenced-based approach; don’t be impulsive and think things through. o Generate Many Alternatives – brainstorm, involve others in the thought process o Think Logically – avoid faulty logic such as overgeneralizaions, affirming the consequences (If a new procedure is heralded as the best way to perform a nursing procedure, but all the nurses on your unit are preforming the procedure in a different way, it is illogical to assume that the technique currently used is “bad”), or arguing from analogy (for example, saying that because intuition plays a part in clinical and managerial nursing, then any characteristic present in a good clinical nurse should also be present in a good nurse manager; this is not necessarily true; a good nurse-manager does not necessarily possess all the same skills as a good nurse-clinician). o Choose & Act Decisively – There is inherently going to be uniqueness and individuality in decision making/problem solving; this cannot be completely overcome, but needs to be considered in order to avoid subjectivity. Objectivity should be increased as much as possible with decision making as a leader/manager Decision Making is based on individual values, beliefs, etc… How to decrease individual vulnerability in decision making: ▪ Be aware of your values, beliefs and feelings; you must be aware of the values on which your decisions are made  helps to avoid stereotyping ▪ Be aware of generational differences ▪ Use available resources, including current research, literature to gain a fuller understanding of the issues involved. Involve other people such as experienced leagues, trusted friends, or superiors as advisors ▪ Be honest with yourself about the choices and perferences of those choices ▪ Be prepared to take some risks; may involve daring to stand alone and be unpopular ▪ Be flexible with your thinking process regardless of they type of thinker you are; seek input from analytical as well as intuitive thinkers No two people are going to value the same thing – this is shown by the choices they make in life. We need to respect this! Some people are concrete thinkers, some are analytical Generational Differences: ▪ Impact our values, views on things, our thinking, how we work, how we communicate ▪ Different generations can learn from one another VETERANS born btw 1922- 1946 – o Key Events: great depressan, Korean War, WWII o Cultural Events: rise of the movie, golden age of radio, labor unions o Traditionalists o Respect for authority, great national pride o Believe in: hard work, stoicism in the face of higher work load BABY BOOMERS born btw 1946- 1964 – o Key Events: Vietnam war, assassination of JFK & MLK, Watergate o Cultural Events: Womens lib, Rock & Roll, civil rights movement, hippies o Values team work and optimism o Willing to work long hours o Lifelong learners

o Love/hate relationship with authority GENERATION X born btw 1964- 1980 – o Key Events: Challenger explosion, MTV o Cultural Events : knowledgeable of alternate lifestlyes, videogames, single- parent households, o Value self-reliance, risk taking, acceptance of diversity, informality o Can be pessimistic o Seek feedback o Technologically oriented GENERATION Y born btw 1981-2000– o Key Events: Columbine shooting, 9/11 Attack, Iraq War o Cultural Events: body piercings, environmental concerns, civic duty, random violence o Need to balance life and work o Team orientation, multitasking o Casual dress & fun o Authority figures not held in high regard o Have confidence o Accept alternative lifestyles Example of Decision-Making Process – Sam Case Study

1. Main Problem – Values vs Job
2. What is the data? What are the pieces of this problem?

• been told to say whatever to the applicants
• He is the sole provider of his family
• he made promises he doesn’t know if he can keep
• he can lose his job
• there is high competition for employees
• has gone 3 days without a single perspective applicant; feels desperate
• Sam loves his job

3. What are all the alternatives?

• quit his job/look for a different job
• contact applicants and tell the truth
• continue to stretch the truth,
• do nothing
• approach supervisors

4. Evaluate Alternatives:

• Quitting  family would suffer financially, may not have a good reference; would this solve the problem? He would keep his values, but he would not solve the problems that he created from what he told the prospective employee - Do Nothing  lose credibility to supervisors
• Approach supervisors  could be fired, but also could see his side of things and offer advice of what he could do
• Contact the applicants  may lose interest if they learn what he promised may not happen

5. Implement Sam approached the supervisors, and ended up getting fired
6. Evaluating results – Sam realizes that his values and people are very important to him, and felt good about his decision  result was that Sam lost his job but he learned a lot about himself and his values.

