Quiz Two Test Bank Flashcards
Role theory has its underpinnings in management theory. Management theories influence managers’ leadership styles. Which would a nurse manager be most likely to follow when
redesigning the staffing schedule?
a. Theory X.
b. Productivity theory.
c. Psychological theory.
d. Theory Y.
ANS: D
Rationale: Theory Y is effective in health care and helps reinforce the concept of team. Because the
manager needs to redesign staffing schedules, it would be important to use this participatory approach, inasmuch as the change involves a group.
A nurse manager has worked rapidly to persuade the staff to accept changes in the unit’s mission, through innovative use of technology, to avoid downsizing. This nurse manager is
displaying:
a. A focus on past concerns related to the mission.
b. How to teach staff members about self-management.
c. Facilitation of goal accomplishment.
d. A requirement that all staff members need to review and reinforce their technological skills.
ANS: C
Rationale: Nurse managers, who are successful in motivating staff, provide a work environment that
facilitates goal accomplishment and personal satisfaction. In this situation, the nurse manager worked quickly to avoid downsizing, thus facilitating the goal of avoiding staff layoffs.
The nurse manager, as the leader of the unit’s “customer (patient) first” initiative, has asked the staff nurses to develop and administer a survey to every patient before discharge. In
asking the staff nurses to accomplish this task, the nurse manager is demonstrating
a. Accountability.
b. Shared governance.
c. A common purpose.
d. Independence in the nursing manager’s role.
ANS: B
Rationale: Engaging staff and others in decision-making and obtaining information is one characteristic of creating a shared governance structure in which nurses are encouraged to make decisions.
A nurse manager is encountering considerable conflict among staff members because o weekend staffing coverage. During a called staff meeting, the nurse manager asks the
disgruntled staff to meet as a group and determine the best staffing practices. In doing this, the nurse manager is using the concept of collaboration to:
a. Demonstrate interdependence.
b. Depict flexibility and broadmindedness.
c. Focus all energies of staff members on a win-win strategy.
d. Defuse the possibility that staff members’ discontent will escalate when staffing the unit on weekends.
ANS: C
Rationale: Conflict resolution skills are important for nursing managers. When collaboration is used to solve a conflict, all energies are focused on solving the problem, rather than on defeating
other people with opposing views.
A nurse manager’s responsibility for financial management involves making budgetary decisions. Budgets that enable the nurse manager to allocate resources at the unit level allow:
a. Minimal nurse manager input.
b. Limited rationale for budgetary requests.
c. Budgetary allocations at the executive nurse level.
d. Budgetary decision making at the point of service.
ANS: D
Rationale: In organizational structures in which decision making occurs at the point of service, nurse managers are given responsibility for preparing and implementing a budget that meets the
long- and short-term needs of their unit without requiring hierarchical approval.
Which represents one of the Canadian Nurses Association’s top six competencies of a good nurse manager?
a. Political activism.
b. Conflict resolution skills.
c. Budgetary responsibility.
d. Current clinical practice knowledge.
ANS: B
Rationale: The top six competencies for nurse managers are: (1) accountability for professional
practice, (2) verbal communication, (3) team-building skills, (4) leadership skills, (5) conflict resolution, and (6) knowledge of ethical and legal issues.
Whenever a staff nurse asks Sue, the nursing manager, about the best way to perform a new procedure, Sue immediately goes to the computer with the staff nurse and searches for
online best practices related to the procedure in question. What is Sue demonstrating?
a. Lack of procedural knowledge.
b. Role-modelling evidence-informed decision-making.
c. Empowerment for the staff nurse to do this on her own, rather than involve the
manager.
d. The key role of informatics in the current health care system.
ANS: B
Rationale: Nurse managers can help staff use research evidence in their practice decision making by valuing research, role modelling, providing encouragement, ensuring policies are based on research and are up to date, and monitoring practice and patient outcomes.
In planning a new wing, the nurse manager complies with the workplace safety requirements of the US Occupational Safety and Health Administration (OSHA). Which of the following groups is considered to be at high risk for violence in the workplace?
a. Pediatric staff.
b. Postsurgical unit staff.
c. Emergency department staff.
d. Medical oncology unit staff.
ANS: C
Rationale: Emergency department staff members are considered to be at high risk for violence.
In orienting a 25-year-old nurse, the unit manager understands that this worker probably
a. Likes to attend to detail.
b. Is highly proficient in math and reading skills.
c. Enjoys being managed by superiors.
d. Likes to solve problems without being given solutions.
ANS: D
Rationale: A role of the manager is to understand various motivations of staff and to bring these together in the accomplishment of goals. In general, younger workers are motivated strongly by shared governance and decision making.
Nurses on Unit 4 are unhappy and frustrated with their nurse manager. They complain that “nothing is ever good enough for him.” Such statements suggest that the nurse manager’s goals may be:
a. Measurable.
b. Unrealistic.
c. Attainable.
d. Too low.
ANS: B
Rationale: Nurse managers need to set goals that are high enough to achieve excellence but reasonable enough to enable achievement. Lack of achievement can result in frustration.
Budgeting and protection of revenues is a function of:
a. Leadership.
b. Management.
c. Team leadership.
d. Followers.
ANS: B
Rationale: Managers address complex issues such as planning, budgeting, and allocating resources, whereas leaders address change.
Which of the following is important in a positive work environment?
a. One-way communication.
b. Accountability and clarity of roles and responsibilities.
c. Hierarchical decision making.
d. Challenge and striving for excellence.
ANS: B
Rationale: One of the six competencies of a good nursing manager is accountability for professional
practice; clarity of roles and responsibilities enhances accountability.
As the manager of a unit with a high percentage of young professionals, you increase job satisfaction among this young staff by:
a. Providing high levels of job structure and task orientation.
b. Developing schedules that are fair and observing contractual obligations.
c. Utilizing skills in the staffing mix to optimize the delivery of patient care.
d. Establishing opportunities to self-schedule.
ANS: D
Rationale: A manager is challenged to motivate staff and increase organizational commitment across
different generations of workers. Carver and Candela’s (2008) findings suggested that strategies such as shared governance and self-scheduling increase satisfaction among younger staff.
On the first day of every month, the nursing manager on the surgical unit posts a staff nurse’s name on the bulletin board with the caption “Look what this great nurse did this month” and outlines nursing behaviours that were displayed by that particular nurse. This is an example of:
a. Negative reinforcement.
b. Valuing employees.
c. Obtaining evidence for performance appraisals.
d. Reinforcing the vision and goals of the organization.
ANS: B
Rationale: Nurse managers must communicate their commitment so that staff members know they are
valued in accomplishing the work of the unit that furthers the mission of the organization. One way of demonstrating that employees are valued is through recognition. Recognizing staff’s efforts is part of effective management practices.
As a nurse manager, you determine that a shift in nursing care models might decrease workplace violence. Members of the hospital administration are reluctant to adopt this new approach to care. To leverage your ideas, you:
a. Ask staff to send e-mails to administration members encouraging consideration of your option.
b. Invite a senior member of administration to your staff meeting, so you can tell him what you are planning.
c. Write a letter of complaint to a member of the institutional board about the lack of openness of the administration.
d. Identify influential members of your nurse manager group with similar ideas and request an opportunity to meet with administration members to discuss options.
ANS: D
Rationale: In addressing issues with higher administration, it is important to develop power strategies such as seeking support from other influences in the organization.
During staff meetings you make it a regular practice to encourage shared problem solving, and to recognize employees who go beyond basic roles and responsibilities to contribute to a
positive team environment and to quality patient care. This practice exemplifies:
a. Values-based management.
b. Shaping of workplace behaviour.
c. Cooperation and collaboration.
d. Recognition of institutional priorities.
ANS: A
Rationale: Values-based management recognizes that commitment to the vision, mission, and purpose of the organization is demonstrated in everyday behaviour and that managers communicate their commitment to staff members by expressing the value of their work in accomplishing the mission, purpose, and priorities of the institution.
The successful integration of informatics into health care settings is key to:
a. Quality decision making and processes related to management of resources.
b. Accessing current information about business practices.
c. Leveraging ideas from other managers.
d. Speeding up calculations and decisions in budget development.
ANS: A
Rationale: The use of informatics to research evidence and alternative models of delivery, to compare
data and solutions with those of other managers, and to assist with integrative functions that make budgeting more efficient is related to a high quality of decision making and processes related to management of resources such as revenues and personnel.
As a nurse manager, you embrace the usefulness of resources such as Smart Bed. This behaviour is important in:
a. Budget development.
b. A manager’s role.
c. Succession planning.
d. Encouragement of staff members’ use of technology.
ANS: D
Rationale: Advances in technology such as the Smart Bed facilitate effectiveness and efficiency in care. By becoming an early adopter of technology, staff members, particularly older staff, who may be less comfortable with technologic advances, are encouraged to value its use in care delivery and management.
A manager who is concerned with ensuring that patients on her surgical unit have the necessary information to make informed choices is:
a. Practicing legal nursing care.
b. Demonstrating respect for patients’ rights.
c. Avoiding risks.
d. Probably experiencing issues with informed consent.
ANS: B
Rationale: In advocating for informed consent, the nurse manager is modelling professionalism and a
professional philosophy that includes patient rights such as the right to informed consent. Concern for this right is associated with safe, competent, and ethical care.
The nurse manager plays a unique role in institutional management in that the nurse manager:
a. Encourages shared decision making.
b. Models professional nursing behaviour.
c. Interprets health care trends and their effect on revenues.
d. Coordinates care and allocates resources.
ANS: B
Rationale: Encouragement of shared decision making, coordination of resources, and interface between internal and external factors in a unit are all associated with effective management but could be performed by a manager from any discipline. The nurse manager’s unique role is modelling professional behaviour.
In developing an orientation program, the hospital educator breaks essential organizational information down into chunks, which she develops as online modules. This is an application of which one of Peter F. Drucker’s functions of management?
a. Establishment of goals and objectives.
b. Motivation and communication.
c. Analysis and interpretation of performance.
d. Organization of activities into manageable tasks.
ANS: D
Rationale: Organizing the information into online modules is an application of Drucker’s organizational analysis and the division of activities, decisions, and relations into manageable tasks.
Julia is a staff nurse who works on a rehabilitation unit. Julia tells you that the assistants are experiencing difficulty with the new lift and wonders what your thoughts on organizing an
educational session would be. Julia is:
a. Communicating a vision for safety.
b. Taking a risk in identifying the problem with safety.
c. Coordinating the development of knowledge and skills necessary to use the lift.
d. Taking responsibility for identifying a safety concern and conceding authority for a solution to you.
ANS: D
Rationale: Communication of a vision and risk taking are leader traits, whereas coordination is a manager trait. Taking responsibility while conceding authority to the leader is depicted in the example.
Which of the following is not one of Peter F. Drucker’s functions of management?
a. Establishment of goals and objectives.
b. Analysis and interpretation of performance.
c. Motivation and communication.
d. Political activism.
ANS: D
Rationale: Establishes objectives and goals for each area and communicates them to the persons who are responsible for attaining them, organizes and analyzes activities, decisions, and relations needed and divides them into manageable tasks, motivates and communicates with the
people responsible for various jobs through teamwork, analyzes, appraises, and interprets performance and communicates the meaning of measurement tools and their results to staff and superiors, develops people, including self.
Managers must understand generational differences related to the nursing work environment. Job satisfaction is crucial to a healthy work environment. Which of the following identifies as having the most job satisfaction?
a. Generation-x
b. Millennials
c. Generation-y
d. Baby boomers
ANS: D
Rationale: This idea was confirmed in a Canadian study of acute care nurses conducted by Widger, Pye, Wilson, et al. (2007). In that study, data were collected from 8207 registered Ontario
nurses and registered practical nurses made up of Baby Boomers, Generations Xers, and Generation Yers. Although Baby Boomer nurses showed a high degree of job satisfaction, Generation X and Y nurses did not.
The most important aspect of budgeting for the nurse manager is:
a. To have hierarchal approval
b. To have decision-making ability
c. To have budgetary control
d. To have input from others
ANS: C
Rationale: Mentoring has been defined as “an intense interpersonal exchange between a senior experienced colleague (mentor) and a less experienced junior colleague (protégé) in which the mentor provides support, direction, and feedback regarding career plans and personal development”. Mentoring is a voluntary, an interactive, and mutually beneficial and multifaceted relationship role that assists staff with setting realistic, attainable goals.
Management practices when instituting complex organizational change include which of the following (Select all that apply.)
a. Creating and sustaining trust.
b. Managing the change process actively.
c. Including workers in the work redesign and workflow decisions.
d. Actively managing the change process.
ANS: A, B, C, D
Rationale: Five management practices have been found to be effective when instituting change in complex organizations: Managing the change process actively, balancing the tension
between efficiency and reliability, creating a learning environment that creates and sustains trust, involving the workers in the work redesign and the workflow decision making.
The Code of Ethics for Canadian Registered Nurses ensures that nurses are accountable for patient care. This framework also includes the following aspects within a professional role (Select all that apply.)
a. Patient rights.
b. Broader social justice.
c. Quality work environments.
d. Is regulated by the Canadian Nurses Association.
ANS: A, B, C
Rationale: Professional nursing within an ethical framework also involves endeavouring to address broad aspects of social justice that are associated with health and well-being. The primary values within the code of ethics that support patient rights include preserving dignity, promoting and respecting informed decision making, and maintaining privacy and
confidentiality (CNA, 2008).
A nurse manager is discussing with unit staff the repeated lack of staff compliance in documenting exercise activity for patients who have undergone cardiac surgery. The unit’s
licensed practical/vocational nurses are responsible for ensuring that patients carry out the prescribed exercise regimen and that the activity is documented. According to Drucker’s
five basic functions of a manager, which of the following are appropriate functions for the nurse manager to use when addressing this situation? (Select all that apply.)
a. Divide the necessary activities into manageable tasks, so that patients adhere to the exercise regimen.
b. Establish objectives and goals for each area and decide who is accountable for them.
c. Allow patients to organize the activities.
d. Engage in activities that motivate the health care team, and communicate effectively with the responsible staff members.
e. Analyze, appraise, and interpret the performance of responsible staff members, and communicate these findings to staff management.
f. Allow patients to establish objectives and goals.
ANS: A, B, D, E
Rationale: Drucker’s five basic functions include division of work into tasks; development and communication of goals and outcomes; motivation and communication; and analysis, approval, and interpretation of staff performance.
The risk manager informs the nurse manager of an orthopedic unit that her unit has had an increase in incident reports about patients falling during the shift from 2300 to 0700 hours. The nurse manager knows that the best way to resolve the problem is to:
a. Use creativity.
b. Obtain support from staff of the shift from 0700 to 1500 hours.
c. Use institutional research.
d. Identify the problem.
ANS: D
Rationale: Identification of a problem is the first step in problem solving and occurs before any other step. Improper identification of a problem is the most common reason for failure to resolve problems.
The nurse manager of a rehabilitation unit wants to purchase a new antiembolic stocking. To make a high-quality decision, the nurse manager would:
a. Involve the rehabilitation staff in the decision.
b. Involve the sales representative.
c. Make the decision alone.
d. Involve administration in the decision.
ANS: A
Rationale: Shared decision making leads to a number of successful outcomes, including team pride, the
team’s ability to engage in discussions with the nurse leader about work issues, and continued team involvement in shared decision making. Involvement of other health care professionals is essential in decisions involving patient care.
Several nurses on an adolescent psychiatric unit complain that the teenagers are becoming unmanageable on the shift from 2300 to 0700 hours. To resolve this problem, the nurse manager decides that the staff should have a brainstorming session. The goal of
brainstorming is to:
a. Evaluate problem solutions.
b. Critique the ideas of other staff members.
c. Generate as many solutions as possible.
d. Identify only practical and realistic ideas.
ANS: C
Rationale: Brainstorming encourages creativity in the beginning of problem solving and avoids premature shutting down of ideas through early evaluation.
During a fire drill several psychiatric patients become agitated. The nurse manager quickly assigns a staff member to each patient. This decision style is most appropriate for:
a. Routine problems.
b. Crisis situations.
c. Managers who prefer an authoritarian style.
d. Followers who cannot agree on a solution.
ANS: B
Rationale: Some problems, such as the crisis situation depicted in this example, necessitate immediate decision making to ensure patient safety.
After the nurses who work on an adolescent psychiatric unit have had a brainstorming session, they are ready to resolve the problem of teenagers who are unmanageable. To maximize group effectiveness in decision making and problem solving, the nurse manager has:
a. Prevented conflict.
b. Formed highly cohesive groups.
c. Used majority rule to arrive at decisions.
d. Encouraged equal participation among members.
