N471 Midterm Flashcards
What is the situation and how will the leader respond
Leader is a MOTIVATOR
Performance and Productivity
Uses PROBLEM-SOLVING process
Has vision, able to EMPOWER, & INSPIRE staff
Manager models behavior, encourages, shared values
Leaders and followers share same passion for work
Interactional Leadership and Transformational Leadership
Interactional Leadership Theory
Transformational Leadership
Strengths-Based Leadership
Leadership Today
Empower the worker
Recognize uniqueness
Provide safe work environment
Learning ready
Positivity and FOCUS ON STRENGTHS
Service to others
Strengths-Based Leadership
- Modeling: values, self-awareness
- Inspiring a shared vision: inspirational vision, follows want to work with leader on goals
- Challenging the process: sees the changes needed and makes it happen
- Empowering others: foster collaboration, trust and the sharing of power
- Encouraging the heart: celebrate others and their achievements toward the goal
Five Practices for Exemplary Leadership
Long term vision
See the bigger picture
Influential
Recognize the effect of interactions with others; team oriented
Deal with conflict well
Sees necessary changes as positive
Manager Traits of a Transformational Leader
Ability to perceive, understand, and control one’s emotions and the effects those emotions have on others
Self-awareness- own emotions, recognize self
Self-regulation- handling emotions
Motivation
Empathy
Social skills
Emotional Intelligence
Control, coercion, closed-minded, criticism, focus on “I” or “me”, sometimes necessary in urgent/emergent situations
Authoritarian (Autocratic) leadership style
Less control, motivated by rewards, OPEN COMMUNICATION, COLLABORATIVE decision making, constructive feedback, focus on “we”, transformational leadership
Democratic leadership style
Lack of control and direction, permissive, open communication, group focus, not typically seen as productive
Laissez faire leadership style
Quality and safety in healthcare (HC)
Limited accessibility to HC
HC disparities
Workload/staffing
Patient satisfaction
Sustainability of HC system and financing
Increase in HC cost
Long waiting times and congestion
Changes in more strict legislations, regulations, and enforcement of such
Increase disease burden, promotion and prevention, people are living longer
Pandemic controls
Leadership Challenges Today
Transferring responsibilities to another staff member
RN still ultimately responsible for those tasks
RNs in leadership roles delegate to RNs working with/under them
Delegation (leadership role)
Taking responsibility for the tasks others perform
Review of workload, understanding skills and knowledge level of staff
RNs in leadership roles supervise RNs and other unlicensed personnel working under/with them
Evaluate job performance
Supervision (leadership role)
Organizing care for patients between two or more participants
Should include the patient/family
Facilitate appropriate delivery of healthcare services
Coordination (leadership role)
Healthcare team comes together
Reach common goal in patient care
Collaboration (leadership role)
A problem exists
A report was filed
A complaint
Something does not fit/work
An idea is born/an innovation
Community/global threats
Why Change is Necessary
What? A person who initiates change within a group
Who? a person who understands and implements the required change process
Change Agent
What? People involved and interested in the change process
Who? People involved in the change, those the change affects
Stakeholder
Unfreezing
Movement (change)
Refreezing
Driving forces (to reach a goal)
Restraining forces (from reaching the goal)
Phases of Lewin’s Change Theory
Determine what needs to change
Ensure there is strong leadership support
Create the need for change
Manage and understand the doubts and concerns
Unfreezing (Change Theory)
Communicate often
Dispel rumors
Empower action
Involve people in the process
Movement (Change Theory)
Anchor the changes into the culture
Develop ways to sustain the change
Provide support and training
Celebrate successes
Refreezing
Mandates/legal
Fiscal
Resources (lack or too many)
Promotion/recognition
Social gain
Personal goals
Support family
Driving forces (to reach a goal)
Lack or resources
Lack of data
Lack of knowledge
Fear of liability
Intrapersonal conflicts
Interpersonal/group conflicts
Restraining forces (from reaching the goal)
Evidence-based practice, what does the literature say; what supports are there?