Organizational Planning: The Planning Hierarchy –

Making a long term plan for an organization or department – how is this done??? Every organization goes through planning – it should encourage the best use of resources: choose from alternatives; should be proactive and deliberate; is ongoing and should take measures to offset any problems. Is required of all managers… ~There are many types of planning; in most organiztions, these plans form a hierarchy with the plans at the top influencing all the plans that will follow. Also, planning at the top of the hierarchy are more generalized and the lower components will be more specific…

1. Mission Statement – states the purpose of the organization; Is usually a brief statement identifying the reason that the organization exists and its aim for the future or function in the future. o Identifies the organization’s constituency and addresses its position regarding ethics, principles, and the standards of practice o Very general 2. Philosophy – The belief of the organization: This is the basic foundation that will direct all further planning towrd the mission… Remember that everything from the hierarchy will flow from the mission statement so the philosophy will tie into the mission. o Provides the basis for developing nursing philosophies at the UNIT LEVEL and for nursing service as a whole  To include quality and scope of nursing services, o How nursing specifically will meet organizational goals 3. Goals – more specific than the philosophy; they direct the aim of the philosophy  are the desired result toward which effort is directed; They will change with time and require periodic reevaluation and prioritization. o Should be measuraable, realistic o Include short and long term for things such as (services rendered, economics, use or resources such as people, funds, and faculties, innovations, and social responsibilities) o Example: “all RNs will be proficient in the administration of IV fluids” 4. Objectives – similar to goals, but are even more specific: they identify HOW and WHEN a goal is to be accomplished! o They motivate people  are very explicit, measurable, observable or retrievable, and are obtainable. o GOALS usually have multiple OBJECTIVES that are each accompanied by a targeted completion date o Both goals and objectives must be clearly written and communicated for all those in the organization responsible for their attainment o Example in accordance to the goal from above, objectives could be: ▪ “All RNs will complete the hospital’s course “IV Therapy Certification” within one month of beginning employment. The hospital will bear the cost of this program.” ▪ RNs who score less than 90% on a comprehensive exam in this course must attend a remedial 4-hr course, etc. 5. Policies – plans reduced to simple statements or instructions that direct organizations in their decision making; for example: (formal dress code, policy for sick leave or vacay time, disciplinary action, etc.) ▪ These comprehensive statements are derived from the organizations’ philosophy, goals and objectives □ explain how the goals will be met and guide the general course and scope of organizational activities

6. Procedures – Plans that establish th customary or acceptable ways of accomplishing a specific tast or delineate a sequence of steps of required actions. (for example, how to do a nursing skill) ▪ They identify the process or steps needed to implement a policy, and are generally found in manuals at the unit level of the organization 7. Rules – these are regulations that define specific action or nonaction; generally are included as part of the policy and procedure statements. Very rigid… ▪ Describe situations that allow only one choice of action ▪ The least flexible type of planning in the hierarchy ▪ There should be as few rules as possible in the organization ▪ Existing rules should be enforced to keep morale from breaking down and to keep the organizational structure intact ▪ Examples: Limits on number of visiters per pt, no smoking in the facility

Time Management in Provision of Care

Health care is in a new era, a new paradigm of thinking concerning the pt – must implement the best use of resources and time management… Time Management Steps –

1. Plan and establish priorities  allow adequate time for planning. THIS IS THE MOST IMPORTANT STEP in good time management. Avoid priority setting traps… - Traps: o Responding to things as they happen – go in the direction where you need to go first; need to prioritize! Divide tasks up into 1)do now, 2)don’t do (delegate) 3) do later o “ Path of least resistance ” - Not delegating appropriately (don’t do everything yourself or you will get burnt out!) o “ Squeaky Wheel ” - Only going to the pt who is the loudest or most vocal, or the pt who is always on the call light – need to go to the pt who is the most critical/unstable, highest priority! Determine what is a true priority! o Default – taking on tasks that no one else will do; o Inspiration – waiting until you become “inspired” to do something; understand that attention must be given to tasks that you may not necessarily want to do o Internal time wasters – procrastination, poor planning, inability to say no, management by crisis, haste, indecisiveness o Avoid assuming that it is easiest to do the job yourself – you need to delegate! **2. Complete the highest priority task first
2. Finish one task before beginning another
3. Reprioritize based on new info
4. Avoid procrastination!** All steps must be accomplished sequentially bc this is a cyclical process! HOW TO MANAGE YOUR TIME: ▪ Gather all supplies before beginning task ▪ Group activities that are in the same location; if you have walked a long distance down a hallway, attempt to do several things there before going back to the nurse’s station ▪ Use time estimates ▪ Take regularly scheduled breaks from work; they allow the worker to refresh both physically and mentally ▪ Deal with interruptions (i.e. avoid frequent sociallizing, don’t be too accessible)