ANS: D
Rationale: The nurse leader or manager needs to provide a nonthreatening and positive environment, in which group members actively participate, by controlling aggressive individuals and encouraging passive individuals to participate actively. Diversity, managed conflict, and moderate cohesiveness are effective in reaching quality decisions.
To solve a problem, the nurse manager understands that the most important problem-solving step is:
a. The implementation phase.
b. Identification of numerous solutions.
c. Accurate identification of the problem.
d. Evaluation of the effectiveness of problem resolution.
ANS: C
Rationale: To proceed effectively, it is important to determine whether a problem exists and to accurately identify a problem. Failure to resolve problems is most often linked to improper identification of the problem.
A clinic nurse has observed another nurse deviating from agency policy in performing wound care. The best approach for the clinic nurse to take is to:
a. Stay out of it.
b. Inform the nursing supervisor.
c. Fill out a notification form (incident report).
d. Assess the risk to the client and the agency before proceeding.
ANS: D
Rationale: In assessing risk, the nurse engages in the initial step of the problem-solving process, which involves asking, “What benefits (or risks) will be derived from solving it?” Purposeful inaction may not be appropriate when the individual cannot resolve the problem or when there is risk to patients.
The clinic nurse understands that problem solving is best defined as
a. A higher order thinking process.
b. Selecting the best option for reaching a predefined goal.
c. Identifying “what is” and “what should be.”
d. Determining creative approaches to resolving a problem or issue.
ANS: C
Rationale: Critical thinking is a higher order thinking process. Problem solving is a step in decision making that is focused on solving an immediate problem, which can be viewed as a gap between “what is” and “what should be.”
The risk manager wants to evaluate the reasons for an increased number of falls on the rehabilitation unit. The risk manager devises a fishbone diagram. A fishbone diagram is a useful tool to:
a. Identify the root causes of problems.
b. List possible solutions to problems.
c. Help leaders select the best options.
d. Evaluate the outcomes of decisions made.
ANS: A
Rationale: A fishbone diagram, also known as a cause-and-effect diagram, is useful for determining the reasons (causes) for an effect (falls).
An outpatient surgery manager is evaluating infusion pumps for the operating room. The manager should:
a. Select the least expensive brand.
b. Use a decision-making tool to evaluate brands.
c. Ask the nursing staff which brand they prefer.
d. Select the vendor from which the institution usually buys.
ANS: B
Rationale: Decision-making tools such as decision grids and SWOT (strengths, weaknesses, opportunities, and threats) analyses are most appropriate when information is available and options known.
Which statement best defines the difference between problem solving and decision making?
a. Decision making skills require critical thinking; problem-solving skills do not.
b. Problem-solving skills require critical thinking; decision-making skills do not.
c. Decision making is a goal-directed effort; problem solving is focused on solving
an immediate problem.
d. Problem solving is a goal-directed effort; decision making is focused on solving an immediate problem.
ANS: C
Rationale: Problem solving is focused on solving immediate problems, whereas decision making is a goal-directed process that is aimed at selecting appropriate actions from among options. Not all decisions begin with a problem.
Silvana, a nurse manager, has a staff nurse who has been absent a great deal for the past 3 months. A coworker gives some information to Silvana indicating that the staff nurse will be
resigning and returning to school. Because of this Silvana decides to do which of the following?
a. Immediately fire the staff nurse.
b. Speak to the coworker and elicit more information.
c. Speak to the staff nurse and ask her to resign.
d. Do nothing.
ANS: D
Rationale: Doing nothing is often warranted because of lack of energy, time, or resources to solve the real problem adequately, and because the benefits are not seen as sufficiently compelling to commit to an action.
The maintenance department wishes to have the nursing lounge renovated so that the lounge will be more “user-friendly.” The department asks the nursing staff to make a wish list of
everything that they would like to see in the new lounge. This process is an example of which part of the decision making process?
a. Assessment/data collection.
b. Planning.
c. Data interpretation.
d. Generating hypotheses.
ANS: A
Rationale: In this particular model (a model similar to the nursing model), data collection is the first step toward identifying important alternatives or determining whether there is a problem or problems.
A good nursing decision maker is one who:
a. Uses various models to guide the process on the basis of the circumstances of the situation.
b. Adopts one model and uses it to guide all decision making.
c. Decides not to use any models because they are all useless.
d. Develops a new model each time a decision has to be made.
ANS: A
Rationale: Research has determined that a structured approach to decision-making increases critical thinking and is the best way to learn how to make quality decisions because it eliminates
trial and error and focuses on proven processes.
From the information supplied in this chapter, which statements best defines critical thinking?
a. Critical thinking is a high-level cognitive process.
b. Critical thinking is a process that helps develop reflective criticism for the purpose of reaching a conclusion.
c. Critical thinking is an orderly approach to considering problems, through the use of knowledge of methods of logical inquiry and reasoning skills.
d. Critical thinking is a discussion that guides all aspects of the nursing process.
ANS: C
Rationale: Critical thinking is associated with a thoughtful and orderly approach to considering problems, knowledge of methods of logical inquiry and reasoning skills, and the ability to apply them. In practice, critical thinking involves recognizing problems and finding ways to solve them by gathering pertinent information, appraising evidence, and evaluating arguments.
Decision making is described by the nursing educator as the process that a person uses to
a. Solve a problem.
b. Choose between alternatives.
c. Reflect on a certain situation.
d. Generate ideas.
ANS: B
Rationale: The hallmark of decision making is choosing among options. Generating options is one phase of decision-making, and solving a problem refers to problem solving, which is problem centred. Decision making does not always begin with problems, but rather it is defined as a purposeful, goal-directed effort in which a systematic process is used to choose among options.
Justin is a nurse manager in a rehabilitation unit in a small urban centre. There is a high turnover rate among rehabilitation assistants because of the heavy work assignments. Justin decides to hire new staff in the order that applications are received until all vacant positions are filled. Which of the following decisions did Justin make?
a. Subjective.
b. Objective.
c. Optimizing.
d. Satisficing.
ANS: D
Rationale: The satisficing decision is a decision-making model whereby the decision-maker selects the solution that is the simplest and provides for the quickest solution.
Which of the following is an intuitive decision-making model?
a. Fishbone model.
b. SWOT model.
c. Clinical judgement model.
d. Bounded rationality model.
ANS: C
Rationale: The clinical judgement model described by Tanner (2006) emphasizes the role of intuition in decision making by nurses, particularly expert nurses.
When confronted with the controversy and the apparent poor morale of the evening staff, the unit manager decided the staff needed to take some time off. He scheduled holidays for the staff without consulting them. A couple of the staff nurses approached the manager and indicated that the problem was not scheduling, but rather the team leader and her patient
assignments. What was the unit manager’s first missed step in problem solving?
a. Not using a problem-solving model.
b. Not considering a number of alternatives.
c. Poor evaluation of outcomes.
d. Incorrect problem identification.
ANS: D
Rationale: The unit manager did not begin with an accurate identification of the problem. Problem solving needs to begin with “why?”
One of three managers at a research laboratory drafted a policy that would allow his department to do more testing in his laboratory. This policy included the times for regular collection in addition to a new process for emergency laboratory testing. The policy and procedures were never followed. The reason was that:
a. The policy was too lengthy and inundated readers with too much detail.
b. The policy made decisions for other departments in the company.
c. The staff did not believe that the new policy would be effective.
d. Testing should not be done in the laboratory.
ANS: B
Rationale: Other departments were not involved in the problem-solving process; therefore they lacked input into the concerns, issues, and possible solutions. Thus it is not surprising that they did not follow the new policy of another department. Problem solving should be a group process that should involve as many personnel as possible.
Decisions are most likely to be of high quality in nursing situations when:
a. Team leaders make the crucial decisions.
b. Individuals are advised of the problems.
c. Group size is neither too small nor too large.
d. Members are passively involved.
ANS: C
Rationale: Research has shown that group size is important. Too small a group means a limited number of options generated. Too large a group can mean lack of structure or lack of meaningful discussion.
Knowing when to have the entire team participate in the decision-making process or when to have only the team leader make the decisions depends on the situation and the desired outcomes. Which situation would warrant individual decision making?
a. The task and the outcome are relatively simple.
b. It is unlikely that the group will reach a consensus.
c. A decision has to be discussed thoroughly.
d. A number of options need to be considered.
ANS: A
Rationale: People respond to cues in the situation and draw from stored information (tacit knowledge that is hard to describe) in the subconscious to make rapid decisions instead of taking an incremental, analytical approach such as that found in the rational decision-making model.
Rational thinking and intuitive thinking are complementary, and successful decision making is a balance between the two approaches. If the task and the outcome are relatively simple, decisions can be made by one individual.
Marcella, an experienced head nurse, is given the task of completing the summer vacation schedule for the pediatric unit. She is fully aware of the hospital’s restrictions on time off
and the number of staff on vacation at any given time, in addition to its issues regarding seniority. She weighs the options of allowing staff choice, such as it takes more time but gives employees options. However, if choice is allowed, this could cause arguments. Which of the following is the best alternative?
a. Ask for requests for vacation time in advance, and post the times.
b. Post the completed vacation schedule.
c. Post a tentative schedule, and request feedback.
d. Post a blank schedule, and ask staff members to fill in their times by a given date.
ANS: D
Rationale: This choice is based on a decision-making model that allows experience and knowledge to predict whether a decision will or will not work. The experience of the head nurse suggests that it is important to involve staff in decisions that affect them the most.
With regard to decision making, critical thinking, and problem solving, which of the following statements are accurate and valid points?
a. The professional decision maker approaches problem solving by beginning with an outcome already in mind.
b. Involvement in decision making is of little use unless you are an expert
decision-maker.
c. Many models aid the nurse in improving his or her decision-making skills.
d. The nursing decision-maker who is successful recognizes that only those with similar experiences should be involved in decision making.
ANS: C
Rationale: A nurse can draw upon many models in making a decision. It is critical to realize that decision-making expertise grows with exposure to decision making, and that diversity in expertise helps in developing options.
The two elements essential to solving any problem are:
a. Problem analysis and decision making.
b. Strategy and rationality.
c. Operational and strategic.
d. Tactical and strategic.
ANS: A
Rationale: Problem analysis includes identifying, clarifying, and verifying a problem, whereas decision making focuses on developing cognitive strategies to solve a problem. Problem analysis begins with an investigation of the presenting problem. Decision making involves the individual, or organization, choosing a rational action, based on individuals’ preferences.
A decision making model based on a rational and logical approach to problem solving is termed:
a. Nursing process.
b. Ethical decision making.
c. Creative decision making.
d. Scientific decision making.
ANS: D
Rationale: The scientific method is a rational, logical, and widely used problem-solving approach. It is the foundation for many models of decision making.
Which decision-making model is based on the use of intuition when making a decision?
a. Bounded rationality.
b. Fishbone diagram.
c. Clinical judgement model.
d. Rational decision-making model.
ANS: C
Rationale: The Clinical Judgement Model described by Tanner (2006) emphasizes the role of intuition in decision making by nurses, particularly expert nurses. This model is systematic and similar in its sequence of steps to other models, although the thinking processes involved differ.
An efficient and useful technique for controlling negative group behaviours is:
a. Six thinking hats.
b. SWOT analysis.
c. SOAR analysis.
d. Nominal group technique.
ANS: D
Rationale: Nominal group technique involves asking individual group members to identify a problem, generate solutions, establish priorities and respond to questions posed by obtaining views on a topic by a moderator and arriving at a consensus (Harvey & Holmes, 2012). Typically this
is accomplished through asking participants to evaluate and prioritize the ideas of a structured, mediated, approach by all group members.
Many factors affect decision-making such as bias. Which of the following reflect bias? (Select all that apply.)
a. Past experiences.
b. Personal attributes.
c. Creativity.
d. Intuition.
ANS: A, B
Rationale: Internal factors include variables such as the decision maker’s physical and emotional state, personal philosophy, biases, values, interests, experience, knowledge, attitudes, and risk-seeking or risk-avoiding behaviours. External factors include environmental conditions, time, and resources.
In a busy rehabilitation unit, the team manager decided that the best way to reward the staff was to give them a monetary bonus rather than time off. The staff was very concerned about
the decision and went to the administration with a number of complaints. Critical thinking is a process that entails a number of steps. What steps did the manager omit? (Select all that apply.)
a. Identifying the assumptions that were underpinning the issues.
b. Considering the context of the current problem or situation.
c. Gathering data and evaluating all possible outcomes before making her decision.
d. Attaining a majority consensus of all staff.
ANS: A, B, C
Rationale: Taking a majority consensus is not a step in the critical thinking process. Steps A, B, and C are considered by most authors to be the essential steps in the process of critical thinking.
Complex care of acutely ill patients is required on a surgical unit in which differentiated nursing practice is its model of care delivery. The concept of differentiated nursing practice is based on:
a. Licensure status.
b. Experience in the agency.
c. Leadership capabilities.
d. Education and expertise.
ANS: D
Rationale: In differentiated nursing practice, rules are structured according to education and experience.
The relief charge nurse has assigned a newly registered baccalaureate prepared nurse to be one of the team leaders for the shift from 1500 to 2300 hours. In making this decision, the
charge nurse has overlooked this nurse’s:
a. Clinical expertise.
b. Leadership ability.
c. Communication style.
d. Conflict-resolution skills.
ANS: A
Rationale: The effective functioning of teams in this model is heavily reliant on the leadership, organization, and communication skills of the leader, in addition to comfort and confidence
in providing care to a specific patient group. Although leadership and critical thinking are part of basic education in baccalaureate programs, the new registered nurse (RN) needs time
to develop clinical confidence and expertise.
When interviewing an applicant for a position, the nurse manager describes the unit’s care delivery system as one in which each nursing assistant is cross-trained to perform specific
tasks, and in which the RNs handle all intravenous medications, admissions, and discharge teaching. The nurse applicant knows this nursing care delivery strategy to be:
a. The case method.
b. Functional nursing.
c. Primary nursing.
d. Nurse case management.
ANS: B
Rationale: The functional care delivery model depends on the decision of care according to tasks or functions that are assigned to specific teams or team members.
You are the nurse manager of a nursing service organization that provides around-the-clock care to patients in their homes. To achieve an optimal outcome for a patient who is
recovering from a hip replacement, the nursing staff will probably follow the nursing care guidelines presented in which of the following?
a. Nursing care plan.
b. Physician’s orders.
c. Critical pathway.
d. Clinical practice guidelines.
ANS: C
Rationale: A critical pathway outlines outcomes, clinical standards, and interventions for a patient in each phase of treatment. The goal of critical pathways is effective coordination of care across various staff and levels of care, and to optimize patient outcomes.
The nurse case manager is working with a patient admitted for end-stage renal disease. The case manager’s major goal during this hospitalization is to:
a. Implement the care map on admission.
b. Provide direct nursing care throughout the hospitalization.
c. Supervise the nursing staff members who implement the care map.
d. Prevent the need for additional hospitalizations resulting from complications of the patient’s disease.
ANS: D
Rationale: The goals and outcomes established in a care map or critical pathway are designed to support the aims of case management, which are shortened hospital stays and prevention of the need for hospital readmissions.
The nurse manager at a cardiac rehabilitation unit was asked to select a care delivery model. Which of the following methods would be the most cost effective?
a. Functional method.
b. Case management method.
c. Primary care method.
d. Team method.
ANS: B
Rationale: Team nursing, functional nursing, and case management are all considered efficient, cost-effective methods of care delivery because they enable use of various types of health
care providers (rather than baccalaureate nurses in direct care, which is the primary nursing method). Case management is considered particularly cost effective in patient care settings that have the potential for high resource consumption, such as settings with medically complex cases, through collaboration and close attention to outcomes.
In an acute care unit, the nurse manager utilizes the functional nursing method as the care delivery model. The nurse manager’s main responsibility is the needs of which of the following?
a. The department.
b. The unit.
c. Staff members.
d. The patient.
ANS: D
Rationale: In a functional nursing model, in which other team members are focused on performing specific tasks, the nurse manager assumes primary responsibility for patient outcomes.
A patient is admitted to a medical unit with pulmonary edema. His primary nurse admits him and then provides a written plan of care. What type of educational preparation best fits the role of primary nurse?
a. Baccalaureate.
b. Associate,
c. Diploma.
d. Licensed practical nurse/licensed vocational nurse.
ANS: A
Rationale: Because of the breadth of nursing knowledge required, baccalaureate education is preferred
for primary nurses.
