Nursing Exam Review: Delegation, Prioritization, and Change Management, Exams of Advanced Education

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2024 NR 465 FINAL EXAM WITH

CORRECT ANSWERS

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Delegation - CORRECT-ANSWERS· Reassigning of responsibility for the performance of a job from one person to another o Direct- usually is verbal direction, RN decides which staff member can perform a specific task o Indirect- contained in approved listing of tasks established by an institution; permitted tasks mat vary from institution to institution (ex: vital signs, blood sugar checks as an aid) Delegation vs. Supervision - CORRECT-ANSWERS- Supervision is usually more direct than delegation

• Requires directly overseeing the work and performance of others and includes checking in with individuals during the day
• May entail delegation of tasks and activities (nursing manager performs both) Elements of a lawsuit malpractice/negligence - CORRECT-ANSWERS- Duty- to patient to provide and follow acceptable standard of care
• Brach- nurse failed to follow acceptable standard of care
• Case- the failure to follow acceptable SOC caused the injury being claimed
• Harm or injury- patient suffered harm as a result of the breach of care Boards of Nursing - CORRECT-ANSWERS- Administer the rules of the Nurse Practice Act
• Authority to regulate standards
• With the expanded role of nursing, it is important to clarify the distinction between nursing & medicine OBN Mission - CORRECT-ANSWERS- Actively safeguard the health of the public through effective regulation of nursing care Public Protection - CORRECT-ANSWERS- Efficiently license the nursing workforce and remove dangerous practitioners from the practice in a timely manner to protect Ohio patients
• Regulation of over 300,000 licenses and certificates
• Public protection if critical, as nursing touches virtually every citizen of Ohio

Nursing Practice - CORRECT-ANSWERS- Address pertinent nursing regulatory issues and requirements for licensees and certificate holders and provide greater clarity about the requirements to those regulated by the Board and to the general public · Average of 297 practice questions per month · Articles in Momentum and FAQs · Interpretive Guidelines to provide practice guidance Key takeaways from Dr. Sharpnack's presentation - CORRECT-ANSWERS- Be aware and understand your Nurse Practice Act in your state

• Familiarize yourself with your institution's standards of care
• Understand the most common causes of negligence/malpractice
• Understand the NPA requirements for moral turpitude
• Adhere to the Code of Ethics
• Document accurately & appropriately Redesigning the workforce - CORRECT-ANSWERS- Nursing shortage had led to work redesign · Provider shortages · Tech shortages
• Improved efficiencies in care delivery
• Designing new roles and interprofessional teams Lewin's "Force Field" Change Model - CORRECT-ANSWERS1. Unfreeze · Motivation for a chance occurs · Person becomes aware for the need for change

2. Change · Change process actually occurs · Status quo no longer works
3. Refreeze · Change is integrated and stabilized in practice · Change is sustained Kotter's 8 Step Process for Change - CORRECT-ANSWERS1. Creating a sense of urgency · Help get others involved and see that change is necessary
4. Creating a guiding coalition · Need a group of people who have enough power to implement the change
5. Developing a change vision · How is the new change going to be different from the past?
6. Communicating the vision for buy-in · Ensuring that as many people as possible understand and accept the vision

5. Empowering a broad-based action · Removing as many barriers as possible and unleashing people to do their best work
6. Generating short term win's · Celebrate little successes and generate short term win's to keep the long term goal moving forward
7. Don't let up · Consolidating gains and producing more change
8. Make it stick · Anchoring new approaches in the culture for sustained change Planning for changes... are we ready for change? - CORRECT-ANSWERS1. Driving forces
9. SWOT analysis
10. Readiness for change
11. Resistance to change Driving forces - CORRECT-ANSWERS- Forces operating for a change or against a change (Lewin) · For change are driving forces · Against change are restraining forces Examples of driving forces (facilitators) - CORRECT-ANSWERS- Pay raises

• Recognition
• Increasing quality
• Increase safety
• Reducing workload
• Desire to please Restraining forces (barriers) - CORRECT-ANSWERS- Fear of unknown
• Fear of loss
• Decrease quality
• Safety concerns SWOT analysis - CORRECT-ANSWERS- Internal vs. external · Strengths · Weaknesses · Opportunities · threats Readiness for change - CORRECT-ANSWERS- Means management and staff are ready to take on the challenge and invest in the effort (have "buy-in")