▪ Document our nursing interventions as soon as possible – this decreases the risk of inaccuracies and incomplete documentation ▪ Strive to end the workday on time; Delegating appropriately to others and making sure that the workload for any given day is reasonable are two strategies that will accomplish this goal

Organizing Patient Care –

Choosing the most appropriate organizational mode to deliver patient care for each unit or orgainzation depends on:

• Skill and expertise of the staff
• Availability of the staff (esp RNs)  bc there are some things only RNs can do
• Economic resources of the organization
• Acuity of the pts
• Complexity of the tasks to be completed 1. Functional Method (Team Nursing grew out of this type of nursing method)
• Grew out of the need to provide care to a large number of patients  focuses on organizing and destributing tasks based on the competency and level of skill of the different nurses… o Trained nurses provided care that required high skill levels o Untrained workers with little skill performed many less complex tasks o They all worked side by side, each performing their assigned tasks
• The goal is efficient management of time, tasks, energy
• However, led to fragmented care and patients had to relate to many different people
• Still used in some settings Advantages: ▪ Efficient; many tasks can be completed in reasonable time frame ▪ Workers only do tasks they are educated to do and become very efficient in them  enhances the organizational skills of the worker ▪ Promotes autonomy Disadvantages: ▪ Care is fragmented rather than holistic bc emphasis is on the task, not the person ▪ Lack of continuity of care **2. Team Nursing **team leader knows all that is going on, brings it all together for the pt****
  • The team leader is in charge of the team and is responsible for providing direction to team members (i.e. Ancillary personnel collborate in providing care to a group of patients under the direction of a professional nurse) o For example, the team usually consists of a RN (or LPN) who would be Team Leader, a LPN and one or more CNAs o As Team Leader, the nurse is responsible for knowing the condition and needs of all patients assigned to the team and for communicating with members on the team o The Team Leader is ultimately responsible for assigning patients to each team member and is responsible for overseeing the activity of patients and team members
  • Each member of the team provides the level of care for which they are best prepared. The least skilled and experienced members care for the patients who requre the least complex care, and the most skilled and experienced members care for the sickest patients who require the most complex care. o This allows the team leader to shift, match and redistribute pt assignments to team members according to their level of education and expertise  the acutiy level of the pt influences the pt assigment

• Team nursing enables the team leader to supervise, coordinate and manage the care given to all the team’s patient’s for the assigned shift. The team leader then reports to the head nurse. o Team leader’s duties vary depending on the patient’s needs and the workload; these duties may include assisting the team members, giving direct personal care to patients, providing instruction and direction, and coordinating pt activities
• Team Nursing requires effective communication between the team leader and all the team members to be effective
• Associated with democratic leadership – the team shares responsibility and accountability collectively o The RN team leader oversees all care for a particular shift, makes assessments, and documents responses to care; o The LPN provides direct care by performing treatments and procedures, reports pt responses to the team leader o The CNA provides direct, personal care Advantages: ▪ Potential for team spirit ▪ Provides comprehensive care ▪ Each worker’s abilities are used to the fullest ▪ Promotes job satistfaction ▪ Decreases nonprofessional duties of registered nurses Disadvantages: ▪ Must allow time for team planning and communication ▪ All team members must work together or this approach is unsuccessful ▪ Team composition variews from day to day, can be confusing and distruptive and decreases continuity of care ▪ Insufficient planning can lead to blurred lines of responsibility, error and fragmented care ▪ Requires effective communication btw team members
• Things to consider when planning the pt assignment: o Time required to provide care to a pt o Complexity of care needed/acuity of pt o Knowledge level of ability of the staff person o Stability of the pt o RN is ultimately responsible for assessment, pt teaching, and evaluation  this cannot be delgated to others! **3. Primary Nursing

