Nursing Leadership and Management, Exams of Nursing

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Engaging Nurses in Unit-Level

Assessment and Planning for

Improved Patient Outcomes

Leading, Managing, and Following

Complexity Theory and Change Implementation

When implementing changes to better meet the needs of older adult patients, the best approach according to complexity principles is to: Engage staff at all levels in the decision-making process, as complexity theory suggests that decision-making occurs throughout the system, not just in a hierarchical manner.

Maslow's Need Hierarchy and Nurse Motivation

To best satisfy the needs of a nurse who must frequently care for his wife undergoing cancer treatment, the manager should: Work with the nurse, staffing office, and other nurses to arrange his scheduled days off around his wife's treatments, meeting the nurse's need for affiliation while also addressing the needs of staff and patients.

Conflict Resolution

When a grievance mediation session is not resolving the conflict, the best course of action is to:

Ask each party to examine their own motives and issues in the conflict, as this addresses the interests and involvement of all participants.

If the manager and staff nurse are unable to reach a resolution after a second negotiation session, the appropriate next step is to:

Elevate the negotiation to the next manager, one level above, as this allows for additional training and facilitation of conflict resolution.

Implementing Change and Motivating Staff

The best initial strategy for implementing a change to add RN assistants, when the RN staff are resistant, is to:

Explore the values and feelings of the RN group in relationship to this change, as this recognizes that values are powerful forces influencing acceptance of change.

A strategy that might motivate LPNs and nursing assistants and lead to greater job satisfaction is to:

Allow the LPNs and NAs greater decision-making power within the scope of their positions, as this addresses motivator factors like recognition and satisfaction with work.

An appropriate action to motivate staff would be to:

Implement a model of shared governance, as this aligns with complexity theory principles of decision-making occurring throughout the system.

Emotional Intelligence and Leadership

The charge nurse's behavior that best illustrates refined leadership skills in an emotionally intelligent practitioner is to:

Reflect to gain insight into how the situation could be handled differently in the future, demonstrating the ability to step outside the situation and manage emotions effectively.

The most appropriate behavior for the staff development coordinator, when hearing RNs complain about a required competency program, is to:

Facilitate a meeting so nurses can articulate their values and concerns about the competency program, engaging staff through sharing of concerns and ideas.

Followership and Evidence-Based Practice

Effective leadership in implementing an evidence-based approach to teach ostomy self-management skills is demonstrated by:

An RN who is already familiar with the new approach volunteering to take the lead in mentoring and teaching others how to implement it, promoting good clinical decisions and use of resources.

The statement that leadership and management belong only to the unit manager, and not the staff nurse, is not true. Nursing staff at all levels are expected to demonstrate leadership and management skills.

Leading and Managing in Nursing

The New Graduate Nurse

The new graduate would benefit from further understanding of her role as a professional, whose influence may affect the decision making of patients, colleagues, and other professionals. The new graduate has been influenced by nurse leaders and managers who leave for other positions, and the general perception is that nurse leaders and managers are not satisfied in their jobs.

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Care Coordination and Leadership

Care coordination that involves the intersection of individual, family, and community-based needs requires that nurses have self-confidence, knowledge of organizations and health systems, and an inner desire to lead and manage. There is often a view that leadership is isolated to those holding managerial positions, and that a direct care nurse is subject to following by adhering to the direction of others. Such views fail to acknowledge that to be a nurse requires each licensed individual to lead, manage, and follow when practicing at the point-of-care and beyond.

Charge Nurse Scenario

The charge nurse walks into Mr. Smith's room and finds him yelling at the LPN. The charge nurse determines that he has not slept for three nights because of unrelieved pain levels. The LPN is very upset and calls Mr. Smith an "ugly, old man." The charge nurse acknowledges the LPN's feelings and concerns and then suggests that Mr. Smith's behavior was aggressive but was related to lack of sleep and to pain. The charge nurse asks, "Can you, together with Mr. Smith, determine triggers for the pain and effective approaches to controlling his pain?" This situation is an example of leadership behavior.

Nurse Manager's Assessment of Dying Patient

After assessing an older adult patient in long-term care who has been slowly deteriorating for weeks, the nurse manager calls the family and asks them to come in, as the patient is dying. The nurse manager is employing knowledge and experience in determining that the patient is dying, because the course of dying is not standardized and cannot be determined by clinical pathways.

Chart Audit and Unit Manager's Response

Chart audits have revealed significant omissions of data that could have legal and financial guideline ramifications. The unit manager meets with the staff to discuss audit findings and to find approaches that will address the gaps in charting and achieve desired goals. This process of guiding others to meet established goals, outcomes, and procedures is management.

Nurse's Role in Family Dynamics

A family is keeping vigil at a critically ill patient's bedside. The nurse speaks with the distant family members and states she is referring them to the hospital social worker, whose role is to work with family in this situation. The nurse is assuming the role of a manager, concerned with managing and coordinating resources to achieve outcomes in accordance with established clinical processes.