· They see the need for change...leadership/followership in place to organize change · Driving forces are greater than the restraining Forces (Barriers are addressed) · Facilitators are Change Champions · Empathy from Change Agents How to manage resistance to change - CORRECT-ANSWERS- Assess Readiness for Change

• Driving Forces are greater than the restraining Forces
• Listen with empathy
• Remove barriers to change
• Use change models to facilitate the change
• Communicate, communicate, communicate
• Emphasize the positives
• Celebrate small successes
• Clarify often and provide feedback Four phases of planned change- things to contemplate - CORRECT- ANSWERS1. Design the change

2. Plan the implementation
3. Implement the change
4. Integrate the change Designing the change - CORRECT-ANSWERS- What is the purpose?

• Is the change necessary?
• Is the change the right thing to do?
• Is it the right time?
• Is the change feasible?
• Is there a better way? Planning the change - CORRECT-ANSWERS- What are the driving forces/restraining forces? · Force Field Analysis
• Who are the supports/resistors?
• Why is their resistance?
• Is the resistance justified?
• What can be done to prevent or overcome resistance? Implementing the change - CORRECT-ANSWERS- What is the magnitude?
• What is the complexity?
• What is the pace?
• What is the current stress level? Integrating the change - CORRECT-ANSWERS- Is the change integrated into every day operations?

• Are people comfortable with it?
• Is it well accepted?
• What else needs to be done?
• How is it going? Vicarious Liability, Respondent Superior - CORRECT-ANSWERS· Healthcare organizations are responsible for the acts of its employees · Failure to delegate/supervise within acceptable standards may be considered malpractice Considerations for Delegation - CORRECT-ANSWERS· Predictability of outcome= if patient's response to an activity cannot be known with some certainty it should not be delegation · Potential for harm= how much risk is involved to the patient due to this task · Complexity of task= the greater the complexity of this task the less likely it should be delegated · Need for assessment/problem solving= if the problem involves a high degree of problem solving it should be done by the RN · Level of patient interaction= don't delegate activities that will interfere with the nurse/patient relationship · Cannot delegate= nursing process (think ADPIE), education, tasks that require clinical judgement/assessment Understanding the Role of the LPN - CORRECT-ANSWERS· Care for stable patients · Collection of patient data and report to RN · Reinforcement of RN education · Medication administration (must be IV certified in OH, can only administer certain IV drugs) · Basic dressing changes · Administration of enteral feeds LPNs and IV medications - CORRECT-ANSWERS· An LPN cannot administer or maintain blood or blood components, solutions for total parenteral nutrition, cancer therapeutic medications, medications administered through any other line that does not run through a peripheral vein including a central venous line and arterial line, and an IV piggyback infusion · An LPN is not able to discontinue medication running through any other line that does run through the peripheral vein · And LPN cannot begin or stop a peripherally inserted central catheter· An LPN cannot program or set any function of a patient-controlled analgesic (PCA) pump

Priority Setting - CORRECT-ANSWERS· A complex step in the decision-making process · Used to rank patient needs, determine order of nursing activities, and manage resources · "Critical thinking" supplies the logic within this process What is priority? - CORRECT-ANSWERS· Something that is more important than anything else at a given time · Could be related to a patient, team, or organization · These are principles that assist in arranging activities based on urgency, importance, significance, or preference Principles of Prioritization- systemic before local - CORRECT-ANSWERSo Something affecting the whole body vs. something affecting a specific area of the body Principles of Prioritization- acute before chronic - CORRECT-ANSWERSo Something that develops very suddenly vs. something that is chronic and life-long Principles of Prioritization- actual before potential problems - CORRECT- ANSWERSo Somebody who is having chest pain with EKG changes vs. somebody who is having chest pain without EKG changes Principles of Prioritization- trending vs. transient - CORRECT-ANSWERSo Dropping BP vs. BP that is all over the place (drops then bounces back) Principles of Prioritization- listen carefully (do not assume) - CORRECT- ANSWERSo If a patient says they are going to die today, then pay attention because patients often have a sense of feeling Principles of Prioritization- recognize medical emergencies vs. expected patient findings - CORRECT-ANSWERSo An actual medical emergency vs. someone with a lot of problems an it is expected for them to present that way Principles of Prioritization- apply clinical knowledge to priority setting - CORRECT-ANSWERSo How to prioritize your patients, who to see first, etc. Priority setting- high priority situations - CORRECT-ANSWERS· Life- threatening (ABCs) o Airway difficulties o Cardiac changes o Tissue perfusion changes o Alterations in fluid volume · Threats to patient safety