4. Case Management FACTORS THAT AFFECT NURSING CARE** When out working, things to keep in mind when providing care (the delivery of care). One is time management. Others include: 1. Communication – begins the moment 2 or more people become aware of each other’s presence. For effective communication to occur, the sender needs to make the message clear and the receiver needs to provide effective feedback... ▪ Nonverbal – o body language: checking watch, rolling eyes, shrugging shoulders, tapping foot, figiting, Facial expression, Tone, You cannot communicate the same way with patients as you would with your peers

▪ Be assertive, not aggressive – change a “you” message to an “I” message; ▪ Use SBAR as a communication tool ▪ The incongruence btw verbal and nonverbal messages is the most significant barrier to effective interpersonal communication  effective leaders should be congruent in their verbal/nonverbal communication so that followers are clear about the messages they receive.

2. Delegation – Effective delegation: ▪ Plan ahead ▪ Identify skill or educational level necessary to complete the job ▪ Identify the person best able for the job ▪ Set time lines ▪ Evaluate performance ▪ Reward appropriate completion of task Underdelegation – limits the managers control, prestigue or power; they may fear that delegation may cause resentment Overdelegation – poor time management or have feelings of insecurity and work the exceptionally competent employees harder What can be delegated??? ▪ Answering phone ▪ Transferring stable pts ▪ Cleaning up after procedure ▪ Ordering supplies ▪ Clerical tasks ▪ Stocking exam rooms ▪ Assisting with certain procedures.. ▪ Certain types of data collection (VS on stable pts, EKGs on stable pt – if it is routine) What cannot be delegated?? ▪ Any task that involves nursing judgment or sophisticated application of the nursing process (assessment, diagnosis, planning, implementation, evaluation) ▪ Initial assessment on new pts ▪ Assessment on unstable/potentially unstable pts (coming back from post-op, invasive procedures, etc.) ▪ Evaluation of wounds, treatment, effects of something, etc. ▪ Establishing plans of care ▪ Identifying pt needs ▪ Triage (determining who is the sickest or who you need to see first) ▪ Matters of confidentiality, counseling, disciplining Things to remember when you delegate: - You are responsible for what you delegate! - Match the task to the individual, experience level, ability – if it’s a new grad (RN), and blood has to be administered, a new grad can do it, but have a preceptor watch them bc they will need some supervison - Determine importance of task and legality – can the person legally perform the task? - Provide clear instruction on what is to be done, and monitor results – tell person clearly “ambulate the patient to the nurse’s station and back – if they become weak or dizzy, return them to bed” or “ambulate the pt in the room and return them to bed”, etc. - Praise and thank the person

3. Conflict – Any time 2 or more individuals work together, you will have conflict… everyone has opposing drives, needs or wishes which will conflict with the other’s.

Causes:

▪ Unclear roles – unsure what your true role is ; you may have been doing a task for a while, then someone else is hired to do what you’ve been doing for so long. Now you don’t know if you should still be doing what you’ve been doing for so long. Ex. You’ve been doing diabetic foot care for a long time, and a diabetic educator is hired. Or you’re away for a while and someone else is doing your job, and when you come back you’re not sure if you can start doing your job again. ▪ Desire for scarce resources – everyone wants the same thing; everyone wants the same holiday off, everyone wants money for a conference ▪ Distancing Mechanisms – basically, not being a team player … for some reason, someone chooses to distance themselves from others; someone is standoffish and wants to work alone. A particular staff person decides they aren’t going to socialize or participate in staff events. The other staff will view them as stuck up or unfriendly, they may not want to work with them or have their back; They are not a good team member… Remember as long as you are a team player and work well with others, you don’t necessarily have to participate in every type of social event ( but remember this could become a sort of “perceived conflict” ) ▪ Perceived or felt conflict – type of conflict that is in the mind of the person perceiving it ; a type of paranoia, you walk in a room and think that everyone is thinking about you; or a decision is made that you were against, and you take it personally. ▪ Unresolved conflict from another prior conflict – You and a nurse get into a disagreement about something (selling Avon), then later on both want to work the day shift. When one of them ends up getting the day shift  passive aggressive behavior. One asks the other to watch her patients, etc. etc. Goals of conflict – Win-Win-Everyone Gains Too little conflict – you will have organizational stasis (you do need a little conflict for change to happen) Too much conflict – reduced organizational effectiveness with eventual immobilization of the employees Conflict Resolution: ▪ Manage the conflict before it manages you ▪ Compromise  Esp common with scarce resources: Parties of equal power give up something they want; for example you have 3 or 4 nurses who want Christmas off. How do you delegate things so that everyone has equal opportunity? Some should get it off this year, some get it off next year… ▪ Communication problems – most common source of organizational conflict ▪ Follow the proper chain of command when conflict arises o Very important to follow the proper chain of command!!