In a small rural nursing home a director of nursing decides to implement a partnership model, because of a shortage of nurses, to help with certain tasks. What combination of health care providers constitutes a partnership care delivery model?
a. RN and licensed practical nurse/licensed vocational nurse.
b. RN and RN.
c. RN and medication assistants.
d. RN and certified nurses’ aides.
ANS: C
Rationale: The partnership care delivery model is a variation of primary nursing in which an RN works with a medication assistant, who performs basic nursing functions.
The case method of care delivery could be best justified for which of the following scenarios?
a. Stable patient population with long-term care and family needs.
b. Acute care surgical unit with predictable postsurgical outcomes and many technical procedures.
c. Pediatric intensive care unit that heavily involves families and also patients.
d. Home health care environment with patients who have varying degrees of acute illness.
ANS: C
Rationale: The setting in which the case method of delivery can be most justified is the pediatric intensive care unit, in which the status of patients can rapidly change and complex functions
of care involve both patients and families.
During times of nursing shortage and increased nursing costs in health care, which of the following nursing care delivery models might come under greatest scrutiny?
a. Case method.
b. Team nursing.
c. Functional nursing.
d. Nurse case management.
ANS: A
Rationale: The case method may involve an RN’s treatment of the “total patient.” Employment of the most highly paid nursing personnel (RNs) for all patient care is the most expensive model and may be difficult to operationalize in times of RN shortage.
A patient complains to you that she has no idea who “her nurse” is on any given day. “I ask one nurse for my pills, and she says, ‘That is not my job.’ I ask the pill nurse about my lab tests, and she says that I should ask another nurse.” The nursing care delivery model most likely to be employed in this situation is
a. Differentiated practice.
b. Team nursing.
c. Functional nursing.
d. Case management.
ANS: C
Rationale: In functional nursing, licensed and unlicensed personnel perform specific tasks for a large
number of patients. A disadvantage of this system is that care is assigned by task and not by patient, which can leave patients with the experience of multiple caregivers and a sense of
confusion.
The functional nursing model might be particularly effective in which of the following?
a. Promoting communication among diverse team members.
b. Facilitating multiple perspectives on the total care of a patient.
c. Avoiding patient–provider conflict.
d. Developing competence and confidence in unlicensed workers.
ANS: D
Rationale: An advantage of functional nursing is that both unlicensed assistive personnel and licensed
staff are involved in performance of specific tasks, and the repeated performance of tasks enables staff to become very efficient in specific functions. Disadvantages of the model
include difficulty in being able to assess the patient’s nonphysical needs effectively and the potential for ineffective communication because of the focus on specific tasks.
For a nurse manager in the functional nursing model, which approach will assist in maintaining staff satisfaction in this specific model?
a. Rotation of task assignments.
b. Frequent opportunities for in service education.
c. Orientation to job responsibilities and performance expectations.
d. Team social events in off hours.
ANS: A
Rationale: Although repetition of tasks increases confidence and competence, it can also lead to boredom. In-service opportunities, adequate orientation, and building a team culture are strategies that are important to all models, but rotation of tasks can specifically reduce the boredom that is a potential disadvantage of this model.
In comparing team and functional models of care, a nurse manager favours the team model. In particular, she finds that the team model:
a. Can be effective in recognizing individual strengths and backgrounds of staff members.
b. Promotes autonomy and independence of the RN.
c. Avoids conflict because of role clarity.
d. Is efficient in delivering care to a large group of patients with the use of a staffing mix.
ANS: A
Rationale: Team nursing delivers care to a small group of patients; the team is a mix of licensed and unlicensed personnel. Assignment is based on the needs and background of the patient and on the strengths, licensure, and roles of team members. Team functioning and satisfaction can be compromised unless the team leader has strong delegation, communication, and leadership skills.
To effectively delegate in a team nursing environment, the RN team leader must be familiar with the legal and organizational roles of each group of personnel and must:
a. Be able to effectively communicate with patients.
b. Build relationships with physicians.
c. Be able to adapt to daily changes in staffing.
d. Adapt in communicating information to the supervisor.
ANS: C
Rationale: A particular challenge in team nursing is that staff mixes and personnel may change daily because of individual schedules and shortages.
A nurse manager questions the true difference between primary nursing and total patient care. After careful consideration of both models, the nurse manager concludes that primary
nursing differs significantly from total patient care in which way?
a. Breadth of nursing knowledge and expertise required.
b. Intention to provide holistic nursing.
c. Time period of accountability.
d. Levels and types of assessment.
ANS: C
Rationale: Significant overlap can be seen between primary nursing and total patient care in terms of breadth of assessment and knowledge required to provide holistic care. A primary difference is that nurses in the total care model assume accountability while on shift, whereas primary nurses assume responsibility from a patient’s time of admission to discharge and 24 hours a day during the hospital stay.
A conflict develops between an associate nurse and a primary nurse over the assessment of a patient with pulmonary edema. On the basis of her assessment of the patient, the associate nurse insists that it is her role to change the care plan because she is the one who has made the assessment. As the nurse manager, you clarify that:
a. It is the role of the primary nurse to make alterations on the basis of assessment data and input.
b. The associate nurse is accountable and responsible while the primary nurse is off duty and therefore is able to alter the care plan.
c. Neither the primary nurse nor the associate nurse should make changes without first consulting you as the manager.
d. It really does not matter who alters the nursing care plan because it depends on situation and time to do so.
ANS: A
Rationale: The primary nursing model assumes that the primary nurse is accountable for patient care, even while off duty. The primary nurse is responsible for establishing the patient plan of care and therefore for altering it with the input of an associate. The associate is responsible for the implementation of the care plan that has been established when the primary nurse is off duty.
When comparing functional nursing and primary nursing, a nurse manager, after evaluating particular models of nursing care for potential adoption, determines that patient and nurse satisfaction in primary nursing are:
a. Similar to those in functional nursing.
b. Not of significance in either model.
c. Low in comparison with that in functional nursing.
d. High in comparison with that in functional nursing.
ANS: D
Rationale: Primary nursing tends to be satisfying for RNs who enjoy a high level of accountability and autonomy in decision-making. Patient satisfaction is also high, inasmuch as patients form
close therapeutic relationships with the nurse because of the continuousness of the relationship. Functional nursing is criticized for low patient satisfaction and potential staff
dissatisfaction related to boredom and an autocratic approach to management.
In transitioning to a primary nursing model, it is important for a nurse manager who enjoys a high level of control over patient care to understand that his or her decision making at the patient care level:
a. Is increased.
b. Is decreased.
c. Is relinquished.
d. Remains the same.
ANS: B
Rationale: The nurse manager who is considering movement to primary nursing needs to consider how the role of the manager changes, in addition to the roles of the staff. The role of decision-making at the patient care level is relinquished to the primary nurse. The nurse manager functions as a role model, advocate, coach, and consultant.
You are considering putting forward a proposal to move the model of care from team nursing to a primary nursing hybrid—a patient-focused care model. In considering this proposal, you recognize that significant costs specific to operationalizing this model are related to which of the following?
a. Implementation of an all-RN staff complement.
b. Significant changes in the physical structure of units.
c. Orientation of staff to new roles and responsibilities.
d. Testing and piloting technology at the patient’s bedside.
ANS: B
Rationale: This particular model includes a focus on patient care that includes multidisciplinary teams and assistants at the patient’s bedside. Services, including those of laboratories and pharmacies, are decentralized to bring them closer to where care is delivered.
When hiring a case manager for a rehabilitation setting, you are most likely to consider which of the following?
a. A registered nurse with a master’s degree.
b. A physiotherapist with a background in stroke rehabilitation.
c. A social worker with a background in counselling.
d. A health care provider with advanced background who is focused on patient and outcome.
ANS: D
Rationale: Case managers can come from a variety of disciplines but should have advanced preparation with the particular at-risk population being served, be comfortable in an advocate role, and be focused on outcome and patient.
Case-managed care may enhance profit in a for-profit health organization by:
a. Minimizing costs in areas of high resource consumption.
b. Combining licensed and nonlicenced care providers in delivering patient care.
c. Increasing reimbursement from third-party payers.
d. Reducing the amount of technology used to support clinical decision making.
ANS: A
Rationale: Case-managed care does not generate revenue; rather, it protects revenue in that better coordination of care enables efficient achievement of patient outcomes, can result in a shorter length of hospital stay, and can prevent the need for readmission.
In the hiring of nurses during the transition from team nursing to a primary nursing model, Benner’s (2001) work suggests that you give priority to nurses who are at least at which level of competency?
a. Advanced beginner.
b. Competent.
c. Proficient.
d. Novice.
ANS: B
Rationale: Nurses who have less than 2 or 3 years of experience in primary nursing or less than 2 or 3 years of nursing experience will probably require more assistance than do other nurses, which will put a greater demand on the unit during a time of transition.
In considering whether to accept a job offer in a hospital in which the synergy model of care is used, you expect that which of the following is the driver of the necessary nurse competencies for practising within this model?
a. Educational background of the nurse.
b. Patient population characteristics.
c. Interdisciplinary health care teams.
d. National nurse-to-patient ratios.
ANS: C
Rationale: The synergy model identifies patient characteristics as “drivers” of the necessary competencies for nurses.
Differentiated nursing practice, or staff mix, is a model of clinical nursing practice that combines different categories of health care personnel employed for the provision of direct
client care. What is the biggest aspect of this model in decreasing its success?
a. Supports each nurse’s level of education.
b. Varied educational backgrounds and philosophies of nurses.
c. Increases satisfaction of patients.
d. Increases satisfaction of nurses.
ANS: B
Rationale: Despite a variety of efforts to differentiate the roles and competencies of nurses with various
educational backgrounds and experience, the demands of the workplace, the chronic shortage of nurses, and the greater use of technology have made it difficult to differentiate nursing practice in many clinical settings even among RNs with differing levels of education.
Nursing case management is geared to providing comprehensive care for those with complex health problems. Which of the following supports the use of a case management model?(Select all that apply.)
a. Decreases length of stay.
b. Increases efficient use of services.
c. Increases nurse sense of satisfaction.
d. Decreases human resource inequities.
ANS: A, B, C
Rationale: Although case management has many benefits, there are also several barriers including financial barriers, lack of administrative support, human resource inequities, turf battles, and a lack of information support systems.
The total patient care method, or patient allocation method, of nursing care delivery is the oldest model of providing care to patients. One nurse provides total care to one or two critically ill patients, or to a group of patients. Which of the following contributes to the success of this model? (Select all that apply.)
a. Current global nursing shortage.
b. High costs.
c. Provides high quality care.
d. Engenders trust between family and nurse.
ANS: C, D
Rationale: In today’s costly health care environment, total patient care provided by one nurse, typically an almost all registered nurse (RN) staff, is very expensive. In a time of a global nursing shortage, there may not be enough nurses to use this model or funding to provide for this model of care. The nurse, patient, and family trust one another and work together toward specific goals. Total patient care remains popular with patients as the care is seen as being consistent and high quality, and care that is provided by highly qualified nursing staff.
The chief nursing officer implements the team nursing model on the acute care units. Expectations of the team leader include which of the following?(Select all that apply.)
a. Being attentive to the needs of the organization.
b. Being newly graduated with a baccalaureate degree.
c. Having several years of clinical nursing practice.
d. Being attentive to the needs of the patient.
e. Being attentive to the needs of the staff.
ANS: C, D, E
Rationale: Team leaders require both leadership skills and knowledge, in addition to clinical confidence and expertise, to effectively delegate responsibilities according to staff background, role, and expertise and according to patient needs.
John is part of an interdisciplinary care team on a surgical unit. Interdisciplinary care teams:
a. Increase fragmentation of care.
b. Improve quality of patient care.
c. Increase duplication of services.
d. Need to include licenced and unregulated care providers.
ANS: B
Rationale: The benefits of interdisciplinary care can be recognized through reduced duplication of services, decreased fragmentation of care, and improved quality of care for patients. Implementation and integration of interdisciplinary teams within Canada’s health care system has the potential to allow health care providers to practise to their full scope of practice and create innovative, sustainable ways to provide high quality health care for all
Canadians.
The nurse manager is setting up the room assignments for the unit. One patient on the unit is in critical condition and is going to require more care than the others. Before delegating a task, a nurse manager should:
a. Delegate the admission assessment to the licenced practical nurse.
b. Review the employee’s performance assessment for the most recent period.
c. Assess the amount of guidance and support needed in a particular situation.
d. Create a task analysis of critical behaviours for the patient.
ANS: C
Rationale: To delegate effectively, the nurse manager must assess the abilities required in the situation
and the abilities that staff have. The nurse manager can thereby anticipate the amount of direction, monitoring, explanation, and independence that are needed.
A key advantage that a nurse manager has in terms of delegating is that:
a. Patients receive less attention because too many staff members make it difficult to coordinate care.
b. Nurses report less pressure to perform necessary tasks themselves.
c. Administration can predict overtime more accurately.
d. Team skills can be used more effectively.
ANS: D
Rationale: The use of multilevel health care providers enables health care organizations and nurses to provide patient-centred care, with a focus on abilities and skills that can be employed to perform what is needed when it is needed. As tasks become more complicated, delegating skills to other workers enables the nurse to deliver a complex level of care effectively.
The nurse on the shift from 2300 to 700 hours is assigning a component of care to an unregulated care provider. The night nurse should remain:
a. Accountable and responsible.
b. Accountable and liable.
c. Authoritative and liable.
d. Responsible and task-oriented.
ANS: A
Rationale: The nurse manager should hold self and others accountable for actions and outcomes.
The night nurse understands that certain factors need to be considered before tasks are delegated to others. These factors include which of the following?
a. Complexity of the task and the age of the delegate.
b. Potential for benefit and the complexity of the task.
c. Potential for benefit and the number of staff.
d. Complexity of the task and the potential for harm.
ANS: D
Rationale: In delegating tasks to others, the nurse considers factors such as stability of the patient, safety of the situation and of the patient, time and intensity of the task involved, and level of critical thinking required to achieve desired outcomes.
During a fire drill, the nurse manager becomes very assertive and directive in her communications with staff. This type of situational leadership depends on:
a. Supportive behaviour by the leader and immature followers.
b. The relationship with the followers and the type of behaviour of the leader.
c. Well-trained followers, combined with a strong leader who acts quickly.
d. The leader’s ability to evaluate personnel and communicate that evaluation.
ANS: B
Rationale: The effectiveness of leaders depends on their relationships with followers, which should develop through motivating and inspiring others, as opposed to managing and controlling them.
The unit manager is working in a large metropolitan facility and is told that two unregulated care providers are to be assigned to work with her. Delegation begins with:
a. Acknowledging the arrival of the second unregulated care provider on the unit.
b. Providing clear directions to both unregulated care providers.
c. Matching tasks with qualified persons.
d. Receiving reports from the prior shift.
ANS: C
Rationale: In delegating tasks to unregulated care providers, the nurse must consider what cannot be delegated, in addition to the factors of safety, time, critical thinking, and stability of patients’ conditions.
Although interdisciplinary health care teams are the ideal in Canada, which of the following is an identified barrier to interdisciplinary collaboration?
a. Power equalities.
b. Overlapping scopes of practice.
c. Lack of legislative authority.
d. Lack of professional association support.
ANS: B
Rationale: Identified barriers to interdisciplinary collaboration include policies (including policy overload), funding, power inequalities, and overlapping scopes of practice.
Who is accountable when a registered nurse performs a “transfer of function” from a physician activity?
a. The physician.
b. The director of nursing.
c. The nurse.
d. The institution.
ANS: C
Rationale: The registered nurse is accountable and responsible for nursing care provided. Activities
considered outside the legislative scope of nursing practice were “covered” by extensive use of delegation, or “transfer of function,” from physicians. In some cases, the physician apparently presumes that it would be the employer’s responsibility to ensure that the nurse was competent to provide the care, whereas the employer placed a large portion of the responsibility on the nurse and thus the nursing regulatory body.
In some provinces, a restricted activities or controlled acts model is currently in place. A main distinction between this model and the model of licensure that is still used in most other provinces is that:
a. Each health care provider is registered to conduct specific tasks.
b. Specific acts are licenced.
c. Acts cannot be shared among health care providers unless they are registered.
d. Nurses are bound by exclusive scopes of practice.
ANS: B
Rationale: In Ontario, Alberta, and British Columbia, a common framework known as a restricted
activities or controlled acts model created consistent approaches among the health professions with regard to discipline, registration, continuing competency, and restricted activities. A main distinction between this model and the model of licensure still used in all other provinces and territories is that nurses are not bound by exclusive scopes of practice. Rather than care providers being licenced, specific acts are licenced. This allows more than one profession to perform the same act, or parts of the act, for example, prescribing medication.