· Situations in which patient and anxiety relief is a concern Priority setting- low priority situations - CORRECT-ANSWERS· Nursing diagnosis involves problems that can usually be resolved with minimal interventions· Have little potential to cause significant dysfunction· No major effect on the person Prioritizing with the nursing process - CORRECT-ANSWERS1. Assessment- · Always done first · Allows for addressing anything emergent · Includes background information

2. Analysis (diagnosis)- · Goals and measurable outcomes; priorities established based on patient need
3. Plan- · Nursing activities appropriate for the specified analysis must be implemented
4. Implementation- · Established priorities and listed activities must be implemented
5. Evaluation- · Reevaluate the plan as the patient status or situation changes · Assess the patient progress toward the outcome criteria estimated in the plan of care · Monitor for improvement or deterioration Prioritization pitfalls to avoid - CORRECT-ANSWERS- Failure to identify tasks that cannot be delayed without serious consequences

• Inadequate assessment and evaluation of patient needs
• Acceptance of others' priorities without assessing all the variables
• Performance of tasks with a "first identified, first completed" approach
• Completion of the easiest task first Quality - CORRECT-ANSWERS· "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" · Safety is the foundation of quality care Safety - CORRECT-ANSWERS· "The absence of preventable harm to a patient during the process of health care" o KSA's o Leadership

o Systems thinking= making sense of something by looking at the whole instead of splitting it into parts; seek to see the big picture o Just culture= A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control; more security around the decisions you make. It means recognizing that humans aren't perfect and that when you make a mistake you are going to be embraced in the process of trying to understand why the error was made rather than being punished for your mistake o Latent error= a process or systems driven error (ex: IV pump fails and delivers wrong dose of medication to a patient), active error= my failure (ex: programming dosage wrongfully on IV pump) Patient Safety - CORRECT-ANSWERS· Freedom from accidental injury or preventable injuries caused by medical care · Involves establishing operational systems and processes that minimize the likelihood of error and maximize the likelihood of intercepting errors when they occur Culture of patient safety - CORRECT-ANSWERS· Encompasses attitudes, shared core values, goals, and behaviors related to patient safety and the promotion of patient centric, safe care · Non-punitive (but accountable) responses to adverse events and errors HRO's - CORRECT-ANSWERS· Sustain excellent safety records despite operating in very complex and hazardous environments where there is high risk of injury (ex: airlines) Regulatory Bodies- TJC - CORRECT-ANSWERS- National Patient Safety Goals

• Sentinel Event (Never Event) Reporting o Events that are preventable errors, preventable injuries, or preventable infections. Effects are significant. Centers for Medicare & Medicaid Services (CMS) - CORRECT-ANSWERSo Rulings in 2007 and 2011 to deny reimbursement to hospitals if a sentinel event occurs o Followed by private insurers State Department of Health - CORRECT-ANSWERSo Provides protection for the public through licensing based on minimum health & safety standards established by regulations & rules o ODH Types of Errors - CORRECT-ANSWERS· Near miss- a hazard or incident that might have resulted in harm but the problem did not reach the patient because of timely intervention by healthcare providers, the patient, or the patient's family