ETHICAL ISSUES & DILEMMAS:

▪ Deological – Moral duty; doing what you know your moral duty is.. you know what your duty is as a nurse (take care of the pt)  so you would make judments based on this responsibility. It is process oriented. “do your moral duty” Doing your duty of care – not abandoning your patient on the job, caring for them according to the policy and your scope of practice. ▪ Beneficence – Principle of doing good; Doing actions that promote good and bring about a benefit to someone; out at a resturaunt and help someone who gets sick ▪ Nonmaleficence – the principle of doing no harm ; compliments beneficence; following policy with restraints, double check dose of a med

▪ Paternalism – A person makes a decision for someone else, acts as their “parent ”; the person believes that the decision maker knows more about the situation and knows what is best. It is a less than desireable principle; person who is about to smoke and the nurse hides the cigarette –-> be careful with this so that you don’t take away the pt’s autonomy ▪ Utilitarianism – ethical decisions re made according to the accomplishments of “ the greatest good for the gretest number of people”. It diminishes the needs of the individual for the needs of the larger group in society. If a drug has negative side effects to a sm number of people, but has benefits to most people, they wont pull it from the market, bc it is an overall “good” drug… ▪ Justice – Obligation to be FAIR ; Assumes that everything should be just, right and fair. An individual works hard to see that all personal behavior meets this criteria. ▪ Varacity – Obligation to tell the TRUTH. Using this princple makes the assumption others are telling the turth ▪ Fidelity – Keeping one’s PROMISES. Requires a high level of accountability ▪ Autonomy : freedom of choice or accepting the responsibility for one’s choices ; involves the right of self- determination (the employee has the choice to meet organizational expectations or be disciplined further) ▪ Respect for others: Highest level of performance of all ethical principles

PROFESSIONAL VALUES: Are guided by the ethical principles…!!!

▪ Asthetics : qualities of objects and people that provide satisfaction o Adapts the environment so that it is pleasing to the patient – move bedpans out of the way! o Creates a pleasant work environment for self and others o Presents self in a manner that promotes a positive image of nursing ▪ Altruism : concern for the welfare and well-being of others. In professional practice, altruism is reflected by the nurse’s concern for the welfare of pts, other nurses, and other healthcare providers. o Gives full attention to the pt when providing care – if the nurse leaves/abandons pt, if you believe in altruism, you should report this! This is a professional value that should guide your behavior (plays into deological (moral duty) and altruism (concern for pt)) o Assists other personnel in providing care when they are unable to do so o Expresses concern about social trends and issues that have implications for health care o Advocates for patients, particularly the most vulnerable o Takes risks on behalf of pts and colleagues o Mentors other professionals – you would mentor a student nurse ▪ Autonomy : the right to self-determination ; Professional practice reflects autonomy when the nurse respects pt’s rights to make decision sabout their health care o Plans care in a partnership w patients; o Honors the rights of pts and families to make decisions about health care o Provides info so that pts can make informed choices; also part of advocacy! ▪ Equality : having the same rights, privileges, status o Provides nursing care based on the pts needs irrespective of personal characteristics, ties into “respect for others” o Interacts wither other providers in a nondiscriminatory manner o Expresses ideas about the improvement of access to nursing and health care ▪ Freedom : Capacity to exercise choise o Honors individual’s right to refuse treatment o Supporst the rights of other providers to suggest alternatives to the plan of care o Encourges open discussion of controversial issues in the profession ▪ Human Dignity: respect for the inherent worth and uniqueness of individuals ; reflected with the nurse values, respects all patients and colleagues o Protects pt privacy – log out of computer! o Addresses others as they prefer to be addressed o Maintains/preserves the confidentiality of pts and healthcare providers o Treats others with respect regardless of background