Nurse's Role in Advocating for Patient

A family is keeping vigil at a critically ill patient's bedside. The nurse approaches the unit manager with concern over the family dynamics for the patient concerned there are patient-family conflicts based on patient's wishes. The nurse suggests that the patient's provider may need to discuss the treatment plan with the family. The unit manager states he will arrange a discussion with the patient's provider and ask the nurse to support the provider's decisions. In this situation, the role of the nurse is that of a follower, bringing concerns to the manager and accepting the direction given.

Nurse Manager's Role in Addressing Staff Concerns

The manager calls the staff together to assess a situation in which the family of a seriously ill patient is anxious and is absorbing a great deal of staff time in consultation, discussion, and questioning of treatment decisions. The manager is demonstrating leadership by providing and communicating vision and direction based on evidence and experience, and engaging others in decision making that moves them toward the vision with a reasonable level of risk taking.

Nurse Manager's Self-Awareness

The manager of a unit is finding it difficult to work with a new graduate nurse. After reflection and discussion with others, the manager recognizes that she feels threatened by his behavior and that the new nurse is trying to establish his own role on the unit, not challenging her. The manager is demonstrating self-awareness, a component of emotional intelligence, to identify the resolve to self-conflict in this situation.

Transformational Leadership in Nursing Education

As the head of a nursing program, you consistently invite the ideas of your team about innovations in teaching, community partnerships, and curriculum design and invite participation in decisions. Many of these ideas have been implemented successfully, and your staff members are keen to try on other ideas. This is an example of transformational leadership, which involves attending to the needs and motives of followers, resulting in creativity, improvement, and employee development.

Complexity Theory and Leadership

According to complexity theory, the manager encourages all staff members to see themselves as having a role in decision making and quality care, with the manager not seen in a hierarchal relationship to other team members. This view of the role is consistent with complexity theory, which involves envisioning each member of the team involved in decision making, management, and leadership.

Complexity Theory and Measurement

According to complexity theory, the focus of measurement would be on staff morale and budgets, as one cannot ignore objective data or nonmeasurable data, as both inform decisions.

Complexity Theory and Mission Statement

When developing a unit mission statement, the suggestion by the manager for the unit mission to be derived from the organization mission is considered a management task, as leadership tags, which are similar to values, reflect the patient-centered philosophies and values-driven characteristics that define an organization and give it personality.

Conflict Resolution

In a dispute between an RN and an LPN that begins to affect other staff members, the initial step in conflict resolution should have involved an expedient response to the issues and putting a focus on the issues involved in the dispute between the LPN and RN through negotiation involving the two parties, before the dispute involved others.

Transitioning to a Team Nursing Model

Addressing Staff Concerns

The unit is shifting from a primary nursing model to a team nursing model in an effort to contain costs. The staff members are upset about this change and have requested a meeting to discuss the new model.

When addressing the staff's concerns related to a reduction in professional autonomy, the initial response by the manager should be to:

a. Acknowledge the loss. The manager should recognize that the change to a team nursing model represents a significant shift in how the staff members have been practicing and that this change can be unsettling. Acknowledging their concerns and the potential loss of autonomy is an important first step.

b. Explain the reasons for the change, emphasizing the need to reduce costs. The manager should provide a clear rationale for the change, focusing on the financial pressures that are driving the decision to move to a team nursing model.

c. Repeat the information several times, giving detailed budget overviews. Providing extensive budget details and repeatedly explaining the rationale is unlikely to be an effective approach. This may come across as defensive and could further alienate the staff.

d. Adjourn the meeting and provide explanation through email. Avoiding a direct discussion with the staff and instead relying on email communication

is not recommended. The staff members have requested a meeting to voice their concerns, and the manager should engage with them directly.

Visioning and Creative Tension

Visioning involves engaging with others to assess the current reality, specify the desired end point, and then strategize to reduce the differences between the two. This requires trusting relationships that acknowledge the differences in values and ideas. When done well, the nurse manager and the nurses within a unit experience creative tension that inspires working in concert to achieve the desired goals.

The key aspects of this process are:

Assessing the current reality: The manager and staff must have a shared understanding of the current state of the unit and the factors driving the change to a team nursing model. Specifying the end point: The manager and staff should collaboratively define the desired future state and the goals they aim to achieve through the transition. Strategizing to reduce differences: The manager and staff must work together to develop a plan for how to bridge the gap between the current reality and the desired future state. Trusting relationships: This process requires a foundation of trust and mutual respect between the manager and staff, allowing them to openly discuss their differences in values and ideas. Creative tension: The creative tension that arises from this collaborative process can inspire the manager and staff to work together effectively to achieve the desired goals.

Followership and Assertiveness

New Nurse Demonstrating Assertiveness and Followership

A new graduate nurse wonders about the directions her preceptor has given regarding the management of incontinent, confused patients. The new nurse locates evidence-based information on incontinence interventions for confused patients and asks to discuss the guidance provided by the preceptor after reviewing the information.