I.e. hourly rounding, bed-side report, chlorhexidine gluconate baths (CHG)
Rational Empirical Strategy (strategies for successful change)
Develops relationships, builds confidence and peer support, change agent more of a team player, change due to social norms, becomes part of the group
I.e. uniforms, 12-hr shifts, self-schedule
Normative Re-educative Strategy (strategies for successful change)
Authority, legal changes, new laws, policies, must accept it or leave
I.e. CMS enacted policy changes for reimbursement- DVT, postop infections, pressure injuries, state mandated changes, JACHO mandates
Power Coercive Strategy (strategies for successful change)
Complacency
Fear of the unknown
Too comfortable/habits
Not broke, don’t fix it attitude
Why do we resist change?
See the vision
Capture the purpose
Strategize for improvement
Empower people
Positive feedback
Build trust/relationships
Communication
Understand the reason
How do we make change easier?
Role model
Good communicator
Stay positive
Support organization
Understand emotional intelligence
Believe in change
See the bigger picture
Fiscal responsibility
Leader/Manager Role in Change
External
Internal
Differences in values, beliefs, opinions, ideas, backgrounds, goals
Expected
How do we filter what’s important
What is conflict?
Conflict from within oneself
Intrapersonal conflict
Conflict from person to person
Interpersonal conflict
Conflict within a group
Intergroup conflict
There is a potential for a problem, can we stop it before it starts
Latent conflict (antecedent condition) (Conflict process)
Conflict has been identified
Perceived conflict (Conflict process)
Feelings about the conflict
Felt conflict (Conflict process)
Action phase, working through it
Manifest conflict (Conflict process)
Conflict is being solved
Conflict resolution (Conflict process)
Consequences of the conflict
Conflict aftermath (Conflict process)
Compromising- both give up something equally, lose-lose
Competing- challenging the other, win-lose
Cooperating/Accommodating- one gives to satisfy the other
Smoothing- one party pacifies the other, focus on positives, temporary win-win
Avoiding- issue not addressed, lose-lose
Collaborating- great strategy, work together toward same goal, win-win
Negotiation- like collaboration, cooperation, helps develop relationships, watch hidden agendas, win-win
Conflict Resolution Strategies
Confrontation
Third-party consultation
Behavior change
Responsibility charting
Structure change
Soothing one party
Alternative dispute resolution
Seeking consensus
Managing conflict
Choosing with a given set of options
Decision making
A process that helps make the decision-making process work
Analyzing difficult situations
Problem solving
Process by which nurses make decisions based on nursing knowledge (evidence, theories, ways/patterns of knowing), other disciplinary knowledge, critical thinking, and clinical reasoning
Clinical judgement
Function of Clinical Nursing
Identify information, subjective, objective, history. What is relevant? What is most important? Is there anything urgent?
Gather info; ASSESS
Recognize cues
Function of Clinical Nursing
Organize the cues, how do they reflect the current condition/s? Is there anything that may represent a different problem? Why are these cues concerning? Is there any other information that would help?
What do the cues mean/Interpreting Info
Analyze cues
Function of Clinical Nursing
Determine urgency of the data, what is most likely happening? Is there anything serious to warrant immediate needs?
Prioritization
Prioritize hypotheses
Function of Clinical Nursing
Identify what outcomes are expected based on data/what interventions can be done to achieve those outcomes?
Does anything need to be avoided? Think of goals and interventions
Problem solve; Planning stage
Generate solutions
Function of Clinical Nursing
Implement the solutions that have the highest priority first. What interventions must be done first? How are these interventions accomplished?
Intervene
Take Action
Function of Clinical Nursing
Compare the observed outcomes. Were goals achieved? Were the interventions effective? Does something need to be altered? How does one determine if goals were met?
Evaluate outcomes
Recognize/celebrate differences and diversity
Gender differences
Values/beliefs
Past experiences
Personal choice
Learning/thinking styles
Supporting others in decision making
- Appropriate frame- what are we deciding?
- Create doable alternatives- what choices do we have?
- Meaningful reliable information- What do we need to know?
- Clear values and tradeoffs- what consequences do we care about?
- Logically correct reasoning- are we thinking straight?
- Commitment to follow through- will we really take action?
Decision Making Process
Skydiving without a parachute
Assumptions overtake real data
Overconfidence can be detrimental- ASK questions
Not considering other points of view
Shooting from the hip with no data to support- KNOW EBP
Doing the first thing that comes to mind bc you PANIC
Results of rushing decisions
Linear thinker; black & white, no gray
React quickly, lack data for rationale
Need clear instructions/guidelines
Task oriented
Learning to delegate and prioritize
Internships and preceptor models well received
Novice nurse qualities
Organize data well
Assess early, put all the pieces together, then act, prioritizes
Know when and how to get things done
Confident, leadership qualities
Pays close attention to patient responses
Vast knowledge, great preceptor/mentor
Expert nurse qualities
Know who the leaders are in an organization; is there equality
What kind of management structure does the organization have?