o Provides culturally competent and sensitive care o Designs care with sensitivity to individual pt needs ▪ Integrity/Truth o Provides honest info to pts and the public o Documents care accurately and honestly o Seeks to remedy errors made by self and others o Demonstrates accountability for own actions o Obtains sufficient data to make sound judgments before reporting infractions of organizational policies o Participates in professional efforts to protect the public from misinformation about nursing – if you see someone (Dr., nurse) documenting false information, follow up on this! ▪ Justice : Upholding of moral/legal principles o Acts as healthcare advocate o Allocates rescources fairly o Reports incompetent, unethical, illegal practice objectively and factually – if working with someone who is chemically impaired, what do you do? ▪ Legally, you have to report it – legal obligation; moral obligation (based on nonmaleficence/beneficence), professional values of altruism  not supposed to confront them if they are impaired because then it gets into “he said, she said”, etc.  you should report to management PATIENT BILL OF RIGHTS: ▪ Right to considerate and respectful care – human dignity ▪ Right to make decisions about care – Freedom/Autonomy ▪ Right to refuse care – autonomy, freedom ▪ Advanced Directives – Living Will – (writes what you would want to happen) or Power of Attourney – (appoints somoent to make decisions for you, handle your affairs): in the event that you are unable to make decisions for yourself ▪ Right to Privacy ▪ Right to Safe & Effective Care – altruism, beneficence, nonmaleficience ▪ Right to Informed Consent – autonomy ADVOCACY: Involves a leadership role, provide necessary info to make decision, allow pt to make the decision… Advocate for subordinates, patients & their families, and the profession of nursing! How do you act on behalf of someone?

• when you provide informed consent
• provide pre-op teaching
• teaching pt risk factors - for example, for cardiac disorders (lifestyle changes, diet, etc.) – up to pt to make the changes, but you provide the info! DOCUMENTATION: ▪ Writing needs to be legible if on paper ▪ Must be consistent & accurate, avoid discrepancies ▪ Use only approved abbreviations ▪ Don’t chart ahead of time – this is fraud! NURSE PRACTICE ACT: ▪ Defines legal scope of nursing practice in every state  defines the duties and functions the nurse can perform

▪ Defines the responsiblities and authorities of the state board of nursing – it is the statuatory law that governs nursing ▪ Defines important terms, activities in nursing including legal requirements and titles for RNs and LPNs; Determines the legal titles and abbreviations nurses may use ▪ Sets the educational qualifications and other requirements for licensure ▪ Provides for disciplinary action of licensees for certain causes ▪ Directs the state board of nursing in establishing criteria for licensure ▪ Is the most important statuatory law affecting nurses ▪ Est in each state and is revised from time to time to keep up with new developments in health care and changes in nursing practice RN Role: ➢ Manage the care of patients with basic as well as complex care ➢ Manage complex situations (those situations that the pt’s clinical condition is not predictable and medical or nursing orders are likely to involve continuous change) ➢ Assessment, planning, implementation, evaluation and/or teaching of nursing care is ultimately the responsibility of the RN ➢ Oversee and coordinate nursing care ➢ Pathways to becoming the RN include: diploma, associate degree, and bccalaureate degree LPN Role: ➢ Scope of practice focuses on meeting basic needs in hospitals, long-term care, and home care ➢ Take care of stalbe pts with predictable outcomes ➢ Must practice under the supervision of a DR or registered nurse ➢ Must be able to recognize and report change in pt status ➢ Assist with the following: data collection, planning strategies for pt care, implementing nursing interventions, and eval of pt response ➢ Administer meds (varies with educational background and nurse practice act) safely ➢ Role focuses on: technical skills, general knowledge, judgment needed to provide basic care to pts with commonly occuring medical conditions ➢ Practical Nursing program – typically lasts 12 months State Board of Nursing:

• Actions, responsiblities and authorities are defined by the NURSE PRACTICE ACT
• the BON are responsible for enforcing the nurse practice act For example, they: o Approve students to take licence exam o Deny, suspend or revoke license o Can disciplin a licensee or deny an application for licensure
  LICENSURE: ▪ Graduate is eligible to apply to take national exam after they have successfully met the requirements from an approved school of nursing – granted state by state ▪ License must be renewed q 2 yrs  in some states, continuing ed is required to maintain license o Complete 30 hrs of continuing ed o Verification of competency of hours on board approved form ▪ License defines only minimum competency to be nurse – this is how it safeguards the public ▪ Licence can be denied, revoked or suspended for professional misconduct: o Incompetency o Negligence o Chemical impairment o Criminal action

CODE OF ETHICS:

Set of principles est by a profession to guide the individual practitioner’s conduct. Every profession has a code like this to guide behavior… “the nurse provides service for respect for human dignity, safeguards a pt’s right to privacy, safeguards the pt from unsafe, illegal or incompetent practice, assumes responsibiility for actions and knows when to seek consultation or assistance from others… Etc.” STANDARDS OF CARE: minimum level of expertise that may be delivered to the patient! ▪ Each nurse is responsible for following standards of care for their particular area of practice ▪ Found in the state nurse practice act, professional organizations federal agency guidelines and regulations, hospital policy and procedure manual, nurse’s job descriptions POLICIES AND PROCEDURES: NEGLIGENCE Conduct which falls below the standards of care that has been established for others – failure to do something that a reasonably prudent person WOULD do; or doing something that a reasonably person WOULD NOT do! ▪ For example, restraints: supposed to be done q2hrs, anything less than that falls below the standards of care. This would be an act of omission – not doing something a prudent person would do! ▪ If you went in at the wrong time, act of omission  you need to delegate the act ▪ If you are working with 2 patients in the same room, and you end up giving the wrong med to the wrong patient  act of commission to the pt who received the med, act of omission to the pt who didn’t receive the right med MALPRACTICE Elements of proving malpractice:

1. Duty – standards of care; prove that there was an obligation to do care (the duty is the standard of care – the care that the pt is entitled to)
2. Breach of Duty – negligence happened– did the action fell below this standard of care; was there an act of omission or comission???
3. Foreseeability – is there prior knowledge that you should know that if you don’t properly monitor restraints, it can cause harm to the pt?
4. Causation – did your action cause the harm to the patient? This is the hardest one to prove.
5. Injury – Did actual harm come to the pt?
6. Damages – what is awarded, money or whatever ▪ Ex. Med is due at 6am, but the dose is missing and it’s now 8:30am – breach of duty (act of omission) ▪ Pt then has a seizure later that day, then hit their head – injury ▪ Now looking to see if pt’s seizure is caused by the late med – causasion ▪ Administer dose of Morphine IM 8mg, but then you see it was supposed to be 6mg – breach of duty (comission) ▪ Dr ordered a dose of med that’s unsafe, it drops BP and it affects seizures and the pt’s apical pulse is 59, what should you do? Go up chain of command You tell the doctor, but the doctor tells you to give anyway.  you tell the charge nurse. If the charge nurse tells you to give anyway, continue to go up chain of command to supervisor! Should get own malpractice insurance in case you provide advice to anyone – you will have backup PROFESSIONAL ORGANIZATIONS: ▪ Should you be a member? o Allows nurses to remain active in decision making process that affects the profession

o Allows networking, exposure to opportunites o Scholarships o Nurses can stay connected with current issues and practice o However, does require some fees which can be very expensive ▪ Nursing and it’s future – a paradigm shift is needed : o LPNs can be charge nurses and leaders o Nurse managers are looking for new grads that can critically think o Work on maintaining a patient load – need to be able to take care of multiple patients!

▪ HIPAA – don’t discuss private info in non-private places, pts have right to request their info