In this situation, the new nurse is demonstrating:

a. Assertiveness : The new nurse is taking an active role in questioning the preceptor's guidance and presenting evidence-based information to support a different approach. This assertive behavior is an important aspect of effective followership.

b. Followership : The new nurse is following the appropriate chain of command by bringing the issue to the attention of her preceptor, who is in a leadership role. She is demonstrating a willingness to engage with her leader and work collaboratively to find the best solution.

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c. Management: While the new nurse is demonstrating leadership qualities, this situation is more focused on followership and assertiveness rather than management.

d. Insubordination: The new nurse is not acting in an insubordinate manner. She is respectfully bringing forward evidence-based information and requesting a discussion with her preceptor.

Reducing Adverse Events through Effective

Leadership

Eliminating Barriers to Best Practices

In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital reduced the number of managers and increased the number of units for which each manager was responsible. Within a year, the number of adverse events on the units had doubled.

The increase in adverse events is related to the decreased number of managers because:

d. Fewer clinical leaders facilitate best practice : When there are insufficient resources for leadership to encourage a culture in which evidence-based practice is embraced, frontline nurses recognize this as a stumbling block for delivering quality care. The reduction in clinical leaders and managers makes it more difficult to implement and sustain best practices, leading to the increase in adverse events.

a. The overload of staff nurse duties: While the increased workload for staff nurses may have contributed to the adverse events, the primary issue is the lack of clinical leadership to support best practices.

b. Resistance to change by staff: The staff's resistance to the change is not identified as the primary factor in the increase in adverse events.

c. A change in reporting system for everyone: There is no indication that the reporting system was changed, so this is not the reason for the increase in adverse events.

Engaging Nurses in Fall Prevention

The Rehabilitation Unit at Pleasant Valley Hospital has a high number of falls. To reduce the number of falls on the unit, the most effective intervention would be:

c. Encouraging involvement of nurses in education related to falls and safety : Engaging nurses in ongoing education and training related to fall prevention strategies is key to reducing falls on the unit. Nurses need to be empowered to take an active role in implementing evidence-based fall prevention practices.

a. Determining who is responsible for the falls: While understanding the root causes of the falls is important, it does not directly address the need to implement effective fall prevention strategies.

b. Strengthening unit policies to avoid inappropriate admissions: This approach does not address the immediate need to reduce falls on the unit.

d. Ensuring that patients are appropriately restrained if they are at risk for falls: Overreliance on restraints is not recommended, as it can lead to other safety issues. A more comprehensive fall prevention program is needed.

Nurse Executive's Role in Improving Safety

To begin increasing safety in patient care areas at Valley Hospital, the nurse executive should:

c. Ensuring that the senior nursing officer attends the board meetings : The IOM report (2004) highlighted the importance of the senior nurse executive's attendance at board meetings to be a key spokesperson on safety and quality issues. This allows the nurse executive to advocate for patient safety initiatives at the highest levels of the organization.

a. Asking the community what the safety issues are: While gathering input from the community is valuable, it should not be the nurse executive's first step in improving safety.

b. Consulting with a management expert about staffing schedules: Staffing is an important factor in safety, but the nurse executive should focus on higher-level strategic initiatives first.

d. Instituting improved practices to reduce needlestick injuries: Addressing specific safety issues like needlestick injuries is important, but the nurse executive should start with a broader, more comprehensive approach to improving safety across the organization.

Engaging Staff in Safety Initiatives

Addressing Incorrect Use of Mechanical Lifts

During a review of back injuries, it is determined that a large number of injuries are occurring despite the use of mechanical lifts. In addressing this concern, the unit manager should:

a. Meet individually with nurses who are observed to be using the lifts incorrectly to review the correct procedure : This approach involves directly engaging with the staff nurses to provide education and support on the proper use of the mechanical lifts. This relationship-building and hands- on approach is more effective than other options.

b. After consultation with the staff about the review, order new lifts to replace older ones that are malfunctioning: While replacing malfunctioning

equipment is important, the manager should first address the issue of incorrect use of the lifts through staff education and engagement.

c. Blame the system for inadequate funding for resources: Blaming the system or lack of resources is not a productive approach. The manager should focus on what can be done within the current constraints.

d. Review the system of reporting incidents to ensure that appropriate reporting is occurring: While monitoring incident reporting is important, it does not directly address the root cause of the back injuries related to improper use of the mechanical lifts.

Addressing Disciplinary Silos in Healthcare

The IOM Health Professions Education report highlighted the education of health disciplines in silos as a major concern for patient safety, endorsing the need for increased and improved communication between the health disciplines.

The key issue identified in the report was:

b. A result of disciplinary silos : The report recognized that the siloed education of different healthcare disciplines, without sufficient emphasis on interprofessional collaboration, was a significant barrier to patient safety.

a. A normal risk in professional practice: The report did not characterize the issue as a normal risk, but rather as a systemic problem that needed to be addressed.

c. A reflection of frontline staff: The report focused on the educational system and its impact on interprofessional communication, not solely on the frontline staff.

d. Related to systems errors: While systems errors are a concern, the report specifically highlighted the disciplinary silos in healthcare education as a key contributor to patient safety issues.