Which of the following exemplifies accountability for a nurse manager?
a. Consistently submitting budgets on time.
b. Consistently performing the responsibilities outlined for nurse managers at the institution.
c. Explaining why registered nurse coverage was reduced on nights to the Nursing Practice Committee after serious patient injury.
d. Actively soliciting ideas regarding scheduling from staff.
ANS: C
Rationale: Reliability, dependability, and obligation to fulfill the roles and responsibilities of the nurse manager are consistent with responsibility. Accountability refers to being answerable for actions and results.
Which of the following is a benefit of the controlled acts model over the licensure model?
a. Decreased flexibility in allowing patients choice in their care provider.
b. Limited range of professional responsibility.
c. No firm boundaries.
d. Recognition that scope of practice is static.
ANS: C
Rationale: Several benefits of the controlled acts model over the licensure model have been identified:
It is viewed as allowing health care providers to perform to the range of their competency and abilities; the scope of practice is recognized as not static or to have firm boundaries; it
places greater emphasis on standards and competence; and it increases flexibility in allowing patients more choice in providers and employers more innovation in optimal skill mix, while protecting the public from harm.
Although benefits of the controlled acts model are advantageous and arguably necessary, the legislative reform to recognize overlapping competencies has caused:
a. Role clarity.
b. A decrease in “turf” competition among health care providers.
c. A difficulty in optimizing skill mix.
d. Static boundaries for health care providers.
ANS: C
Rationale: The legislative reform of the controlled acts model to recognize overlapping competencies has caused increased role confusion, further competition over “turf” for various providers, and difficulty in optimizing skill mix.
In delegating to an unregulated care provider in a home health setting, which of the following represents the most appropriate delegation communication?
a. “You will be taking care of Mrs. Srivastava. Mrs. Srivastava needs assistance with her bath.”
b. “You will need to help Mrs. Srivastava get into and out of her shower. Ensure that you check the condition of her feet, and let me know if you have any concerns when you check in.”
c. “I am not sure that you know how to do this, but I am giving you Mrs. Srivastava. She is quite obese and needs skin care.”
d. “Mrs. Srivastava needs help to get into and out of her bathtub. Her bath will need to be completed by 10:00. When you are helping her to dry, please check between her toes and toenails, and phone me by 10:30 if you notice nail discoloration or redness.”
ANS: D
Rationale: Delegation communication is very important and needs to be specific. Communication also includes conveying recognition of the authority to do what is expected.
Which of the following is a domain of the National Interprofessional Competency Framework?
a. Quality improvement.
b. Interprofessional conflict resolution.
c. Contextual issues.
d. Interdisciplinary communication.
ANS: B
Rationale: The framework consists of six competency domains: interprofessional communication;
patient-centred care; role clarification; team functioning; collaborative leadership; and interprofessional conflict resolution.
According to the National Interprofessional Competency Framework, which domain is considered relevant in every situation?
a. Role clarification.
b. Team functioning.
c. Patient-centred care.
d. Collaborative leadership.
ANS: C
Rationale: In every situation, the domains of patient-centred care and interprofessional communication are relevant and consistently influence and support the other four domains.
Which of the following is considered a system-relevant barrier to primary care and public health collaboration?
a. Lack of common agenda.
b. Power and control issues.
c. Resource limitations.
d. Relationship challenges.
ANS: B
Rationale: Although all the choices are considered barriers, only the barrier of power and control issues is considered a system-relevant barrier.
Which of the following is considered an organizational facilitator to primary care and public health collaboration?
a. Shared protocols.
b. Role clarity.
c. Education and training.
d. Philosophy and personal identity.
ANS: A
Rationale: Although all choices are considered facilitators, only shared protocols is considered an organizational facilitator.
Sammi, a registered nurse, is part of an interdisciplinary team that provides care to patients with acute cardiac interferences. The team has not been functioning optimally and Sammi is aware that this may cause a(n):
a. Increase in the cohesiveness of the team.
b. Escalation of turf protection.
c. Increase in the quality of patient care.
d. Decrease in workplace stress.
ANS: B
Rationale: When collaboration is ineffective or unsuccessful, disciplinary silos are reinforced, and turf protection escalates. These environments contribute to workplace stress and adversely affect patient care.
When there is lack of role clarity within an interdisciplinary health care team, health care providers tend to:
a. Work more closely together for role clarity.
b. Move away from their own disciplinary silos.
c. Revert to what is familiar and what they know in relation to health care roles.
d. Increase communication to enable a sharing of role expectations.
ANS: C
Rationale: Role clarity is defined as having an understanding of one’s own role and that of others, and this understanding is applied through description, performance, and communication to achieve patient goals (Canadian Interprofessional Health Collaborative, 2010). When there is lack of role clarity, health care providers tend to revert to what is familiar, often their own disciplinary silos.
When there is lack of role clarity, health care providers tend to remain in their own disciplinary silos. Which of the following would counteract this tendency?
a. Rearranging team membership.
b. Assigning a team leader.
c. Engaging licencing organizations to increase scope of practice details.
d. Practising patient-centred care.
ANS: D
Rationale: When there is lack of role clarity, health care providers tend to revert to what is familiar, often their own disciplinary silos; one way to counteract this tendency is to practise
patient-centred care.
In transferring a patient, Leslie, an unregulated care provider, uses improper techniques. The patient is injured, and as a result, a lawsuit is launched in which both Neha, the delegator, and Leslie, the delegatee, are named. Neha is named in the suit because she:
a. Retains responsibility for the care of the patient.
b. Worked the same shift as Leslie.
c. Has passive accountability for delegation.
d. Retains accountability for the outcomes of care for the patient.
ANS: D
Rationale: Whenever care is provided by someone other than a registered nurse, accountability for care remains with the manager/delegator even though other people provide aspects of care.
One strategy to facilitate clarity about team members and the team process is to:
a. Ensure a range of personality styles on the team.
b. Establish colocation of the team.
c. Appoint a physician as the team leader.
d. Engage a variety of healthcare providers on the team with different levels of power.
ANS: B
Rationale: All team members should be clear about what skills they bring to the health care and team process, and this can be facilitated by the colocation of the team. Although simply grouping a variety of healthcare providers together in the same building will not create a team, colocation can have many benefits, including timely and personal consultations or referrals regarding patient care, increased understanding, and respect for all members’ roles, and informal opportunities to connect, whether personally or professionally.
The rationale for the shift to interdisciplinary teams for health care delivery in Canada is related to: (Select all that apply.)
a. The aging of the population.
b. Increased utilization of unregulated care providers.
c. Nurse shortages.
d. An increase in acute illness and comorbidity.
e. Increasing specialization of health care providers.
ANS: A, C, D
Rationale: Every jurisdiction in Canada is currently implementing interdisciplinary teams in a variety
of settings. The rationale for this shift toward interdisciplinary care is directly related to changes in Canadian health care: the aging population, who have increasingly complex and comorbid illnesses; health care provider shortages; and the realization that no single health care provider can adequately address patient needs in the twenty-first century.
Barriers to initiating interprofessional collaboration are many. Which of the following apply? (Select all that apply.)
a. Practice protection.
b. Regulatory mechanisms.
c. The concept is well accepted.
d. Outdated legislation.
ANS: A, B, D
Rationale: Despite the laudable benefits of interprofessional collaboration, it is a concept that can be difficult to implement and measure in practice. Barriers to collaboration include macro-level restrictions impacting micro-level processes such as outdated legislation, regulatory mechanisms, and practice protection.
The controlled acts model is structured so that those outside a particular profession are not necessarily restricted. The controlled acts model has several benefits over the licensure
model. Which of the following is not a benefit over the licensed manner? (Select all that apply.)
a. It allows professionals to perform to the range of their competency and abilities.
b. It places greater emphasis on standards and competence.
c. It increases flexibility in allowing patients more choice in providers.
d. Perform particular services or functions within professions.
ANS: A, B, C
Rationale: Perform particular services or functions within professions is part of the licensure system. Over time several provinces have replaced health professional licensing, which allowed only professions with a particular license to perform particular services or functions within regulation. Ontario, Alberta, and British Columbia have adopted a common framework known as a “restricted activities” or “controlled acts” model.
What is an intraprofessional team is composed of? (Select all that apply.)
a. A mix of same discipline with different levels of education.
b. Members of same discipline.
c. Members of different disciplines.
d. Members of different disciplines with extended levels of education.
ANS: A, B
Rationale: Nurses working in an intraprofessional team can registered practical nurses, degree nurses, advanced practice nurses, and nurses holding a doctoral degree.
The number of adverse events such as falls and pressure ulcers on your unit is increasing. An ideal staffing plan to address this issue would include which of the following?
a. Increasing the total number of staff on the unit.
b. Increasing the staff and registered nurse (RN) hours per patient.
c. Increasing the total number of staff and implementing 12-hour shifts.
d. Increasing the number of RNs and number of RNs with experience on the unit.
ANS: D
Rationale: A number of studies (for example, Dunton et al., 2007) have demonstrated that adverse events such as falls can be reduced by increasing the number of RNs on a unit (relative to other personnel), and the number of experienced RNs. Overtime and 12-hour shifts are linked to higher incidences of errors.
A small rural hospital has been designated as a critical access hospital. It has 40 beds and an average occupancy rate of 34 beds. To prepare the staffing, the chief nursing officer computes the occupancy as being;
a. 90%.
b. 85%.
c. 75%.
d. 60%.
ANS: B
Rationale: The occupancy level is calculated as 34/40, or 85%.
To prepare staffing schedules, a nurse manager needs to calculate paid nonproductive time. When calculating paid nonproductive time, the nurse manager considers:
a. Work time, educational time, and holiday time.
b. Paid hours minus worked hours.
c. Vacation time, holiday time, and sick time.
d. Paid hours minus meeting time.
ANS: C
Rationale: Nonproductive hours are hours of benefit time and include vacation, holiday, and personal or sick time.
An important aspect of managing the costs on a unit is to plan accurately for staffing needs. Nurse managers use staffing plans to:
a. Assign staff on the unit on a daily basis.
b. Ensure that days off are planned for the staff.
c. Outline the number of individuals by classification on a per-shift basis.
d. Predict the numbers and classifications of float staff needed to augment regular staff.
ANS: C
Rationale: Among the largest expenditures for a nursing unit are employee salaries and benefits. In
order to manage the costs on a unit, it is important that the nurse manager develop staffing plans that outline the number of individuals by classification that are needed on a per-shift basis, thus optimizing the management of financial resources.
A nurse manager must consider a number of external variables when preparing the personnel budget and projecting the unit’s staffing needs. An external consideration is:
a. Organizational staffing policies.
b. Staffing models.
c. Changes in services that will be offered.
d. Department of Health licensing standards.
ANS: D
Rationale: Internal considerations are staffing policies, regulations, or recommendations and how they can relate to the minimum number of regulated or professional nurses required on an acute care unit at a given time, or to the amount of minimum staffing in an ambulatory care program, a continuing care facility, or correctional facility. Licensing standards and staffing
recommendations by provincial and territorial professional association and regulatory bodies affect staffing plans and are considered to be external, or outside of the organization.
A nurse manager must also consider a number of internal variables that will affect staffing
patterns. Which of the following is an internal variable to be considered?
a. Organizational staffing policies.
b. Provincial/territorial licensing standards.
c. Canadian Nurses Association guidelines.
d. Consumer expectations.
ANS: A
Rationale: Internal policies determine what a nurse may do in a particular setting—for example,
organizational staffing policies. External variables to consider are provincial/territorial licensing standards that outline what a nurse can do; the Canadian Nurses Association is a national regulatory organization; and consumer expectations fall within the public realm, which is also an external variable that affects staffing plans.
A nurse manager uses many sources of data when planning the unit’s workload for the year. Which of the following data must be considered in the planning?
a. Hours of operation of the unit.
b. Trends in the numbers of acutely ill patients on the unit.
c. Maximum work stretch for each employee.
d. Weekend requirements.
ANS: B
Rationale: The numbers of acutely ill patients are determined through classification systems, which determine the nursing resources required.
Scheduling is a function of implementing the staffing plan by assigning unit personnel to work specific hours and specific days of the week. To retain nursing staff, the nurse manager must schedule:
a. All weekends off.
b. All holidays off.
c. A variety of scheduling options.
d. Rotating shifts.
ANS: C
Rationale: It is important for staff retention to have a variety of scheduling options. Exact constraints regarding weekends and holidays are determined through contracts and policies.
The difference between staffing and scheduling is that staffing:
a. Puts the right person in the right position.
b. Puts the right person in the right time and place.
c. Refers to the number of nursing hours per patient per day.
d. Accounts for interpretation of benefits and compensation.
ANS: A
Rationale: Staffing is concerned with finding and assigning qualified individuals to care for a group of
patients. Scheduling assigns personnel to specific hours and days of the week.
A busy neurologic intensive care unit and a step-down unit are most likely to use which patient classification system?
a. Factor evaluation.
b. Prototype evaluation.
c. Canadian National Database of Nursing Quality Indicators.
d. Agency for Healthcare Research and Quality (AHRQ) system.
ANS: A
Rationale: In complex patient care areas, a factor evaluation system, in comparison with a prototype system, would be used. The AHRQ produces studies related to staffing and scheduling. As of yet, there is no National Database of Nursing Quality Indicators in Canada, although it does exist in the United States.
Factor evaluation systems involve classification systems in which:
a. Financial data are used to determine staff-to-patient ratios.
b. Diagnosis-related groups are used to determine the number of acutely ill patients on a unit.
c. Interventions and time required for interventions are combined to determine the levels that are required.
d. Financial resources and nursing interventions are combined to determine patient contact hours.
ANS: C
Rationale: In a factor evaluation system, tasks, thought processes, and patient care activities are considered and given a time or rating. These times or ratings are then used to determine the number of patient care hours required.
Staff members on your unit raise concern that the number of acutely ill patients on the unit is rising and responsiveness in addressing these needs through appropriate staffing is lacking. They point to increased incidences of adverse and sentinel events on the unit. To address this concern, the best action for your hospital organization is to:
a. Implement a patient classification system immediately.
b. Participate in databases that compare the outcomes and staffing levels versus those of institutions similar to yours.
c. Provide increased numbers of staff to the unit.
d. Ignore such concerns because the number of acutely ill patients is variable.
ANS: B
Rationale: Staff morale suffers both when models of acute illness indicate a gap between staffing and the number of acutely ill patients, and when there is no model but perceived acute illness that is not being addressed. A truer approach is to monitor patient outcomes and participate in national databases that measure staffing levels through comparison with similar institutions.
A particular classification system assigns revenue according to the functional capacity of patients and the progression of patients during their stay in rehabilitation units. More independent patient activities such as prompted voiding require higher staff utilization than do dependent activities but do not result in increased staff resources. This is an example of:
a. Bureaucracy.
b. Concern related to the validity of classification systems.
c. Inadequate reliability of classification systems.
d. Inappropriate subjectivity in making judgements about staffing.
ANS: B
Rationale: Validity of categories and implications for staffing levels are in question in this situation because staffing levels do not reflect the levels of activity required for patient care.
In the past year, you have noticed an increase in patient falls on your unit. In reading studies related to staffing and patient outcomes, you realize that you will need to plan for:
a. Higher patient care hours.
b. Safer facilities.
c. Institution of a patient classification system.
d. An increased number of RN positions.
ANS: D
Rationale: Lower fall rates are shown to be related to higher total nursing hours and a higher percentage of nursing hours supplied by RNs.
In evaluating mortality rates, the head nurse on the cardiac unit is surprised to find that they are higher on the weekend than on weekdays. In exploring the reasons for this apparent anomaly, the head nurse focuses on:
a. Availability of diagnostic personnel.
b. Availability of physicians.
c. Communication with on-call providers.
d. Numbers of acutely ill patients.
ANS: C
Rationale: Studies of off-peak hours (weekends and nights) are limited to date, but those that have been done indicate that mortality increases during weekends and nights, when staff work with fewer and often less experienced staff, and when communication among on-call healthcare providers may be strained.
What does a nurse staffing plan take into account?
a. Specific nurse-to-patient ratios per shift.
b. Participation of nurses in projecting staffing needs.
c. Compensation and benefits for each level of staff.
d. The occupancy load of a unit.
ANS: B
Rationale: Nurse staffing plans employ nursing judgement and flexibility that is based on the number of acutely ill patients, nurse experience, and unit configuration rather than set nurse-to-patient ratios.