o Example- a nurse realizes she grabbed the wrong medication while going through her 5 rights of medication administration · Adverse event- harm from medical care rather than an underlying disease o Example- allergic bronchospasm from a medication requires treatment in the ED · Accident- any unexpected or unplanned event that may result in death, injury, or property · Sentinel event Quality & Safety Education in Nursing (QSEN) - CORRECT-ANSWERS· Nationwide effort to establish quality and safety competencies to integrate in curriculum o Quality improvement o Safety o Teamwork & collaboration o Patient centered care o Evidence based practice o Informatics Benchmarking - CORRECT-ANSWERS· A method to measure quality and/or safety comparing current results or outputs with an accepted standard · Can look at structure, process, or outcome Benchmarking- structure - CORRECT-ANSWERSStructural measures give consumers a sense of a health care provider's capacity, systems, and processes to provide high-quality care Benchmarking- process - CORRECT-ANSWERS-Process measures indicate what a provider does to maintain or improve health, either for healthy people or for those diagnosed with a healthcare condition -Can inform consumers about medical care they may expect to receive for a given condition or disease. The majority of health care quality measures used for public reporting are process measures Benchamarking- outcome - CORRECT-ANSWERS-Reflects the impact of health care services or interventions on the health status of patients -Represents the "gold standard" in measuring quality Leapfrog & NQF Recommendations in Management of "Never" Events - CORRECT-ANSWERS· Apologize to the patient · Report the event (transparency) · Perform a root cause analysis · Waive costs directly related to the event

Apology following an adverse event - CORRECT-ANSWERS1. Care for the patient

2. Communicate with the patient
3. Report the event with appropriate parties
4. Document (facts only) in medical record Incident reports and charting - CORRECT-ANSWERS· Only chart the objective facts · Never document that an incident report was completed. This is an institutional process/policy, not part of the medical chart Human error (remember just culture/systems thinking) - CORRECT- ANSWERS· Not the cause of events · Symptom of deeper troubles in the system · Not the conclusion of an investigation, it is the beginning · Events are the result of multiple causes Swiss cheese model - CORRECT-ANSWERS· Error o All your system process errors will line up and you will have a major error · Near miss o When the first system process error is caught by the next and prevents more from occurring The gap - CORRECT-ANSWERS· What is happening compared to what should be happening Continuous Quality Improvement (CQI) - CORRECT-ANSWERS- Overarching philosophy that focuses on applying scientific methods to improve all aspects of care on a going basis o CQI Methods and Tools-

• CQI initiative should address structure, process, and outcomes o Some CQI models- -IHI Quality Improvement Project Charter
• Six Sigma
• LEAN Six Sigma IHI Model for Improvement - CORRECT-ANSWERS· Simple, straightforward strategy · Gradual, incremental, sustained approach · Focus on developing goals for improvement and team building · Strategies are based on the plan-do-study-act (PDSA) cycle IHI Model for Improvement Steps - CORRECT-ANSWERS- Form a team
• Establish goals
• Determine measures

• Select the change
• Test the change
• Implement the change
• Spread the change Plan-Do-Study-Act - CORRECT-ANSWERS1. Plan- select goals, predict, plan data collection

2. Do- test the plan, document problems, reassess and revise
3. Study- complete data analysis, review lessons, decide action
4. Act- implement, evaluate, decide next cycle Maslow's Hierarchy of Needs - CORRECT-ANSWERS(level 1) Physiological Needs (level 2) Safety needs (level 3) Social needs & love/belonging (level 4)Esteem needs (level 5) Self Actualization The 5 Rights of Delegation - CORRECT-ANSWERS1. Right person- task must be within the person's scope of practice & the person must have the right competence and training
5. Right task- identify what tasks can be delegated. Normally repetitive, requires little supervision and is non-invasive for the patient
6. Right circumstance- assess the health status and complexity of care required by patient and match with skill of worker. Also, must consider the workload of the team member
7. Right direction/communication- communicate either orally or in writing, data needs to be collected, specific tasks, communication of unusual findings, client specific data and when to complete task and/or report back to RN
8. Right supervision- provide direct or indirect supervision, monitor performance, and provide constructive feedback. Assess the patient and evaluate whether their needs were met. Identify needs for quality improvement and/or additional training Why focus on communication? - CORRECT-ANSWERS- Root cause in almost every sentinel event reported to TCJ Sentinel Event Database Communication Process - CORRECT-ANSWERS- Sender

• Receiver
• Message
• Mode of Transmission (verbal-written-nonverbal)
• Internal Climate (values-feelings-stress)
• External Climate (organizational culture-timing-power/status) Channels of Communication- Verbal - CORRECT-ANSWERS· Uses words · Written