Promoting Patient-Centered Care and

Collaboration

Implementing the AHRQ "Five Steps to Safer Health Care"

When implementing strategies to support the steps in the AHRQ document "Five Steps to Safer Health Care," the nurse manager should include:

a. Patients are actively encouraged to make decisions related to care : One of the key steps in the AHRQ document is to encourage patients to be active partners in their own care, which aligns with a patient-centered approach.

b. Rules and decisions are made through centralized processes: This approach does not align with the patient-centered focus of the AHRQ recommendations.

c. You monitor the performance of each staff member closely: While monitoring staff performance is important, it is not a primary focus of the AHRQ "Five Steps to Safer Health Care."

d. Preference is given to increasing staff numbers rather than staff credentials: The AHRQ recommendations do not specifically address staffing levels or credentials, but rather focus on engaging patients and promoting a culture of safety.

Implementing Interprofessional Education

After consulting with practice environments about quality and safety concerns in healthcare, a dean in a healthcare program implements an interprofessional program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams.

This approach is consistent with the recommendations from the IOM Health Professions Education report, which highlighted the need for:

d. An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams : The report emphasized the importance of breaking down disciplinary silos and promoting interprofessional education and collaboration to improve patient- centered care and safety.

a. A nursing program that emphasizes the development of a strong disciplinary identity: This approach would reinforce the siloed education that the report aimed to address.

b. Programming that stresses discipline-based research: While research is important, the report focused on the need for interprofessional education and collaboration.

c. Partnerships with healthcare to develop software for the reporting of adverse events: This is a valuable initiative, but it does not directly address the core issue of interprofessional education identified in the report.

Focusing on the Patient

The IOM report "Crossing the Quality Chasm" aimed to shift the focus of healthcare from concerns about who controls care to a focus on what care is provided to and with patients. This aligns with the principle of:

d. The patient : The report emphasized the need to place the patient at the center of healthcare delivery and decision-making, moving away from a provider-centric approach.

a. Evidence-based practice: While important, evidence-based practice is a means to an end, not the end goal itself.

b. Informatics: Informatics is a tool to support patient-centered care, but is not the primary focus.

c. Staffing: Staffing is a critical component of patient care, but the report's emphasis was on the overall shift to a patient-centered approach.

Educating Patients on Healthcare Safety

Educating Older Adult Patients on Healthcare Safety

When educating older adult patients on staying safe in the healthcare system, the nurse should include information on:

a. The need to understand and record all medications being taken : One of the "Five Steps to Safer Health Care" for patients is to keep a list of all medications they are taking, which is particularly important for older adults.

b. Bringing their own linens and other personal items to the hospital: While this may be a personal preference, it is not a key safety recommendation for patients.

c. Washing hands frequently while in a healthcare environment and using a hand sanitizer: Hand hygiene is important, but this is not the primary focus of the education for older adult patients.

d. Following closely the directions and orders of healthcare providers: While following provider instructions is important, the emphasis should be on the patient's active role in their own care and safety.

Improving Patient Safety and Outcomes

Recommendations from the IOM "The Future of Nursing"

Report

As a nurse manager on the West Surgery Unit, to increase patient safety and reduce morbidity and mortality, a recommendation consistent with the IOM "The Future of Nursing" report would be:

d. Increase in the percentage of baccalaureate-prepared nurses to 80% : The report advocated for having 80% of the nursing population at a baccalaureate-prepared level, as research suggests that improved mortality and morbidity rates occur with a better-educated nursing workforce.

a. Careful screening of nursing staff for substance use and abuse: While important, this is not a specific recommendation from the IOM report.

b. Increased RN staffing on the unit: Staffing is important, but the report's emphasis was on the education level of the nursing workforce.

c. Salary and benefits that reflect nursing accountabilities: This is a valid consideration, but not a direct recommendation from the IOM report related to patient safety and outcomes.

Implementing New Safety Practices through Rapid

Adoption

On the West Surgery unit, to institute a new system for checking armbands that evidence suggests may increase safety in medication administration, the most effective strategy to assist with rapid adoption of the technology and system would be:

d. Use early adopters among the staff as leaders and role models in implementation : The Institute for Healthcare Improvement (IHI) recommends using a rapid cycle change approach, which involves leveraging early adopters among the staff to serve as champions and role models to facilitate the quick diffusion of the innovation.

a. Employ a centralized decision-making approach: A centralized approach is less likely to result in rapid adoption, as it does not engage the frontline staff.

b. Use simulators for initial practice to build confidence: While simulation can be valuable, it is not the primary strategy for rapid adoption of a new system.

c. Bring in a nurse consultant who is familiar with the technology: While a consultant can provide expertise, the key is to empower the staff themselves to lead the implementation.