As the unit manager you post the staffing plan and compliance reports. This initiative is aimed at:
a. Maintaining unit morale.
b. Complying with national requirements.
c. Demonstrating patient outcomes.
d. Inviting staff participation in decision making.
ANS: A
Rationale: Adequate staffing, as demonstrated through a staffing plan and compliance reports, contributes to staff morale.
To maintain patient safety, studies suggest that scheduling should avoid which of the following?
a. Rotating shifts.
b. Weekends.
c. Eight-hour shifts.
d. Mandatory overtime.
ANS: A
Rationale: Rotating shifts and overtime past 12 hours (mandatory or not) are being shown to increase
nurse error and jeopardize patient safety.
In a job interview for a staff position, which of the following indicates your knowledge of patient safety?
a. “Will I be able to get overtime hours on your unit?”
b. “If there is an opportunity to work extra shifts, I would really like that.”
c. “Is there a strategy in place to reduce the number of overtime hours on the unit?”
d. “I see no reason why I wouldn’t be able to work overtime.”
ANS: C
Rationale: Strategies to reduce overtime increase patient safety. Studies suggest that every additional 10% of overtime hours worked contributes to a 1.3% increase in hospital-related mortality.
To reduce reliance on overtime hours, an organization develops a strategy for floating nurses during staff shortages. To maximize patient safety and reduce costs, the health care organization:
a. Develops a centralized pool of float nurses.
b. Assigns nurses from less busy units to ones with increased numbers of acutely ill patients.
c. Floats nurses only between units on which the nurses have been cross-trained.
d. Assigns float nurses to basic care only.
ANS: A
Rationale: A centralized pool usually includes experienced nurses who maintain a broad range of competencies. Other approaches are less satisfying for nurses, are less efficient, and may be less safe.
To project staffing needs and to avoid understaffing, it is important that nurse managers consider which of the following?
a. Maximum productive hours.
b. Average nonproductive hours.
c. Minimum benefit hours.
d. Maximum vacation time.
ANS: B
Rationale: To avoid understaffing, average nonproductive or benefit hours need to be considered, so that the unit is properly staffed when staff members are off.
Your health care organization has a decentralized system for scheduling. As part of this process, after you have developed a draft schedule, you may need to:
a. Seek budgetary approval.
b. Balance personal schedules against institutional needs.
c. Negotiate the schedule with unit staff.
d. Submit the schedule to a centralized staffing office for review.
ANS: D
Rationale: In a decentralized model, you may be completely responsible for approving all schedule changes and for development of the schedule, or you may need to submit a draft to a centralized office for review and determination of supplemental staff. Balancing personal schedules and negotiation are characteristics of staff self scheduling models.
Patient classification systems have been developed in an effort to give nurse managers the tools and language to describe the acuity of patients. “Sicker” patients receive higher classification scores, indicating that more nursing resources are required to provide patient care. Which of the following describes a factor evaluation system?
a. Subjective and descriptive.
b. More objective.
c. Uses broad categories to predict patient-care needs.
d. Patient-care needs based on diagnosis-related groups.
ANS: B
Rationale: Factor evaluation system is more objective and gives each task, thought process, and patient-care activity a time or rating. These indicators are then summed to determine the hours of direct care required, or they are weighted for each patient. Used for patients with more complex care needs and a less predictable disease course.
Which of the following increase the risk of patient mortality rates? (Select all that apply.)
a. Staff burnout.
b. Positive leadership support.
c. Increase of casual or temporary positions.
d. Staffing numbers and levels.
ANS: A, D
Rationale: Leadership support ensuring adequate staffing levels and appropriate skill, education, and experience of staff including staff mix decreases mortality rates. An increase in staff burnout and casual or temporary positions has been demonstrated to increase mortality rates.
The growth in evidence on nursing sensitive indicators has been accompanied by significant controversy regarding the level of nurse staffing required for various groups of patients, primarily in acute-care hospitals. Two major approaches to sufficient staffing have been put forward in Canada. These are? (Select all that apply.)
a. Mandated nurse-patient ratios
b. Increased numbers of registered nurses
c. Development of a staffing plan for a period of time
d. Better staff mix
ANS: A, C
Rationale: Although an increase in the number of registered nurses and a better staff mix will support
better patient care and decreased mortality rates. It is more important that, in Canada, mandated nurse-patient ratios and development of a staffing plan for a period of time, usually a budget cycle, will provide consistency and ensure the nurse-patient ratio is appropriate based on evidence.
Eschiti and Hamilton (2011) learned that support services and numbers of nonnurse staff are greatly diminished on off-peak shifts leading to increased mortality rates. Which of the following factors influence the risk to patients in off-peak times (weekends and evenings
and night shifts)? (Select all that apply.)
a. Rotating shifts
b. Mandatory overtime hours
c. Good staff mix
d. Nurse fatigue
ANS: B, D
Rationale: Research demonstrates that mandatory overtime hours and resulting nurse fatigue are primary factors for increasing mortality rates in off peak hours. Rotating shifts may have a minor influence and a good staff mix increases mortality rates.
In reviewing the job description of a nurse manager, the staff members become aware that a nurse manager’s role is complex. Which of the following duties are required of a nurse manager? (Select all that apply.)
a. Responsibility for nursing benchmarks.
b. No responsibility for knowledge of staffing benchmarks.
c. Responsibility for planning staffing of unlicensed assistive personnel only.
d. Preparing a unit budget.
e. Changing staffing plans on the basis of service needs.
ANS: A, D, E
Rationale: A nurse manager manages financial resources by developing business and staffing plans. They also prepare nursing benchmarks and change staffing plans according to their unit’s needs.
The nurse manager schedules evaluations of staff members by using a newly developed performance appraisal tool. The development of a performance appraisal tool should include:
a. The organizational mission and philosophy and the position requirements.
b. A generalized overview of the duties of a position.
c. A skills checklist and accreditation requirements.
d. An ordinal scale that ranks all employees.
ANS: A
Rationale: Performance appraisal tools and processes should reflect the organizational mission and philosophy, and also position requirements.
Joshua, a new graduate, reviews the employee evaluation for his new position. The first section requires that he list his own specific objectives to be accomplished. This is an example of:
a. The traditional rating scale.
b. Learning goals or management by objectives.
c. A forced distribution scale.
d. A behaviourally anchored rating scale (BARS).
ANS: B
Rationale: In management by objectives, the employer and the employee jointly establish clear and
measurable objectives for the next performance period.
Joshua notes that the next section of the evaluation tool is specific to the organizational philosophy and has a four-point ordinal scale that describes performance from “always meets expectations” to “does not meet expectations.” This type of evaluation is most commonly known as:
a. A BARS.
b. Management by objectives/learning goals.
c. The forced distribution scale.
d. A traditional rating scale.
ANS: D
Rationale: Traditional rating scales are commonly used in evaluation and reflect generalizations rather than specific behaviours.
On your unit, despite efforts to build a strong sense of team, conflict between some of the staff is ongoing. Nonetheless, you want to proceed with developing a systematic and effective performance appraisal system. Which of the following approaches would be most appropriate for you to implement?
a. Peer review.
b. A combination of tools.
c. Anecdotal notes.
d. Rating scale.
ANS: B
Rationale: A combination of tools is probably superior to any one method in any situation. Peer review would not be recommended alone or in combination because it is not useful in an environment characterized by a high degree of mistrust or conflict.
Which of the following is a strategy that clinical nurse educators can use to ensure understanding and retention of information in newly hired staff nurses?
a. Provide written information of all orientation topics.
b. Evaluate whether there is fit between learner and organizational values.
c. Develop a range of strategies that cover a variety of learning styles.
d. Organize group sessions for orientation to increase cost effectiveness.
ANS: C
Rationale: Preceptors teach newly hired nurses in the clinical setting. Clinical nurse educators can assist
in developing strategies that cover a variety of learning styles of new employees. This allows the preceptor to ensure uptake and retention of information in the newly hired staff member.
Which of the following might best conclude an interview?
a. “Thank you for your interest. Someone will be in touch with you soon.”
b. “Before you go, we will make sure that we have your contact information. Thank you for coming.”
c. “I will be in contact with all candidates by telephone by next Friday. It has been a pleasure to meet you.”
d. “We have several excellent candidates so I am not sure about the outcome of the interview, but I will let you know. Thank you for coming.”
ANS: C
Rationale: An employment interview should always conclude with information as to how and when follow-up to the interview will occur.
In addressing the primary challenge in the recruitment of new staff, which of the following interview questions might be asked?
a. “Could you review your resume for us, highlighting your certifications and experience?”
b. “If we were to ask your references, what would they list as your strengths? Weaknesses?”
c. “We have a number of older adult patients on this unit. If you noticed another staff member addressing one of these patients impatiently, how would you respond?”
d. “Tell us about your work and academic experiences and qualifications.”
ANS: C
Rationale: The primary challenge in the recruitment of new staff is finding candidates who can function
well within your work culture. Asking behaviour-related questions in the interview allows you to assess how a candidate may function in real-life situations and to assess whether this behaviour is compatible with the culture on the unit.
The biggest challenge in the recruitment of staff is:
a. Finding well-qualified candidates who can function well within a particular work culture.
b. Recruiting individuals with the appropriate qualifications and experience.
c. Screening out candidates who are unable to function well within a team.
d. Determining whether candidates have had previous negative experiences in a work environment.
ANS: A
Rationale: Choosing the right individual is the challenge for managers and involves finding qualified candidates who will work well within the culture.
Anecdotal notes:
a. Should be completed only when there are performance concerns.
b. Can be used to support and justify fairness in termination discussions.
c. Are unnecessary if the evaluation instrument is thorough.
d. Need to be completed at the end of a performance period.
ANS: B
Rationale: Anecdotal notes should be kept consistently throughout the evaluation period and should reflect both favourable and unfavourable behaviours if they are to provide an accurate assessment of performance. Anecdotal notes provide documentation to support scale ratings and narrative evaluation summaries.
An outpatient clinic advertised for registered nurse positions. Before authorizing a position opening, the nurse manager should:
a. Review the position description and performance expectations for the opening.
b. Place an advertisement in the local newspaper and on the telephone job line.
c. Review all current applications on file.
d. Look for employees within the system who might best fill the position.
ANS: A
Rationale: The position description provides the basis for this position within the organization and communicates expectations for the role.
Yasmine is a likable and popular staff member. Despite occasional complaints from patients about inappropriate comments and rough handling of patients, Yasmine continues to receive positive performance appraisals. This is an example of:
a. A halo effect.
b. Rare conflict.
c. Role ambiguity.
d. Evaluator bias.
ANS: A
Rationale: A halo effect occurs when the performance rating is based on a characteristic of the individual that actually has nothing to do with the work traits being considered. Managers may give higher ratings to individuals they like (halo effect) and lower ratings to individuals they do not like (negative halo effect).
The validity of comments and ratings related to performance is enhanced by which of the following:
a. Maintenance of anecdotal notes over the entire evaluation period.
b. Quantity of information gathered for appraisal purposes.
c. Agreement of the employee with the ratings and comments.
d. Whether other individuals have contributed to the observations.
ANS: A
Rationale: Anecdotal notes compiled consistently over the entire rating period are a much more equitable method of providing an accurate summary of the employee’s performance.
A nurse manager in the intensive care unit works with his staff to develop an appraisal instrument that includes quantitative data and respects standards for a registered nurse working on that unit. What type of appraisal is this?
a. Rating scale.
b. Collaboratively based appraisal system.
c. Narrative instrument.
d. BARS.
ANS: D
Rationale: A BARS describes performance quantitatively and qualitatively, and when staff members are involved in the development of these instruments, they are more likely to understand the importance of evaluation for each criterion selected and to have an understanding of their performance expectations.
The primary disadvantage of a BARS is that it is:
a. Situation specific.
b. Well understood by the staff.
c. Too generalized.
d. Expensive to develop.
ANS: D
Rationale: BARS take a considerable amount of time to implement, and although they are specific to the specialty of nursing and are potentially well accepted by staff, they are expensive to develop.
Marcia, a nurse manager, discusses her concerns about the hospital’s employee appraisal system with her work group, noting that all it includes is one rating scale, which means nothing unless the manager is effective in her job. Marcia’s concerns reflect which best practices associated with performance appraisal?
a. Rating scales are too generalized to be considered valid or reliable.
b. The effectiveness of any appraisal system is tied directly to the skills and communication abilities of the manager.
c. BARS are considered superior to simple rating scales in terms of performance appraisal.
d. Rating scales need to be designed by users to be well accepted.
ANS: C
Rationale: Rating scales are relatively easy to construct and easy to complete but usually consist of generalizations and nonspecific behaviours, and the rating is relatively subjective in nature; these characteristics do not reflect best evaluative practices. The effectiveness of any system is tied directly to the skills and communication abilities of the person who is using it. However, the system itself must be effective. BARS combine ratings with critical incidents (specific examples that have occurred) or criterion references (examples usually based on standards of practice or competency-based standards).
During a performance appraisal, Joanne, the nurse manager, indicates that Alysha has difficulty mentoring students on the unit. Alysha responds that this is not her responsibility. In responding to Alysha, Joanne needs to consider:
a. Alysha’s level of confidence.
b. Whether mentoring is included in the position description.
c. Whether mentoring is an essential component of the position description.
d. Whether mentoring can be accurately observed and measured.
ANS: B
Rationale: Performance appraisal is tied to roles and responsibilities of the position, as outlined in the position description. If roles and responsibilities are not included specifically, they cannot be appraised.
The final section of a performance appraisal is a rating scale. This scale is very detailed and relates to competency standards specific to surgical patients. The scale is a summary of performance directly observed or documentation reviewed and is specific to patient care situations in which the employee has been involved. This type of evaluation is most commonly known as:
a. A traditional rating scale.
b. Management by objectives/learning goals.
c. A forced distribution scale.
d. A BARS.
ANS: D
Rationale: A BARS contains both quantitative (rating scales) and qualitative data. It is specific to situations and positions.
John’s performance was satisfactory during the first month, but after that time he was very inconsistent in the provision of nursing care. One month before the end of the rating period, he cared for a very wealthy and influential patient, who is a close friend of the clinical manager. This patient donated new furniture for the staff lounge in John’s name to show appreciation for his care. Joshua’s subsequent performance appraisal resulted in outstanding ratings in all areas. This is an example of:
a. A performance rating based on justifiable evidence.
b. A bias related to recent events.
c. The effect of personality on the appraisal of performance.
d. The effective use of a BARS.
ANS: B
Rationale: To obtain and provide an accurate evaluation of performance over time, anecdotal notes need to be maintained throughout the evaluation period. This process assists in avoiding bias related to recent or sensational events that make a particularly strong impression.
As a manager, you are interested in developing behavioural questions for an interview. You know that there is team conflict at times on your unit. Which of the following questions would satisfy your interest in behavioural questions?
a. “Tell me about a time you were involved in a conflict related to a project. What was your role in the conflict? In the resolution of the conflict?”
b. “If you were to employ one strategy for managing conflict, what would it be?”
c. “What is your preferred style of conflict resolution?”
d. “How effective are you in working in a group? In dealing with conflict?”
ANS: A
Rationale: Behaviour-related questions seek demonstrated examples of behaviour from the candidate’s past experiences and concentrate on job-related functions and accomplishments.
Which of the following strategies might be effective in empowering staff?
a. Communication book in which new information on policies and processes is communicated and mistakes are highlighted.
b. Monthly staff meetings during which a portion of the agenda is devoted to sharing ideas and presentations on best practices for implementation on the unit.
c. Once-yearly summative evaluations based on what the manager likes best about each individual.
d. Immediate discussion of errors in care and with involved staff with direction as to how errors are to be prevented in the future.
ANS: B
Rationale: Empowerment is a process in which people acknowledge the values and judgements of other people and trust their decisions. It allows freedom for making decisions while retaining accountability and provides an environment that is safe in which to explore.
The chief nursing officer establishes a shared governance model to help empower the nursing staff, thus empowering the organization. Common characteristics of empowered organizations are:
a. Shared values, high salaries, and a human focus.
b. Shared values, flexibility, and a human-capital focus.
c. Commitment to communication, high salaries, and flexibility for evaluations.
d. Creation of community and of effective stress management in the midst of divergent goals.
ANS: B
Rationale: Shared governance involves valuing the contributions of each member of the team, releasing the need to control, and understanding that accountability rests with members of the team.