How can staff implement change; is there shared governance?
Does the organization value nurse decision making?
Magnet hospitals
Many tools can be used to help guide decision making
Administrative Decision Making
Prioritization
Leads to clinical reasoning
More time with patients
Focus goals of care
Protects your license
Importance of time management in nursing
Crises
Pressing Problems
Deadline driven projects, meetings, preparations
Urgent Important Tasks
Preparations
Presentations
Values clarification
Planning
Relationship building
True Recreation
Not Urgent Important Tasks
Interruptions, some phone calls
Some mail, some reports, some meetings
Many proximate pressing matters
Many popular activities
Urgent Not Important Tasks
Trivia, busy work
Junk mail
Some phone calls
Time wasters
“Escape activities”
Not Urgent Not Important Tasks
Organization is key
Group activities
Estimate time gaps
Document in real time
Use tools (i.e. report sheets, time grids, etc.)
Complete work on time
Work time is work time
Time management strategies for staff nurse
Unit and personal priorities for the day
Identify goals
Know the staff (strengths/needs)
Evaluate changes/needs of the unit
Keep planner/calendar updated for meetings
Prepare meetings with agenda items in advance
Allow time for unexpected issues
Anticipate changes and needed adjustments often
Plan in breaks
Leave on time
Time management strategies for nurse leaders
Deal with interruptions
Avoid procrastination
Be mindful of personal time
Set limits
How to prioritize time
A dynamic process that assesses, plans, implements, coordinates, monitors, and evaluates to improve outcomes, experiences, and value
Professional and collaborative process that occurs in a variety of settings
In pursuit of health equity, priorities include identifying needs, ensuring appropriate access to resources/services, addressing social determinants of health, and facilitating self care transitions
Case management definition
Utilization management (medical necessity and provide clinical information to insurance companies via AI software)
Case management responsibilities
Regulatory requirement outlined in the CMS conditions of participation
Must be available to ALL patients
Must be reassessed regularly to ensure the needs of the patient have not changed
Initiated by care management within 24 hours of admission
Discharge planning by case management
Patient’s ability to participate in the plan
Lack of support network
Lack of payor or payor-approved services
Complexity of the discharge needs (wound care, IVAB, etc.)
Limited availability of resources (skilled nursing facilities, home care, etc.)
Barriers to discharge planning
Send referrals online to homecare/skilled nursing facilities
Arrange equipment needed: oxygen, wound vac, IVAB, BiPap
Assistance providing medications if needed (meds to beds or transitional care pharmacist)
Make transitional care management appointments
Establish a care management plan
An independent nonprofit organization that works outside the government to provide unbiased and authoritative advice to decision makers and the public
Over 2000 members from all disciplines
75 members chosen every year to serve on committee
SAFETY SAFETY SAFETY
Institute of Medicine (IOM)
How safe are you in the hospital
44,000-98,000 deaths each year due to preventable medical errors
Medication errors are the #1 cause of preventable medical errors
Lessons:
Errors are usually NOT the fault of people
Error contributed by: FLAWED SYSTEMS, lack of proper training, perverse incentives
To Err is Human
The healthcare system is in need of improvement
Six goals for improvement: safe, effective, patient-centered, timely, efficient, equitable
Crossing the Quality Chasm
Provide patient-centered care- identify, respect, and care about patient’s differences
Work in interdisciplinary teams- cooperate, collaborate, communicate, and integrate care in teams
Employ evidence-based practice
Apply quality improvement
Utilize informatics
5 Core Competencies
Culture of safety
Blame-free work environment
Staff safety (needle sticks, infections, violence)
Institute for healthcare improvement (IHI)
Transforming Care at The Bedside (TCTB)
Joint Commission Annual Safety Goals
IOM Recommendations
A formal approach to the analysis of performance and systematic efforts to improve it
Quality Improvement (QI)
Hospitals strive for this
Organizations that function well with minimal patient/system error in outcomes
Health services that improve outcomes
Organizations can provide this but still have poor outcomes- therefore it is difficult to define
Challenged by the definition of quality and reliability
High-Reliability Organizations
Older term
Retrospective process- target currently existing quality
Policing and often punitive
Determine who’s at fault
Quality Assurance (QA)
Newer term
Involves prospective and retrospective views- target ongoing and continually improving quality
Goal is improvement
Attempts to avoid blame
Create systems to prevent errors
PREVENTION
Quality Improvement (QI)
Improve accuracy of patient identification
Improve effectiveness of communication between caregivers
Improve safety of using medications
Reduce harm associated with clinical alarm systems
etc.