Advocating for Nurse-Sensitive Care Standards

To achieve Nurse-Sensitive Care Standards developed by the National Quality Forum (NQF), the appropriate recommendation would be to advocate for:

a. Evidence-based practice to reduce the prevalence of pressure sores : The NQF outlines nursing-centered intervention measures, including the prevalence of pressure sores, as a key indicator of nurse-sensitive care.

b. Implementation of informatics at the bedside: While informatics can support nurse-sensitive care, it is not a direct NQF standard.

c. Staff-manager conferences to review reporting of adverse medical events: Reviewing adverse events is important, but does not directly address the NQF nurse-sensitive care standards.

d. Patient councils to review food, recreation, and nurse-patient relations: These are valuable initiatives, but do not specifically align with the NQF nurse-sensitive care standards.

Providing Feedback and Guidance to a

Student Nurse

Responding to a Student Nurse's Patient Education

After observing a student nurse, Sally, providing information to an anxious young teen about an upcoming upper GI series, the appropriate response for the nurse to give Sally is:

a. Encourage her to ask the patient if he has questions or concerns about the procedure : This approach allows the nurse to provide constructive feedback to the student, encouraging her to engage the patient and assess their understanding, rather than simply providing information.

b. Provide a detailed explanation of the correct procedure for the upper GI series: While providing the correct information is important, the focus should be on encouraging the student's engagement with the patient.

c. Commend Sally for her thorough explanation of the procedure: While positive feedback is valuable, the nurse should also provide guidance on how the student can improve her patient education approach.

d. Instruct Sally to refrain from providing any patient education in the future: This would be an overly restrictive response that does not allow the student to learn and develop her skills.

Promoting Patient Safety and Involvement in

Care

The Five Steps to Safer Health Care for Patients

The text highlights the importance of patients taking an active role in their healthcare by following the Five Steps to Safer Health Care:

Ask questions if there are doubts or concerns. Keep and bring a list of all medications, including natural remedies. Ensure understanding before surgery is performed. Speak up if something doesn't seem right. Participate in all decisions about your treatment.

The nurse can encourage patients to take these steps and provide them with coaching to become more involved in their care. This helps patients have a greater influence over their own healthcare.

Promoting Patient Involvement

The text suggests several ways nurses can promote patient involvement in their care:

Advise the patient to consider asking more questions if they have doubts or concerns. Suggest leaving brochures on the procedure with the patient. Provide teaching to the adolescent patient's parents. Encourage patients to ask questions when there are doubts and concerns. Ensure patient understanding before procedures are performed.

These strategies empower patients to be active participants in their healthcare and improve safety.

Identifying "At-Risk" Patients

The text identifies certain patients who may be considered "at-risk" consumers during a healthcare visit:

Patients who require anticoagulants and can provide a list of their medications. New parents who find the nurses on the children's unit helpful. Patients scheduled for bowel surgery.

These patients may need additional support or education to be active participants in their care.

Organizational Approaches to Patient Safety

The text discusses how healthcare organizations can promote patient safety:

The Centers for Medicare and Medicaid Services (CMS) have adopted a policy based on the National Quality Forum's (NQF) "Never Events" - they will no longer pay for patient conditions or events that result from poor practice. The Joint Commission (TJC) emphasizes patient safety and sets annual patient safety goals for accredited healthcare organizations. TJC also provides a list of "do-not-use" terms, abbreviations, and symbols, as well as guidance on sentinel events. The Magnet® model requires organizations to demonstrate excellence in areas like empirical quality results between designation and redesignation.

These organizational approaches help drive improvements in patient safety and quality of care.

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Nurse Competencies and Strategies

The text highlights several nurse competencies and strategies related to patient safety:

The Quality and Safety Education for Nurses (QSEN) project provides resources on competencies like teamwork, collaboration, and leading/ managing. The SBAR (Situation, Background, Assessment, Recommendation) approach encourages consistency in assessment and practices to improve patient safety. Reflection on decision-making enables nurse managers to improve their skills and eliminate inappropriate strategies. Involving direct care nurses in determining reasons for medication errors and solutions can increase the safety of medication administration.

These competencies and strategies empower nurses to be leaders in improving patient safety.

Multidisciplinary Collaboration

The text emphasizes the importance of multidisciplinary collaboration to address patient safety concerns:

When a patient with cognitive impairment is at risk of falls, a multidisciplinary and family meeting should be held to discuss the patient's needs and evidence-based safe practices. When a patient has limited English proficiency, the nurse should suggest involving an interpreter to ensure the patient understands the procedure and can ask questions.

Engaging the patient, family, and healthcare team promotes a collaborative, patient-centered approach to safety.

Paternalism and Respect for Others

Autonomy and Beneficence

Autonomy refers to the freedom to make a choice, such as refusing a procedure. Beneficence refers to doing good, such as performing a procedure that will benefit the patient.

The Americans with Disabilities Act (ADA) of 1990

The ADA requires employers to make reasonable accommodations for persons who are disabled. It does not allow for modified job expectations for persons recovering from alcoholism, hiring disabled individuals before hiring other qualified, non-disabled persons, or treating homosexuals and bisexuals as disabled for employment purposes.