Nora, a new nurse manager, writes certain assumptions regarding the organization’s objectives into her budget. Her supervisor tells her that the objectives implied in her assumptions are not entirely consistent with the organization and that she needs to clarify these objectives with her supervisor. Nora apologizes and says she had more latitude with the budget where she previously worked. This is an example of:
a. Role complexity.
b. Role ambiguity.
c. Role conflict.
d. Time-dependent roles.
ANS: B
Rationale: Role ambiguity in the workplace creates an environment for misunderstanding and hinders effective communication. Without clear expectations of performance, missteps in performance can occur.
A survey of staff satisfaction is conducted. The results indicate that staff members are satisfied, are loyal to the organization, and believe that they have reasonable control in their individual responsibilities. The findings best exemplify:
a. Clarity in roles and valuing of contributions.
b. Satisfaction but not empowerment.
c. Effective coaching of new staff.
d. Role attachment.
ANS: A
Rationale: Satisfaction is linked to clear role expectations and a feeling that contributions are valued.
You have hired Bumika as a new staff member on your unit. Although she is an experienced intensive care unit nurse, this is her first educator role. A month into her new position she confides that she feels really incompetent in her new position and bursts into tears. Your response is based on application of your understanding of:
a. Role acquisition.
b. Role conflict.
c. Role complexity.
d. Performance appraisal.
ANS: A
Rationale: Acquisition of a role is time dependent and involves application of life experiences to each role and interpretation of the role within a person’s own value system. As roles become more complex, an individual may take longer to assimilate the components of each role.
An environment that fosters misunderstanding and that hinders effective communication leads to:
a. Role conflict.
b. Role ambiguity.
c. Role clarity.
d. Role certainty.
ANS: B
Rationale: Employees must have role clarity or clear role expectations and perceive that their contributions are valued. Role conflict is where employees know what is expected of them, but they are either unable or unwilling to meet those expectations due to differences in personal values and/or behavior fit. Role certainty is present when the nurse is confident in the work and satisfied with personal performance.
Nurse Managers are increasingly being held accountable for nurse retention. Which of the following actions should a nurse manager focus on to retain nurses? (Select all that apply.)
a. Support and encourage employees.
b. Clarify the organization’s mission.
c. Be unclear about expectations.
d. Select the right person for the right position.
ANS: A, B, D
Rationale: Retention is based on understanding the role, being the right person for the specific role, understanding the organization’s mission and expectations, and knowing that support and encouragement are part of the unit’s culture. Being unclear about expectations for the role places the employee at a disadvantage and leads to a lack of job satisfaction and leaving for a more appropriate and supportive environment.
In staff development which of the following would support retention of nurses? (Select all that apply.)
a. Residency-type programs for new graduates.
b. Preceptorship program.
c. Nonexistent ongoing staff development plan.
d. Orientation to the role and the organization.
ANS: A, B, D
Rationale: Residency programs usually of a year duration are recognized as a method of easing new graduates transition from school to clinical practice. Having a preceptor for up to 12 weeks is also a transition support. A thorough orientation program eases the new nurse into the organization and assists in understanding the expectations and norms of the organization. Nurses expect ongoing staff development throughout their careers and not having support in this area leads to a retention issue.
Coaching is an approach that retains nurses. Which of the following are coaching behaviours? (Select all that apply.)
a. Is costly.
b. A learned process.
c. Promotes optimal performance.
d. Is a personal approach.
ANS: B, C, D
Rationale: Coaching is a process in which a manager helps others learn, think critically, and grow through communications about performance. This coaching process is a personal approach in which the manager and the employee interact on a frequent and regular basis with the ultimate outcome that the employee performs at an optimal level. Coaching is not financially costly as it occurs mostly during working hours, and is mutually beneficial to both employee and manager.
During the performance appraisal session, what should the manager do? (Select all that apply.)
a. Maintain a relaxed and professional manner.
b. Inquire about the employee’s personal life and how it is affecting performance.
c. Allow the employee to express opinions orally and in writing.
d. Plan to give specific examples only for poor performance.
ANS: A, C
Rationale: During a performance appraisal, it is important to provide examples of both strong and problematic performance and to provide opportunities to express opinions. The supervisor needs to maintain a relaxed professional manner.
In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital reduces the number of its nursing managers. Within a year the number of adverse events on the units has doubled. This may be attributable to:
a. The overload of work for staff nurses.
b. Inability of staff at the bedside to make good choices.
c. A change in reporting systems.
d. Fewer clinical leaders and advocates for necessary resources.
ANS: D
Rationale: Strong leadership across the nursing profession is essential to ensure the delivery of safe care. Reducing nursing managers who provide support, consultation, and leadership in securing resources and in inspiring standards of excellence may increase the number of adverse events related to lack of leadership.
Traditional approaches to ensuring patient safety have focused on:
a. Assigning blame.
b. Finding solutions to systems issues.
c. Instituting best practices in response to errors.
d. Hiding errors from potential litigation.
ANS: A
Rationale: When health care facilities create a culture of safety, their staff are more willing to report adverse events because the focus is on addressing issues in the system and not blaming individuals.
What is the primary purpose of nursing standards?
a. To inform performance appraisals at the unit level.
b. To identify the desired level of performance.
c. To inform the courts in relation to negligence and malpractice cases.
d. To educate other health care professionals about the role of the nurse.
ANS: B
Rationale: The primary purpose of standards is to identify for nurses, the public, government, and other stakeholders the desired and achievable level of performance expected of nurses in their practice, against which actual performance can be measured.
During review of back injuries, it is determined that mechanical lifts and transfer belts are not being properly used. In addressing this concern, the unit manager:
a. Meets individually with nurses, who are observed using the lifts incorrectly, to review the correct procedure.
b. Consults with the staff about the review to determine how best to proceed.
c. Blames the system for inadequate funding for resources.
d. Reviews the system of reporting adverse events to ensure that appropriate reporting is occurring.
ANS: B
Rationale: Consulting with the staff enables the nurse manager to ascertain the root of the problem, inasmuch as the equipment may be faulty or unsafe because of its age and needs to be replaced. Client focused provision of care requires the nurse administrator to communicate, collaborate, and consult with nurses and other members of the health care team about the provision of health care services.
The nursing manager changed the current model of implementing nursing rounds of patients each day at 1200 hours to implementing interdisciplinary rounds of patients at 1000 hours. This change reflects:
a. A patient-centred care initiative.
b. Delegation of responsibility from nursing to other health care professionals.
c. Lack of consultation among the nursing staff.
d. An inappropriate time to complete patient rounds and will probably not work.
ANS: A
Rationale: Patient-centred care is a priority in two main roles for nursing managers: making policies and ensuring system accountability. A number of activities can be implemented to enact these two roles, and nurses can support or implement many of them. For example, nurses can lead changes that promote team-based and collaborative care, as demonstrated in this question.
Which of the following represents an activity that supports patient centred care?
a. Posting of visiting hours on the entrance way to each hospital unit
b. Regular staff surveys to monitor organizational satisfaction
c. Reserved parking spots at the main hospital entrance for physicians
d. Creating e-health stations on each inpatient unit
ANS: D
Rationale: Governance and management activities that support patient-centred care include e-health stations and other technologic devices that facilitate communication, efficiency, and convenience.
After consulting with practice environments about quality and safety concerns in health care, the Dean of Health Programs at a Canadian university develops:
a. A nursing program that emphasizes the development of a strong disciplinary identity.
b. Programming that stresses discipline-based research.
c. Partnerships with health care professionals to develop software for reporting of adverse events.
d. An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams.
ANS: D
Rationale: Working within interprofessional teams optimizes patient safety and quality of the care that patients receive.
In designing a high-quality, safe health care environment, the primary emphasis needs to be on:
a. Evidence-informed practice.
b. Informatics.
c. Staffing.
d. The patient.
ANS: D
Rationale: Patient-centred care contributes to a safer health care environment. Patient focus is integrated in the entry-level competencies for nurses that guide nursing education programs. These entry-level competencies are developed through collaboration among nursing regulatory bodies in Canada. The competencies are grounded in a standards-based conceptual framework in which the patient is central.
As a patient care advocate, you regularly coach patients in how to stay safe in health care by educating them about:
a. The need to understand and record all medications being taken.
b. Bringing their own linens and other personal items to the hospital.
c. Washing hands frequently while in a health care environment and using a hand sanitizer.
d. Following closely the directions and orders of health care providers.
ANS: A
Rationale: One of the patient outcomes includes self-care, that is, the patients’ perceptions and abilities to manage their care, including medication administration. It is important that a patient advocate educate patients about their medications and assess their ability to correctly take their own medications.
What is the focus in a culture of safety?
a. Employee safety.
b. Investigating who is making health care errors.
c. Effective systems and team work
d. Professional nursing standards and ethical codes
ANS: C
Rationale: In a culture of safety, the focus is on effective systems and teamwork to accomplish the mutual goal of safe, high-quality performance. When something goes wrong, the focus is on what the problem is, rather than who. The intent is to expose process failures and system issues and to solve them in a nonbiased, nonthreatening way.
Which attribute is a common feature of a culture of safety?
a. Voluntary reporting of incidents.
b. Organization behaviour.
c. Individual-focused policies.
d. A nonpunitive approach to adverse event reporting and analysis.
ANS: D
Rationale: Attributes of common features of a culture of safety include a nonpunitive approach to adverse event reporting and analysis; open communication; teamwork; organizational learning; shared belief in the importance of safety; and leadership commitment to safety.
Which of the following depicts a nursing-sensitive outcome?
a. Programming that increases individual nurse competency to offer smoking cessation programs.
b. Implementation of informatics at the patient’s bedside.
c. Staff–manager conferences to review reporting of adverse events.
d. Patient council meetings to review food, recreation, and nurse–patient relations.
ANS: A
Rationale: Nursing-sensitive outcome is the phrase used to describe patient outcomes that are sensitive to nursing practice or interventions; therefore programming that incorporates individual nurse competency into smoking cessation programs is an example.
Having team “huddles” each day on the nursing unit is a reflection of:
a. Nurses’ need to socialize.
b. Creating a culture of safety.
c. Ensuring distribution of equal workloads.
d. The manager`s need to talk with staff nurses on a daily basis.
ANS: B
Rationale: Some examples of activities that health care organizations can implement to support a culture of safety include establishing Quality Improvement (QI) teams, having regular team “huddles” on the unit, debriefing with regard to adverse events, and requiring completion of a surgical safety checklist.
Approximately what percentage of Canadian hospital admissions can be expected to include an adverse event?
a. 5
b. 7.5
c. 10
d. 12.5
ANS: B
Rationale: The adverse events rate was found to be 7.5 per 100 Canadian hospital admissions. This means that an adverse event was experienced in 7.5% of hospital admissions.
Having access to information, evidence, and research is an important driver for quality and;
a. Nurse safety.
b. Patient safety.
c. Organizational policy development.
d. Patient-centred care.
ANS: B
Rationale: The Canadian Patient Safety Institute’s (CPSIs) Effective Governance for Quality and Patient Safety: A Toolkit for Healthcare Board Members and Senior Leaders provides information on the drivers of quality and patient safety, references (including Canadian studies), and stories from health care organizations. Important drivers of quality and patient safety include access to information, evidence and research, and relevant measures.
Which of the following represents a potential use of nurse-sensitive outcomes?
a. Informing best practices.
b. Accountability for nursing behaviours.
c. Performance appraisals.
d. Maintaining the status quo.
ANS: A
Rationale: Doran, Harrison, Laschinger, et al. (2004, p.3) suggested the following uses for nurse-sensitive outcomes:
* Develop treatment plans for individual patients.
* Evaluate different approaches to patient care.
* Inform best practices.
* Improve the quality of nursing care.
* Improve patient outcomes.
* Inform staffing policies and decisions.
* Assist organizations to balance the competing demands of access, cost, and quality.
Which of the following is a CPSI safety competency?
a. Practise patient-centred care.
b. Optimize human and environmental factors.
c. Analyze nurse-sensitive outcomes.
d. Assess nurse staffing and skill mix.
ANS: B
Rationale: One of the six CPSI competencies is to optimize human and environmental factors, managing the relationship between individual and environmental characteristics to optimize patient safety.
On the basis of a review of increased falls with injury and increased use of restraint during evening hours, you as the unit manager are most likely to:
a. Review daytime and evening staffing mixes.
b. Schedule continuing education for all staff members.
c. Review the safety of ambulation devices.
d. Continue your current practices and procedures.
ANS: A
Rationale: It is the nurse manager’s responsibility to challenge any action that is unsafe and to stop actions that are not performed in the patient’s best interest. This includes ensuring that staffing mixes are appropriate for care provided on each shift.
As the nurse was about to administer an oral medication, the patient states, “That pill is the wrong colour.” The nurse goes back to the medication administration area to check the medication and realizes that it is indeed the wrong pill. Does this situation require the completion of an adverse event report?
a. No; there was no actual error.
b. No; it was the patient who stopped an error from occurring.
c. Yes; an error almost occurred, and close calls are to be reported.
d. It is up to the nurse to decide whether to complete an adverse event report.
ANS: C
Rationale: Recognizing the occurrence of an adverse event or close call and responding effectively help mitigate harm to the patient, ensure disclosure, and prevent recurrence. In this case, the error would have occurred if the patient had not questioned the colour of the medication.
Which of the following is the CPSIs flagship program?
a. Patients Are First.
b. Safer Healthcare Now.
c. Safe Healthcare for All.
d. Patient Safety Culture Improvement.
ANS: B
Rationale: The CPSIs flagship program is Safer Healthcare Now, with its vision as safe health care for all Canadians.
Organizational changes that promote systems thinking, collective accountability, and team-based care are examples of:
a. Activities that promote patient-centred care.
b. Accreditation standards that hospitals must meet.
c. Outdated practices that are not grounded in current evidence.
d. Quality improvement initiatives.
ANS: A
Rationale: Organizational changes that promote systems thinking, collective accountability, and team-based care are examples of activities that promote patient-centred care.
Robert, an experienced nurse, discovered a medication order was incorrectly translated. The pharmacist filled the medication and sent it to be administered to the patient. When the medication arrived Robert questioned the dose and consulted with the nurse manager. The order was clarified with the physician and changed to the correct dose. When reviewing the incident the nurse manager determined the near miss was related to which of the following?
a. Individual error.
b. System error.
c. An individual and system error.
d. Attributed to increased workload.
ANS: C
Rationale: Studies have found that when health care facilities create a culture of safety, their staff are more willing to report adverse events (Vogus, Sutcliffe, & Weick, 2010). This willingness is because they understand that the focus is on addressing issues in the system and not blaming individuals. The CNA (2009) position statement on patient safety is as follows: “Although individual competency may be a contributing factor, and individuals remain accountable for their own actions, it is increasingly evident that system competency plays a major role in patient safety.
Gail, a senior nursing student, consults with her preceptor about a patient who has refused his medication. When speaking with the patient he expresses that he does not believe the medication is helping with his pain level. From a nursing-sensitive outcome, which outcomes are addressed in this situation? (Select all that apply.)
a. Quality of nursing care.
b. Symptom management.
c. Patient satisfaction.
d. Functional status.
ANS: B, C
Rationale: Several broad categories of patient outcomes were identified by Doran (2011): Symptom management: how well symptoms are managed. Examples: pain, and fatigue. Patient satisfaction: patient satisfaction with nursing care.
Gathering information on patient outcomes leads to which of the following? (Select all that apply.)
a. Evaluating different approaches to care.
b. Increasing quality of nursing care.
c. Decreasing nursing autonomy.
d. Having a positive impact at the individual, unit, and organization levels.
ANS: A, B, D
Rationale: Doran, Harrison, Laschinger, et al. (2004, p. 3) suggested the following uses for nurse-sensitive outcomes: Develop treatment plans for individual patients. Evaluate different approaches to patient care. Inform best practices, improve the quality of nursing care, improve patient outcomes, inform staffing policies and decisions, and assist organizations to balance the competing demands of access, cost, and quality.
Rose a new nursing graduate chose hospital X for its culture of safety. Which of the following attributes contribute to this culture of safety? (Select all that apply.)
a. Trusting and open communication
b. Organizational learning
c. A system rather that an individual approach to safety
d. Teamwork
ANS: A, B, C, D
Rationale: Halligan and Zecevic (2011, p. 340) list the following attributes as common features of a culture of safety: Leadership commitment to safety, open communication founded on trust, organizational learning, a nonpunitive approach to adverse event reporting and analysis, teamwork, shared belief in the importance of safety.
Which of the following contribute to improved patient safety? (Select all that apply.)
a. Leadership capability.
b. Patient involvement in own care.
c. Data collection.
d. Increased staff mix.