National Patient Safety Goals (Created by Joint Commission)
How do we identify what’s best
Measure products, practices, and services against best performing organizations (compare to industry standards)
Allows organizations to compare performance within the organization and with others
Data drives improvement
Benchmarking
How do we identify what’s best?
A program or protocol relating to improvements to quality of life, quality of care, staff development, or cost-effectiveness practices
Institutions submit outcomes related to quality improvement initiatives; and may be designated a “best practice”
Best practices
Assumes a relationship exists between quality care and appropriate structure
The physical environment in which healthcare is delivered
Structure (measure of quality)
Used to measure the process of care or how the care was carried out; assume that a relationship exists between the process used by the nurse and the quality of care delivered
Policies/procedures/protocols, critical pathways
Standards of care tools used to measure deviations from best practice standards
Process (measure of quality)
End result of care or patient’s health status changes as a result of an intervention
Non nursing sensitive outcomes (mortality, morbidity, LOS)
Nursing sensitive outcomes (falls, nosocomial infections, pressure injuries, patient satisfaction scores)
Outcomes (measure of quality)
Founded by ANA
GOLD STANDARD for nursing quality data
Tracks up to 19 nursing sensitive quality measures based on structure, outcome, and process
Hospitals can compare their nursing quality against national, regional, and state norms for hospitals of the same type and down to the unit level
National Database of Nursing Quality Indicators
Plan- create an action plan for implementation, including a list of required steps, the implementation schedule, ownership, responsibilities, and desired outcomes
Do- start implementing the plan, following the plan steps, and adhering to the schedule to stay on track
Check- take measurements against the success criteria set when selecting the strategy to ensure implementation is progressing as it should be
Act- based on check results, determine if the process was successfully changed
Plan, Do, Check, Act (quality model)
Define, Measure, Analyze, Improve, Control
involved management of greater extent in monitoring performance and ensuring favorable results
1. customer focus
2. data driven
3. process emphasis
4. proactive management
5. boundary-less collaboration
6. aim for perfection; tolerate failure
Six Sigma (quality model)
Focus: collect data
Analyze: what can we change?
Develop: IV
Execute: initiate IV
Evaluate: measure
FADE (quality model)
The conscientious use of current best practice in making decisions about patient care
A problem solving approach to clinical practice that integrates a systematic search for and critical appraisal of the most relevant answer to a clinical question, clinical expertise, patient preferences & values, etc.
Evidence based practice
QI (no theoretical underpinnings, evaluates a work process to improve practice, data collected and reported internally)
EBP (uses theory, seeks to generate new knowledge or test interventions, results add to the body of knowledge)
Difference between QI and EBP
Level I- Systematic Review of RCTs
Level II- RCTs
Level III- Controlled trials w/o randomization
Level IV- Case control and cohort studies
Level V- Systematic reviews of descriptive or qualitative studies
Level VI- Single descriptive or qualities study
Level VII- Expert opinions
Hierarchy of evidence
Process of aligning an organization’s structure with its mission
Organizational design
Emphasis on organizational positions and formal power; framework for providing managerial authority, responsibility, and accountability
Roles and functions defined
Rank and hierarchy are evident
i.e manager –> nurse –> nursing assistant
Formal organizational structure
Focus on naturally forming social network of employees and their relationships
Typically based on camaraderie
Rely on the informal structure if the formal structure becomes ineffective
“Grapevine” communication within the informal group
i.e. nurse to nurse colleagues
Informal organizational structure
Max Weber- founder of organizational theory
Bureaucracy = the ideal, intentionally rational, most efficient form of organization
Efficiency through design
Classical Theory
- Division and specialization of labor
- Chain of command
- Organizational structure
- Span of control
Four elements of Classical theory