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Whistleblower Lawsuits

A valid whistleblower lawsuit claiming retaliation by a nurse would be upheld if the nurse had previously reported the complaint, in writing, to hospital administration. The court would not uphold the lawsuit if the nurse had threatened to give full details of the patient abuse to local media sources, was discharged after three unsuccessful attempts at progressive discipline had failed, or had organized a work stoppage action by fellow employees before filing the complaint.

Employee Handbooks

Employers are bound to statements in the employee handbook based on the employee's or the employer's expectations, not under the doctrine of apparent agency or respondent agency, or based on the theory that the handbook creates an explicit contract.

Risk Management

Risk management involves taking proactive steps to identify and eliminate risks and liability, not compensating for previous injuries, superseding the need for staff members to file incident reports, or disciplining staff members who have been involved in previous incident reports.

Floating Nurses

Nurses should be floated to units as similar as possible to their own to decrease the potential for liability. Negotiating cross-training, a proactive approach to temporary staffing problems, reduces the potential for liability.

Patient Privacy and Confidentiality

Privacy refers to the right to protection against unreasonable and unwarranted interference with the patient's solitude. Institutions can reduce potential liability in this area by allowing access to patient data, either written or oral, only to those with a "need to know."

Nursing Practice Acts

In all states, you will need to be familiar with at least one nursing practice act. In some states, there may be two nursing practice acts if RNs and LPNs/ LVNs come under different licensing boards.

Malpractice and Duty of Care

Malpractice requires the conditions of injury, causation, breach of duty, and breach of duty of care owed. In a situation where a nurse made sexually explicit remarks to a patient with a history of sexual abuse, the condition of injury would not apply, as no physical harm was incurred.

As a charge nurse, you could be held liable for assault if you fail to do what a reasonable and prudent nurse would do in the same situation, such as advocating further for the patient in light of the evident seriousness of the child's condition.

Vicarious Liability

The doctrine of respondeat superior makes employers accountable for the negligence of their employees, using the rationale that the employee could not have been in a position to have caused the wrongdoing unless hired by the employer.

Apparent Agency

Apparent agency may apply if a patient believes that a temporary agency nurse was an employee of the institution, and the institution could be held liable for the nurse's actions.

Consent and Minors

Generally, the legal age for consent is 18. However, emancipated minors, minors seeking treatment for substance abuse, and minors seeking treatment for communicable diseases can provide their own consent.

Ethical Principles

The ethical principle of beneficence, doing what's good for the patient, is reflected in the decision to assign an ICU bed to the patient with the best chance of recovery.

The ethical principle of autonomy, the right to choose freely, is primarily involved in informed consent.

The principle of fidelity, upholding one's promise to practice as a reasonable and prudent nurse would do and in an ethically competent manner, is a professional obligation for nurses.

The ethical principle of privacy protection includes protection against unwarranted intrusion into the patient's affairs.

Duty of Care

A nurse manager is legally responsible for notifying staff of changes to policies related to medication administration, scheduling and staffing to ensure safe care, and delegating in accordance with practice acts, but not for ensuring that staff members follow those policies and procedures.

Cultural Diversity and Inclusion in Health

Care

Understanding Cultural Diversity

According to Leininger, "cultural imposition" is a major concern in nursing, as nurses have a tendency to impose their own values, beliefs, and practices on patients of other cultures. The discussion topic most likely to be without cultural imposition would be wound management, as it is less heavily imbued with values, beliefs, and practices that may differ between patients and nurses. Cultural diversity is the term used to describe a vast range of cultural differences. Events that have symbolic meaning for the nurse manager and staff, such as the celebration of National Nurses Week with a focus on cultural care, are most likely to provide symbolic meaning.

Addressing Cultural Biases and Stereotypes

When a staff nurse makes a comment about a co-worker's race or ethnicity, the best response from the nurse manager is to invite cultural awareness, which involves self-examination and in-depth exploration of one's own biases, prejudices, and assumptions. Prejudices enable us to predict behaviors and make sense of situations, but they can also constrain our understanding and development of new insights. The nurse manager's response to a staff member's stereotypical comment should aim to address the underlying prejudice without judgment.

Demonstrating Cultural Sensitivity

When a family member of a dying Native American patient requests to have the patient's eight-member family recite the rosary by the bedside, the nurse manager's affirmative response is likely an exhibition of cultural sensitivity. Cultural sensitivity involves the capacity to feel or react to ideas, customs, and traditions unique to a group of people. When a Chinese patient hospitalized for a myocardial infarction asks about seeing an acupuncture doctor for a migraine headache, the best response from the nurse manager is to acknowledge the patient's use of acupuncture, demonstrating cultural sensitivity.

Addressing Cultural Differences in Patient Care

On a palliative care unit, the nurse manager may encounter concerns from families about ineffective pain management, which may be influenced by the cultural and religious backgrounds of the nurses. The nurse manager should encourage conversation with patients and among staff that facilitates learning about cultural beliefs and priorities

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in dying, rather than simply reinforcing practice guidelines or advising families about the nurses' expert clinical judgment. The cultural and religious backgrounds of nurses can influence their perceptions of dignity-conserving care, such as the use of analgesics to relieve suffering or attempts to hasten death.