ANS: A, B, C
Rationale: Halligan and Zecevic (2011) list the following attributes as common features of a culture of safety: Leadership commitment to safety. Patient involvement in their own care has been shown to reduce adverse events and increase patient satisfaction.
A nurse manager was orienting new staff members with regard to computerized charting. To understand computerized charting, staff members must understand informatics. Which of the following are the core concepts in informatics?
a. Hardware, software, competency, and printers.
b. Data, information, knowledge, and wisdom.
c. Decision-making, data gathering, data analysis, and reporting.
d. Wireless technology, voice recognition, and handheld devices.
ANS: B
Rationale: Informatics is the application of technology to all fields of nursing to facilitate and extend nurses’ decision-making abilities and to support nurses in the use, storage, and linkage of clinical information in providing effective and efficient patient care. Nursing informatics, like all nursing communication, is founded on the concepts of data, information, knowledge, and, more recently acknowledged, wisdom.
The nursing manager of a surgical unit has been asked by administration to evaluate patient outcomes after cardiac catheterization. Using data about patient outcomes after cardiac catheterization for the past 6 months so as to modify practice is an example of:
a. Gathering information.
b. Cost-effective care.
c. Meeting standards.
d. Evidence-informed practice.
ANS: D
Rationale: Evidence-informed practice is a systematic approach to clinical decision-making; to provide the most consistent and best possible care to patients in this scenario, evidence is being used to optimize care for patients after cardiac catheterization.
The clinic nurse has just accessed a patient’s chart on the computer. The resident comes over and asks her to stay logged on because he needs to add a note to that patient’s chart. What should she say?
a. “No problem. Just log me off when you’re done.”
b. “I’ll put the note in for you. What do you want to say?”
c. “Just make sure that you sign your note because it’s under my password.”
d. “I’m sorry, but you will have to enter the information using your own password.”
ANS: D
Rationale: Passwords must be protected to guard against unauthorized access to patient information and intrusion of privacy.
A home health nurse has been assigned to cover a 500-km2 area of remote Alberta. Mrs. Banister has just been discharged home and will need daily contacts for the next week. Because it is not possible to visit Mrs. Banister in person every day and see all the other patients, the nurse gives her a laptop computer with Internet meeting software installed. Each morning, both dial in at an agreed-upon time and discuss her progress. The home health nurse assesses whether the patient needs to be seen that day. This type of technology is called:
a. Distance learning.
b. Knowledge software.
c. Telecommunications.
d. Biomedical technology.
ANS: C
Rationale: Telecommunications facilitate clinical oversight and provision of health care at a distance via telephone, remote monitoring, and the Internet.
Nurses need to know how to operate a computer, compare data across time, and look for patterns in patient responses to treatments. These are examples of which of the following?
a. Canadian Nursing Informatics Association standards.
b. Information systems.
c. Informatics competencies.
d. Requirements for nursing licensure.
ANS: C
Rationale: Nurses must utilize hospital database management, decision support, and expert system programs to access information and analyze data from disparate sources for use in planning for patient care processes and systems.
The chief nursing officer understands that to be able to compare data across patient populations and sites, it is important that nurses use:
a. Similar settings.
b. Information systems.
c. Knowledge systems.
d. Consistent nursing languages.
ANS: D
Rationale: Consistent nursing language, such as the uniform minimum health data set and the nursing minimum data set (NMDS), enables comparison of data across patient populations and sites and aids in the retrieval of meaningful comparison data from an information system.
Leaders in nursing must advocate for information and knowledge systems that support nursing practice. How is this best accomplished?
a. Participating in organizational information technology committees.
b. Submitting written requests for needed information systems.
c. Requesting budgetary funds needed for systems.
d. Sending staff nurses to conferences that discuss cutting-edge technologies.
ANS: A
Rationale: The nurse manager must recognize the utility of nursing involvement in the planning, design, choice, and implementation of information systems in the practice environment.
You are in the process of designing a patient education program that will provide education and monitoring for patients with hypertension. To support your planning, you obtain and present patient data from which of the following?
a. A clinical database.
b. Biomedical technologies.
c. Email.
d. Internet sources.
ANS: A
Rationale: Clinical databases are collections of elements organized and structured for the processing, organization, and presentation of data for interpretation as information, which in this particular instance includes outpatient data.
As the head nurse involved in determining which patient surveillance systems to acquire for your unit, one of your aims is to avoid adverse events through the implementation of appropriate technology. What does this particular aim recognize?
a. Human error is significant in contributing to adverse events.
b. Documentation of patient data is often illegible and therefore misinterpreted.
c. Data systems provide backup documentation with adverse events that staff cannot provide.
d. Physiologic monitoring systems enable detection of early changes before an adverse event occurs.
ANS: D
Rationale: Data about adverse events suggests that a majority of physiologic abnormalities are not detected early enough and may be present hours before an adverse event actually occurs. Physiologic monitoring aids in early detection of such changes.
As a nurse manager in a multisite facility, you are comparing the effectiveness of prompted voiding training programs for staff by examining the effect of prompted voiding on the frequency of incontinence in patients. To do this, you access an NMDS, which allows you to:
a. Retrieve standardized information regarding patient care and trends.
b. Access medical diagnoses and pharmacologic interventions.
c. Learn sociodemographic and population-based trends.
d. Find information on public funding and private health insurance revenues.
ANS: A
Rationale: Although there continues to be inconsistency in nursing language, the NMDS defines essential nursing data to be collected for all patients that enable comparison of patient data, description of patient care, determination of trends, stimulation of nursing research, and provision of nursing data to influence decision-making.
As a nurse manager representative on a team to select a clinical information system, you would be particularly concerned if the favoured system has which of the following characteristics?
a. It involves screen displays that are best configured for nonclinical users.
b. It requires an upgrade to servers in the facility.
c. It requires staff orientation and training during implementation of the software.
d. It minimizes the amount of data entry necessary.
ANS: A
Rationale: An ideal hospital information system should include as much instrumentation as possible to minimize data entry. As a clinical end-user, you would expect orientation and training on how the screen display can be configured so as to suit the purposes and preferences of users in clinical areas.
When assessing the appropriateness of adopting personal digital assistants (PDAs) for a nursing unit, you need to consider which of the following advantages?
a. Lower cost in relation to personal computers.
b. Small display screen.
c. Font size.
d. Speed of operation.
ANS: A
Rationale: PDAs offer a lower-cost method of documentation and communication than do personal computers, and also easy portability. Disadvantages of PDAs include small screen size, suboptimal readability, and slowness in situations when speed is most needed.
A nurse manager is excited by the possible use of speech recognition (SR) systems for documentation of patient care, especially during crisis situations when staff members need to focus on performing rapid assessments and implementation of procedures. She learns, however, that SR systems would be impractical at this point for this. What characteristic would lead to this conclusion?
a. SR systems are not available outside pilot projects.
b. The type of speech required for voice recognition is unlikely in a pressured situation.
c. The hands-free function has not been perfected in SR technology.
d. Wireless communications are prone to unreliability in transmission.
ANS: B
Rationale: Speech recognition systems rely on staccato-like speech, pauses between words, and programming for each user, any and all of which would be rare in a pressured crisis situation. SR is being used primarily for therapeutic purposes and in situations in which data entry is stable.
For a nurse manager, one challenge is to orient new staff to the agency’s policies and procedures, and also to provide training across various shifts. Which of the following would be a cost-effective and effective learning strategy?
a. Development of new learning modules and software to support document retrieval.
b. Email distribution to staff home email addresses regarding important policies.
c. Preparation of digital video disks (DVDs) that can be viewed on computers at the nursing station during “down times.”
d. Linking policies and procedures to the network for access when required at the point of care.
ANS: D
Rationale: The most accessible and cost-effective approach would be use of what is already available in the work environment. Development of new software is often expensive; DVDs are visually appealing but less nimble in enabling staff to find answers quickly at the point of care.
What is the most critical factor in ensuring nurses’ comfort and knowledge in the use of technology in health care regardless of age, education level, or area of practice?
a. Confidence in using technology.
b. Adequacy and substance of professional development.
c. Repeated training sessions.
d. Peer and leader support.
ANS: B
Rationale: Confidence in using technology was found to be the result of the adequacy of professional development in the (Wang, Nagle, Li, et al., 2004) study. Regardless of age, education level, and area of practice, peer and leader support appropriate professional development was critical to success.
Peggy, a nurse leader on a busy medical surgical unit, is concerned that the rapid expansion in use of EHRs and clinical decision support systems may lead to leaked patient information and breach of confidentiality. She decides to form a nurse led committee to address these concerns. Which of the following must be addressed to prevent breach of confidentiality?
(Select all that apply.)
a. Assign a password that uniquely identifies a user to the system by name and title.
b. Ensure nurse confidentiality through ongoing discussion.
c. Ensure nurses understand privacy legislation that applies to them, and their work setting.
d. Monitor individual nurses.
ANS: A, B, C
Rationale: Password must have a unique signature assigned to a nurse that is traceable to documentation and care the nurse provides. Having staff nurses involved in this process provides maximum input on the issue and keeps the information at the critical level to ensure confidentiality. Understanding privacy legislation and work policies provides a framework for ethical standards. Monitoring individual nurses is unlikely as the unique individual identifiers will highlight a problem if an anomaly is detected.
Nurses rely on technology to lessen the number of adverse events that are well documented, yet are challenged in keeping the unique therapeutic relationship between nurse and patient with increasing use of technology. What approaches can be used to ensure the therapeutic relationship is preserved (Select all that apply.)
a. Involving patients in decisions about their own care.
b. Actively listening while conducting electronic charting.
c. Showing patients what is being documented.
d. Repeatedly monitoring equipment while documenting.
ANS: A, B, C
Rationale: Therapeutic relationships can be enhanced through the use of technology and patient safety increased when nurses engage the patient in their care and incorporate technology and patient engagement when documenting and recording data from medical devices. Keeping the patient at the centre of care avoids the likelihood of losing the therapeutic connection between nurse and patient.
As a nurse manager, you want to institute point-of-care devices on your unit. The rationale that you provide to support the point-of-care devices includes which of the following? (Select all that apply.)
a. Reduction in incidents of medication error.
b. Immediate documentation of care.
c. Improving discharge planning.
d. Increasing confusion with nursing workflow.
ANS: A, B, C
Rationale: Point-of-care devices that allow documentation of assessment, care, and teaching at the patient’s bedside reduce the gap in time between care and documentation, thereby reducing error, increasing accuracy, and improving communication of care, discharge planning, and teaching, in addition to fitting better with nursing workflow.
A new graduate is asked to serve on the hospital’s quality improvement (QI) committee. The nurse understands that the first step in quality improvement is to:
a. Collect data to determine whether standards are being met.
b. Implement a plan to correct the problem.
c. Identify the standard.
d. Determine whether the findings warrant correction.
ANS: C
Rationale: Identifying standards most important to the user of health care services is the first step in a six-step process for quality improvement.
The chief executive officer asks the nurse manager of the telemetry unit to justify the disproportionately high number of registered nurses on the telemetry unit. The nurse manager explains that nursing research has validated which statement about a low nurse-to patient ratio?
a. “It promotes teamwork among health care providers.”
b. “It increases adverse events.”
c. “It improves outcomes.”
d. “It contributes to duplication of services.”
ANS: C
Rationale: Findings related to staffing and patient outcomes suggest that patient outcomes are
improved with a low ratio of nurses to patients and especially with a low ratio of registered
nurses to patients.
A nurse manager wants to decrease the number of medication errors that occur in her department. The manager arranges a meeting with the staff to discuss the issue. The manager conveys a philosophy of total quality management (QM) by:
a. Explaining to the staff that disciplinary action will be taken in cases of additional errors.
b. Recommending that a multidisciplinary team assess the root cause of errors in medication.
c. Suggesting that the pharmacy department explore its role in the problem.
d. Changing the unit policy to allow a certain number of medication errors per year without penalty.
ANS: B
Rationale: QM emphasizes improving the system, rather than focusing on staff errors. If errors occur, reeducation of staff is emphasized, rather than the imposition of punitive measures such as disciplinary action or blaming.
The nurse educator of the pediatric unit determines that vital signs are frequently not being documented when children return from surgery. According to QI, to correct the problem the educator, in consultation with the patient care manager, would initially do which of the following?
a. Talk to the staff individually to determine why this is occurring.
b. Call a meeting of all staff to discuss this issue.
c. Have a group of staff nurses review the established standards of care for postoperative patients.
d. Document which staff members are not recording vital signs, and write them up.
ANS: B
Rationale: Leaders must identify safety shortcomings and must locate resources at patient care levels to identify and reduce risks. One method of doing this is to invite all staff into a discussion related to solutions to an identified concern. This approach encourages teamwork.
A nurse is explaining the pediatric unit’s QI program to a newly employed nurse. Which of the following would the senior nurse include as the primary purpose of QI programs?
a. Evaluation of staff members’ performances.
b. Determination of the appropriateness of standards.
c. Improvement in patient outcomes.
d. Preparation for accreditation of the organization by The Joint Commission.
ANS: C
Rationale: The primary purpose of QI is improvement of patient outcomes. Quality improvement refers to an ongoing process of innovation, prevention of error, and staff development that is used by institutions that adopt the QM philosophy.
Before beginning a continuous QI project, a nurse should determine the minimal safety level of care by referring to which of the following?
a. The procedure manual.
b. Nursing care standards.
c. The litigation rate of unsafe practice.
d. Job descriptions of the organization.
ANS: B
Rationale: Standards establish the minimal safety level of care. Within health care systems, QI combines the assessment of structure, process, and outcome standards. Policies should be reviewed frequently and updated so that they reflect best practice standards and do not become barriers to innovation.
The nurse gives an inaccurate dose of medication to a patient. After assessment of the patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication understands that:
a. The error will result in suspension.
b. An incident report is optional for an event that does not result in injury.
c. The error will be documented in her personnel file.
d. Risk management programs are not designed to assign blame.
ANS: D
Rationale: QM emphasizes improving the system, rather than focusing on staff errors. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.
The nurse manager is concerned about the negative ratings that her unit has received on patient satisfaction surveys. The first step in addressing this issue from the point of view of quality improvement is which of the following?
a. Assemble a team.
b. Establish a benchmark.
c. Identify a clinical activity for review.
d. Establish outcomes.
ANS: C
Rationale: In theory, any and all aspects of clinical activity could be improved through the QI process. However, QI efforts should be concentrated on changes to patient care that will have the greatest effect.
With the rise of workplace violence in the emergency department, the nurse manager decides that she should work with the risk manager in violence prevention. The nurse manager should:
a. Request all staff to accept new risk management practices.
b. Hold staff accountable for safe practices.
c. Document inappropriate behaviour.
d. Hire more police security.
ANS: B
Rationale: Active involvement of staff in risk management activities is key to prevention of adverse events. Accountability for safety can be one aspect of performance evaluations.
The nurse manager is performing a root-cause analysis related to medication administration errors with insulin. A root-cause analysis is very similar to the QI process except that a root-cause analysis is:
a. Retrospective.
b. Prospective.
c. Legislated for completion with all near-miss events.
d. Conducted by only one person.
ANS: A
Rationale: A root-cause analysis is very similar to the QI process described in this chapter except that the root-cause analysis is a retrospective review of an incident to identify the sequence of events with the goal of identifying the root causes of the incident and may lead to the development of specific risk-reduction strategies.
Hospital ABCD is a Magnet hospital. This designation has been applied to Hospital ABCD because it:
a. Facilitates active staff participation in decision-making related to quality nursing care.
b. Has implemented a graduate nurse orientation program.
c. Espouses commitment to excellence in patient care.
d. Is establishing career ladders for nurses.
ANS: A
Rationale: Magnet hospitals are particularly successful in implementing excellence in patient care through use of standards, evidence, and participatory decision-making in quality improvement. Organizations that cannot pursue Magnet status can implement strategies such as career ladders.
In determining the relationship between injury-producing falls and proposed preventive measures as part of the QI process, a QI team might turn to which of the following for confirmatory evidence?
a. Best Practice Guidelines (BPGs).
b. North American Nursing Diagnosis Association (NANDA).
c. National Quality Institute.
d. Agency for Healthcare Research and Quality.
ANS: A
Rationale: The Registered Nurses’ Association of Ontario launched the Nursing Best Practice Guidelines (BPGs) program. To date, the program team has developed and disseminated 50 guidelines covering clinical topics in five broad areas: gerontology, primary health care, home health care, mental health care, and emergency care.