· Spoken · Language is mutually understood · Able to control the communication Channels of Communication- Non-verbal - CORRECT-ANSWERS· Sets of behaviors · Conveys messages without words · Unconscious · More difficult to control Communication Direction- Downward - CORRECT-ANSWERS- Starts at the CEO and moves down throughout the rest of the organization for everyone else to hear Communication Direction- Upward - CORRECT-ANSWERS- A nurse is concerned about something and talks to her manager about it Communication Direction- Lateral & Horitzontal - CORRECT-ANSWERS- Two nurses discuss a matter (at the same level of power) Communication Direction- Diagonal - CORRECT-ANSWERS- At the same level of power, but have different functions on the unit

• Something happens on the ICU and everyone gathers to discuss the matter; nurses, RT, OT, PT, etc. Three Styles of Communication- Aggressive - CORRECT-ANSWERS- Loud, heated, arguing
• Physically violent encounters
• Blaming, name-calling, and verbal insults Three Styles of Communication- Assertive - CORRECT-ANSWERS- Expressing feelings without being nasty or overbearing
• Acknowledging emotions but staying open to discussion · "I am very upset ri ght now, but I am open to hear your side of the story"
• Expressing self and giving others the change to express themselves equally
• Use "I" statements to defuse arguments Three Styles of Communication- Passive - CORRECT-ANSWERS- Concealing one's own feelings
• Denying one's own anger
• Feeling that one has no right to express anger
• Avoiding arguments Ohio Board of Nursing (OBN) Members - CORRECT-ANSWERS- 13 members total · 8 RNs, 4 LPNs, and 1 consumer member

· Of these 8 RNs, 2 must be authorized to practice as APRNs · The consumer member who is not a nurse, is appointed to represent the interest of consumers of healthcare · The Board elects one of its registered nurse members to serve as the supervising member for disciplinary matters Law - CORRECT-ANSWERS- Principles and regulations established in society by some authority and enforced by judicial decision

• Enacted to preserve public welfare and manage relationships (such as contracts) within society) Sources of Law- Statutory law - CORRECT-ANSWERSNurse Practice Acts Sources of Law- Regulatory law/administrative law - CORRECT- ANSWERSgoverns the activities of administrative agencies of government Sources of Law- Common law (A.K.A case law or precedent) - CORRECT- ANSWERSdeveloped by judges through decisions of court Sources of Law- Criminal law - CORRECT-ANSWERSoffenses against the state- felony & misdemeanor Sources of Law- Civil law - CORRECT-ANSWERSusually involves the violation of one person's rights against another's right's- tort-intentional and unintentional and Quasi-intentional tort, negligence & malpractice Ethics - CORRECT-ANSWERS- Deals with values related to human conduct
• Issues of "right" and "wrong" associated with actions
• Concerned with motives & ends of actions
• Legal and ethical issues often overlap and complement or conflict in nursing practice Healthcare ethical decision making - CORRECT-ANSWERS- Makes focuses on the right and just thing to do
• Guided by four principles= autonomy, beneficence, justice, and veracity Nursing standards - CORRECT-ANSWERS- Established as guidelines for the profession to ensure quality of care Used as criteria to determine whether appropriate care has been delivered Types of standards - CORRECT-ANSWERS1. Internal standards

2. Organizational standards
3. Accepted state and national standards
4. Nurse practice acts
5. Patient care partnerships

Uses of standards in nursing negligence of malpractice - CORRECT- ANSWERS- Standards are used as a guide

• State, local, or national standards
• Institutional policies that alter or adhere to the nursing standards of care
• Expert opinions on appropriate standards of care
• Available literature substantiating current standards
• Refuse to practice beyond legal scope double effect concept - CORRECT-ANSWERS- Nonmaleficence- one should do no harm · Double effect is a concept that supports interventions that may be harmful o Four conditions necessary-

1. The action must be "good"
2. The practitioner must intend only a good effect
3. An undesired effect must not be the means of attaining the good effect
4. There is a proportional balance between the desirable & undesirable effect of the action Malpractice - CORRECT-ANSWERS- The failure of a professional person to act in accordance with the prevailing professional standards or failure to foresee consequences that a professional person, having the necessary skills and education, should foresee