Approaches to Working with Differences in

Cultural and Religious Backgrounds

Understanding Culture

Culture is determined by behaviors and beliefs, and it develops slowly over time. Culture may or may not maintain a strong work ethic, as it is a patterned behavioral response that evolves as times change. When working with various cultural groups, it is important to recognize that diversity also exists within groups. Cultural differences among groups should not be taken to mean that all members of a certain group or subgroup are indistinguishable.

Addressing Health Needs of Diverse Populations

Hispanics with diabetes are twice as likely to die from diabetes as non- Hispanics. When designing programs to address the health needs of Hispanics in the community, programs related to diabetes would be most likely developed. Within the deaf culture, there is considerable disagreement about the use of Signed Exact English (SEE) and American Sign Language (ASL), which is indicative of the need to recognize diversity within groups.

Cultural Sensitivity and Awareness

Ethnicity refers to groups of people who are classified according to common racial, tribal, religious, linguistic, or cultural backgrounds. Cultural sensitivity refers to the affective capacity to feel, convey, or react to ideas, habits, customs, or traditions unique to a group of people. Cultural awareness involves self-examination and in-depth exploration of one's own cultural and professional background, including biases, prejudices, and assumptions.

Acculturation and Assimilation

Acculturation refers to adapting to a particular culture, while assimilation occurs when individuals now define themselves as members of the dominant culture. Socialization is when individuals grow up within a culture and take on the characteristics of that culture.

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Assisting staff to recognize differences in the relationships between physicians and nurses on the unit and those in their country of origin is promoting positive patient outcomes.

Multicultural and Transcultural Considerations

Multiculturalism refers to maintaining several different cultures, such as the uniqueness of different work units. Cross-culturalism means mediating between/among cultures, and transculturalism denotes bridging significant differences in cultural practices. Transcultural care involves consideration of health beliefs and practices between genders among races, ethnic groups, and those with different socioeconomic status.

Cultural Behaviors and Communication

Body movements, eye contact, gestures, verbal tone, and physical closeness when communicating are all part of a person's culture. Understanding these cultural behaviors is critical in accomplishing effective communication within a diverse work force population. A new graduate nurse caught between the cultures of work and education may express feelings of belonging to neither, experiencing cultural marginality. The behavior of a large family and friend network in the room of an East Indian patient reflects the cultural value placed on the family and social support network, not a lack of understanding of the seriousness of the illness.

The Social Organization of Friendships and

Family Networks in East Indian Culture

Giger and Davidhizar Transcultural Model

The Giger and Davidhizar Transcultural Model identifies six phenomena to assess the provision of care for patients from different cultures, including:

Social Organizations : This refers to how relationships are formed and expressed in different cultures.

Lack of Caring about the Hospital Environment by Friends

and Family

The text indicates that the lack of caring about the hospital environment by the friends and family of the patient is a notable aspect of the social organization of friendships and family networks in East Indian culture.

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Circle of Familiarity

The "circle of familiarity" refers to a constrained interpretation based on one's own values, attitudes, and beliefs. This concept is relevant when trying to understand why an Aboriginal patient, Jim, wants to do a "smudge", which may not be familiar or understandable to a nurse, Sarah, from a different cultural background.

Cultural Competence for Nurse Managers

To be effective in managing a culturally diverse staff, nurse managers should possess the following attributes:

Respecting others Understanding the importance of language Encouraging the potential in all staff

Cultural competence involves knowledge of diverse cultural and ethnic groups, including knowledge of staff members and respect for others and their cultural differences.

Becoming an Effective Leader

The first step to becoming an effective leader is being an effective follower. A leader may take classes on leadership and management and secure an advanced degree, but the foundation is effective followership.

Nurse Manager's Primary Role

As a nurse manager, the primary role when evaluating the care provided on the nursing unit is to ensure quality patient care is rendered. This is the priority, in addition to focusing on cost outcomes, assessing staff, and providing education.

Formal Leadership Position

The appointment of a Chief Nursing Officer (CNO) in a rural hospital is an example of a formal leadership position. Formal leadership positions often have a title and are assigned leadership by the role of the position.

The Four Agreements for Personal Growth and Awareness

The book "The Four Agreements" by Don Miguel presents a set of agreements to enhance personal growth and awareness, including:

Be impeccable with your word. Do not make assumptions. Do not take anything personally. Always do your best.

Leadership Integration

The core of nursing leadership incorporates the integration of unique qualities, including the person, the leader, and the nurse. The position is not considered part of this leadership integration.

Informal Leadership

In a scenario where a new graduate nurse is assigned a preceptor with several years of experience, and the other staff seek out this preceptor for answers and as a resource, the preceptor is considered an informal leader. Informal leaders do not hold an actual leadership title but lead from an informal position based on experience and behavior.

Reflection for Self-Awareness

Practicing self-reflection, such as a nurse manager journaling their feelings about working with a new graduate nurse, is a way to develop self- awareness and go beyond the surface to explore one's individual thoughts and experiences.

Emotional Intelligence

Excellent leaders need to have or develop the skills of empathy and expressiveness when dealing with others in the workplace. This is an example of emotional intelligence, which is the understanding and management of one's own feelings and emotions, as well as the ability to discern the emotions of others.

Inspiring a Shared Vision

When a nurse manager in a formal leadership position attempts to translate the vision of the facility across to the staff nurses, who are resistant to the vision, the manager needs to utilize the theory of "Inspiring a Shared Vision." This is an expectation of leaders to be able to contribute by translating the big picture vision to the staff.

Authentic Leadership

In developing leadership skills, the top priority in the theory of authentic leadership is the development of honest relationships. Valuing what each person brings to the group, trusting the group, exploring other ideas, accomplishing goals, and being an effective organizer are all important, but the foundation is the development of honest relationships.

Lifelong Learning for Nurse Leaders

A chief nursing executive should be concerned if a manager demonstrates complacent behavior, as nurse leaders should continuously seek to improve their leadership skills through behaviors such as journaling for self-

reflection, building authentic relationships, and improving their knowledge of staff.

Being an Effective Follower

The Role of Followers in Nursing

The concept of followership is relatively new in relation to leadership principles. In the context of nursing, the primary role of followers (often staff nurses) is that of a direct care provider. Followers in nursing are not passive or devalued members of the healthcare team. Rather, they are independent thinkers who implement policies with understanding and are able to question when necessary. Nursing theories, such as Dorothea Orem's theory of self-care, highlight the active, participatory role of the nurse as a follower in relation to the patient. Similarly, Patricia Benner's theory of novice to expert describes the progression of nurses as they follow their role and advance through stages to become experienced practitioners.

The Leader-Follower Relationship

In the leader-follower relationship, it is important to recognize that leaders are also followers. The old notion of a linear, dictatorial leadership structure is outdated. Instead, modern leader-follower relationships involve mutual influence and shared decision-making. Effective followers are engaged, participatory members of the team who work to achieve the team's goals. Nurse managers who foster an environment of engaged, effective followers are demonstrating strong leadership skills.

Attributes of Effective Followership

Critical thinking Patient advocacy Ability to influence leaders Participation in decision-making

Developing Effective Followership

Attending professional conferences Reading books on leadership Joining professional organizations Connecting with other leaders in the organization Learning from the experiences of new nurses

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Power, Politics, and Influence

The Lack of Power in Nursing's Past

In the early decades of the nursing profession, nurses lacked power due to the legal, social, and political barriers that women faced at the time. Nursing mirrored the lack of legal, social, and political power that was prevalent in the early decades of the profession.

The Importance of Political Activism in Nursing

Becoming an active, productive, and collegial member of groups and teams within the workplace and in professional associations and community groups ensures that the nursing voice is heard on healthcare issues and problems, which is an appropriate exercise of power. Political involvement is a professional responsibility, and nurses' perspectives of the critical issues for improving the healthcare system can shape the policy agenda of the nation's political leadership.

Types of Power and Influence

The director in the advisory situation may exercise referent, expert, and information power. Empowerment is the process of exercising one's own power to facilitate the participation of others in decision making and taking action so they are free to exercise power. Influence involves the use of power to effect certain outcomes, such as arranging days off for a valued employee.

Developing Organizational Savvy

Identifying the real decision makers and those persons who have a high level of influence with the decision makers is important for a new graduate nurse like Sondra who is struggling to have her leadership recognized. Engaging in shared decision making can help improve morale on a unit. Rural settings may be more closed systems, which can make it challenging for a new graduate to be accepted.

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Projecting a Powerful Image

Confident behaviors such as greeting others, smiling, and showing respect for the opinions of others through listening can contribute to a powerful and positive image for a nurse manager. Maintaining a professional appearance, such as wearing a suit and tie or suit and high-heeled shoes, is not as important as the behaviors that demonstrate respect and confidence.

Effective Communication and Conflict Resolution

Negotiation involves the presentation of an opening position with each party, then moving on until they achieve a mutually agreeable result or until one or both move away from a failed negotiation. Listening to each nurse speak to the other without interruption and asking clarifying questions can help the manager effectively resolve a conflict between two nurses.

Networking and Professional Development

Active participation in nursing organizations is the most effective method of establishing a professional network outside one's place of employment. Reviewing one's address book or card file for names and phone numbers of former colleagues, meeting with a former instructor, and returning a call to a former colleague are all ways to expand one's professional network.

Healthcare Organizations

Informal Leaders and Power

Informal leaders within an organization may have more power than the formal leader due to their greater knowledge of the organization, more informational power, or more expertise.

Oppression in Nursing

The literature on oppression in nursing has demonstrated the presence of behaviors associated with oppression within nursing. Oppressed group behavior is apparent when a population is dominated by another group and begins to take on the characteristics of the dominant group, often bullying and abusing their peers. Bullying and incivility have become epidemic in both nursing education and clinical settings in the 21st century.

Politics in Organizations

Politics permeates all organizations, workplaces, legislatures, professions, and even families.

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