As a nurse manager, you know that the satisfaction of patients is critical in making QI decisions. You propose to circulate a questionnaire to discharged patients, asking about their experiences on your unit. Your supervisor cautions you to also consider other sources of data for decisions because:
a. The return rate on patient questionnaires is frequently low.
b. Patients are rarely reliable sources about their own hospital experiences.
c. Hospital experiences are frequently obscured by pain, analgesics, and other factors affecting awareness.
d. Patients are reliable sources about their own experiences, but are limited in their ability to gauge clinical competence of staff.
ANS: D
Rationale: Patients are reliable and motivated sources of their own experience but often do not have sufficient knowledge of clinical procedures to provide feedback about clinical competence.
An example of an effective patient outcome statement is:
a. “Eighty percent of all patients admitted to the emergency department will be seen by a nurse practitioner within 3 hours of presentation in the emergency department.”
b. “Patients with cardiac diagnoses will be referred to cardiac rehabilitation programs.”
c. “The hospital will reduce costs by 3% through the annual budget process.”
d. “Quality is a desired element in patient transactions.”
ANS: A
Rationale: Statements about patient outcomes must include measurable, specific, and patient-centred information.
Patient perceptions are useful in:
a. Determining disciplinary actions in QI.
b. Establishing the competitive advantage of QI decisions.
c. Establishing priorities among possible changes to care identified in QI.
d. Establishing blame for poor-quality care.
ANS: C
Rationale: Quality and patient dissatisfaction are useful indicators of the areas that are of greatest concern to patients, and of what matters to nurses and organizations. Patient perceptions guide areas of inquiry; however, they do not establish which disciplinary decisions would be made.
A nursing unit is interested in refining its self-medication processes. In beginning this process, the team is interested in how frequently errors occur with different patients. To assist with visualizing this question, which organizational tool is most appropriate?
a. Histogram.
b. Flowchart.
c. Fishbone diagram.
d. Pareto chart.
ANS: A
Rationale: Histograms are bar graphs that are useful in outlining and identifying frequency.
The outcome statement “Patients will experience a 10% reduction in urinary tract infections as a result of enhanced staff training related to catheterization and prompted voiding” is:
a. Physician sensitive and nonmeasurable.
b. Measurable and nursing sensitive.
c. Precise, measurable, and physician sensitive.
d. Patient care centred and nonmeasurable.
ANS: B
Rationale: Nursing-sensitive outcomes are outcomes that are affected by nursing activity and are precise, measurable, and patient centred.
Your institution has identified a recent rise in postsurgical infection rates. As part of your QI analysis, you are interested in determining how your infection rates compare with those of institutions of similar size and patient demographics. Such a determination is known as:
a. Quality assurance.
b. Sentinel data.
c. Benchmarking.
d. Statistical analysis.
ANS: C
Rationale: Benchmarking is a widespread search to identify the best performance against which to measure practices and processes.
At Hospital Ajax, staff members are reluctant to admit to medication errors because of previous litigation and a culture that seeks to assign blame. This culture demonstrates:
a. QM principles that emphasize customer safety.
b. a deep concern with improvement of quality and processes.
c. effective employee orientation and development in relation to QM.
d. goals that are inconsistent with QM.
ANS: D
Rationale: The aim of QM is improvement, not the assignment of blame.
Which of the following is not a principle of high reliability organizations?
a. Sensitivity to operations.
b. Preoccupation with failure.
c. Commitment to resiliency.
d. Reluctance to simplify.
e. Indeference to expertise.
ANS: E
Rationale: The fifth and final principle of HROs is deference to expertise. Those who have the most knowledge about the situation are encouraged to speak up, voice concerns and share ideas. Preoccupation with failure, the first principle, relates to the relentless focus of organizations on safety concerns in the work environment. The second principle, reluctance to simplify, focuses on the need for staff to look beyond the obvious and avoid jumping to potential quick fix solutions. Sensitivity to operations, the third principle, outlines the importance of situational awareness related to how systems and processes are working in the organization so that potential risks to safety can be identified and actioned. The fourth principle, commitment to resiliency, focuses on the ability of individuals and teams to address problems, implement solutions and bounce back from errors.
The ability to compare data across health care sectors or organizations, such as hospital acquired infection or hand hygiene rates may be hindered by?
a. Reluctance to share information.
b. Fear of reduced funding.
c. Fear of reduced reputation.
d. Differences in terminology.
ANS: D
Rationale: Information technology plays a vital role in QI by increasing the efficiency of data entry and analysis. A consistent information system that trends high-risk procedures and systematic errors would provide a useful database regarding outcomes of care and resource allocation. Efforts are underway to develop standardized indicators of performance so that true comparisons can be made across health care settings, provinces, and territories.
The QI process begins with:
a. identifying implications for practice.
b. identifying the aim.
c. team assembly.
d. sustaining the improvements.
ANS: B
Rationale: The QI process begins with the selection of a clinical activity or issue for exploration and improvement—what is the goal or aim of the improvement? Theoretically, any and all aspects of clinical care could be improved through the QI process. However, the aim of QI efforts should be concentrated on changes to patient care or systems that will have the greatest effect.
Examples of sentinel events include (Select all that apply.)
a. Forceps left in an abdominal cavity.
b. Patient fall, with injury.
c. Short staffing.
d. Administration of morphine overdose.
e. Death of patient related to postpartum hemorrhage.
ANS: A, B, D, E
Rationale: Sentinel events are serious, unexpected occurrences leading to death or to physical or psychological harm.
A group of staff nurses is dissatisfied with the new ideas presented by the newly hired nurse manager. The staff members want to keep their old procedures, and they resist the changes. Conflict arises from:
a. Group decision-making options.
b. Perceptions of injustice.
c. Increases in group cohesiveness.
d. Debates, negotiations, and compromises.
ANS: B
Rationale: Interpersonal factors such as distrust, perceptions of injustice or disrespect, and inadequate or poor communication style can lead to conflict.
Two staff nurses are arguing about working on holidays. In trying to resolve this conflict, the nurse manager understands that interpersonal conflict arises when:
a. Risk taking seems to be unavoidable.
b. People see events differently.
c. Personal and professional priorities do not match.
d. The ways in which people should act do not match the ways in which they do act.
ANS: B
Rationale: By definition, conflict involves a difference in perception between two or more individuals.
The nurse manager is aware that conflict is occurring on her unit; however, she is focused on preparing for a provincial health department visit, so she ignores the problem. A factor that can increase stress and escalate conflict is:
a. The use of avoidance.
b. An enhanced nursing workforce.
c. Accepting that some conflict is normal.
d. Managing the effects of fatigue and error.
ANS: A
Rationale: Purposeful avoiding is an appropriate strategy when the conflict is interpersonal and the individuals involved in the conflict have the necessary skills and insight to be able to own the problem and solve it themselves. When these conditions are not present and avoidance is not purposeful, then avoidance can increase stress and escalate conflict.
The nurse manager decides to use a mediator to help resolve the conflict among staff. Which of the following is a basic strategy for truly addressing this conflict?
a. Identify the conflicting facts.
b. Be determined to resolve the conflict.
c. Schedule a meeting time for resolution.
d. Have a clear understanding of the differences between the parties in conflict.
ANS: D
Rationale: The manager must determine whether a conflict is constructive or destructive. In this situation, the manager has determined that the conflict is destructive and does not want the conflict to escalate, and so a mediator has been engaged.
Ylena, a staff nurse on your unit, witnesses another nurse striking a patient. Ylena wants to remain friends with her colleague and worries that confrontation with her colleague or reporting her colleague will destroy their relationship. Ylena is experiencing which type of conflict?
a. Intrapersonal.
b. Interpersonal.
c. Organizational.
d. Professional.
ANS: A
Rationale: Intrapersonal conflict occurs within a person when confronted with the need to think or act in a way that seems at odds with one’s sense of self. Questions often arise that create a conflict over priorities, ethical standards, and values. Some issues present a conflict over comfortably maintaining the status quo and taking risks to confront people when needed, which can lead to interpersonal conflict.
The chief nursing officer plans a series of staff development workshops for the nurse managers to help them deal with conflicts. The first workshop introduces the four stages of conflict, which are:
a. Frustration, competition, negotiation, and action.
b. Frustration, conceptualization, action, and outcomes.
c. Frustration, cooperation, collaboration, action, and outcomes.
d. Frustration, conceptualization, negotiation, action, and outcomes.
ANS: B
Rationale: Thomas (1992) determined that conflict proceeds through the four stages of frustration, conceptualization, action, and outcomes, in that particular order.
A nursing instructor is teaching a class on conflict and conflict resolution. She relates to the class that conflict in an organization is important and that an optimal level of conflict will generate which of the following?
a. Creativity, a problem-solving atmosphere, a weak team spirit, and motivation of its workers.
b. Creativity, a staid atmosphere, a weak team spirit, and motivation of its workers.
c. Creativity, a problem-solving atmosphere, growth, and motivation for its workers.
d. A bureaucratic atmosphere, a strong team spirit, and motivation for its workers.
ANS: C
Rationale: Differences in ideas, perceptions, and approaches, when managed well, can lead to creative solutions and deepened human relationships. Conflict can stimulate growth, creativity, and change.
Jane has transferred from the intensive care unit to the critical care unit. She is very set in the way she makes assignments and encourages her new peers to adopt this method without sharing the rationale for why it is better. This is a good example of a process and procedure that creates ________ conflict.
a. Organizational.
b. Intrapersonal.
c. Interpersonal.
d. Disruptive.
ANS: C
Rationale: Interpersonal conflict transpires between and among nurses, physicians, members of other departments, and patients.
Two nurses on a psychiatric unit come from different backgrounds and have graduated from different universities. They are given a set of new orders from the unit manager. Each nurse displays different emotions in response to the orders. Nurse A indicates that the new orders include too many changes; Nurse B disagrees and verbally indicates why. This step in the process is which of the following in Thomas’s (1992) four stages of conflict?
a. Frustration.
b. Conceptualization.
c. Action.
d. Outcomes.
ANS: B
Rationale: Thomas’s stages of conflict include conceptualization, which involves different ideas and emphasis on what is important or about what should occur.
Mrs. Gordon, aged 68, was hospitalized after a stroke. The speech therapist recommended that oral feeding be stopped because of her dysphagia. During visiting hours, Mr. Gordon fed his wife some noodles. The nurse noticed this and stopped Mr. Gordon from feeding his wife, telling him it was the doctor’s decision. An hour later, the nurse returned and found Mr. Gordon feeding his wife again. The nurse tried to stop him again. Mr. Gordon refused and claimed that the clinical staff was trying to starve his wife; he also threatened to get violent with the nurse. The nurse decided to walk away and documented the event in Mrs. Gordon’s chart. According to Thomas’s (1992) four stages of conflict, in which stage could the nurse have been more effective?
a. Frustration.
b. Conceptualizing.
c. Action.
d. Outcomes.
ANS: C
Rationale: The nurse’s actions did not include actions such as clarifying Mr. Gordon’s views on feeding his wife, clarifying what was necessary to achieve good care for his wife, and engaging in dialogue with Mr. Gordon, thus preventing identification of a common goal. The action stage involves a behavioural response such as clarification or dialogue.
Jill is the head nurse on a unit in a large hospital. Two of the staff nurses are constantly arguing and blaming each other for mistakes, and a resolution has not occurred in months. To solve the existing conflict, which is the most desirable conflict resolution?
a. Avoiding.
b. Competing.
c. Compromising.
d. Collaborating.
ANS: D
Rationale: The collaboration technique has both sides in the conflict working together to develop an optimal outcome. This results in a win-win solution.
A nurse educator is giving a workshop on conflict. During the sessions he makes various statements regarding conflict. All of the following statements are true except:
a. “Conflict can decrease creativity, thus acting as a deterrent for the development of new ideas.”
b. “Conflict can arise over the most trivial issues.
c. “A variety of definitions of conflict are known.”
d. “All conflicts involve some level of disagreement.”
ANS: A
Rationale: Research has shown that conflict, like change, increases creativity and allows for the
development of new ideas.
The nurse manager performs his role in a way that he believes empowers his staff; however, the staff feel smothered by his micromanagement approach. This is a good example of which of the following conditions that propel a situation toward conflict?
a. Incompatible goals.
b. Role conflicts.
c. Structural conflict.
d. Competition for resources.
ANS: A
Rationale: Goal conflicts often arise from competing priorities. In this example, the nurse manager desires to empower employees, but his behaviours indicate to the staff that he is practising micromanagement.
Kala, a unit manager, in discussing a role the hospital’s chief executive officer would like her to perform, makes the following statement, “I will sit on the hospital task force on improving morale if you send me to the hospital’s leadership training classes next week, so I can further develop my skills and thus be more effective.” Which of the following conflict management styles is Kala using?
a. Collaborating.
b. Avoiding.
c. Negotiating.
d. Accommodating.
ANS: C
Rationale: In this particular situation, an exchange of concessions (membership on a committee in return for attendance at a workshop) or trading occurs. This strategy supports a balance of power.
Marcus is a circulating nurse in the operating room. He is usually assigned to general surgery, but on this day he is assigned to the orthopedic room. He is unfamiliar with the routines and studies the doctor’s preference cards before each patient. The fourth patient comes into the room, and Marcus prepares a site for a biopsy by using a Betadine solution. The surgeon prefers another solution. He notices what Marcus has done and immediately corrects him by rudely insulting him. Which of the following is the most appropriate approach to conflict resolution in this example?
a. Collaboration.
b. Compromising.
c. Avoiding.
d. Withdraw.
ANS: B
Rationale: Negotiation must occur for the situation to be rectified. Marcus must apologize for his error, and so must the surgeon for his inappropriate response. Resolution must be accomplished with the understanding that time is of importance. This strategy results in appeasement of each side to some degree.
Successful resolution of conflict yields constructive outcomes and leads to:
a. Inhibition of movement.
b. Improved team functioning.
c. Diminished resolutions.
d. Lower employee satisfaction levels.
ANS: B
Rationale: Successful resolution of conflict yields constructive outcomes and leads to improved team functioning. Unsatisfactory resolution is typically destructive and results in inhibition of movement, or diminished resolutions, and lower employee satisfaction levels.
The head nurse and a staff nurse are having a conflict over how to use and apply a new procedure for dressings in the medical/surgical unit. The staff nurse wishes to use the new procedure, which is based on newly released nursing research. The head nurse wishes to use a protocol that has been used in the department for a number of years. The head nurse later makes comments to other staff on her unit about the credibility of the staff nurse. This behaviour is associated with:
a. Lateral violence.
b. Horizontal violence.
c. Confrontation.
d. Bullying.
ANS: D
Rationale: Bullying involves aggressive or destructive behaviour or psychological harassment of a recipient who has less power than the perpetrator (the head nurse). Bullying is closely related to lateral or horizontal violence and involves such behaviours as withholding information, undermining activities, sabotage, and backstabbing.
Which of the following exemplifies the preferred conflict management style of nurse managers?
a. Elizabeth, the head nurse on neurology, finds that Tom, the RN on duty at night, is irritable in relation to any suggestions or new ideas, and so she comes in to work after Tom leaves the unit.
b. The technology committee has recommended a clinical system for implementation on the nursing unit. Staff members are anxious about the change. Stefano, the head nurse, asks staff for ideas on how to meet the technology goals and to meet staff needs
c. During management meetings, George, the head nurse on the nephrology unit, dominates meetings and decisions. Lou, the head nurse on the cardiac stepdown unit, begins to miss the management meetings.
d. Ann, RN, asks her head nurse if she can go on the permanent evening shift. The head nurse, Rajib, agrees as long as Ann agrees to be involved in assisting to mentor evening staff in the use of the new clinical information system.
ANS: D
Rationale: Compromise involves trading and negotiation and is the preferred conflict management style of managers.
Lee, the head nurse in ER, has attempted to meet Jillian, one of her staff RNs, for several days to discuss concerns about Jillian’s relationships with her team members. Lee hopes to offer Jillian coaching so that Jillian’s relationships can be more satisfying with her team members. Each time Lee and Jillian set a time to meet, Jillian phones in sick. In this situation, Lee and Jillian are demonstrating:
a. Similar conflict management strategies.
b. Escalation of conflict.
c. Avoidance and compromise strategies.
d. Competing and compromise strategies.
ANS: C
Rationale: Jillian is demonstrating avoidance by staying away from meetings to discuss her team relationships, and Lee is demonstrating compromise by offering coaching in return for Jillian’s being able to engage in more satisfying relationships.
Which of the following best exemplifies the accommodation style of conflict management for staff nurses?
a. Leni and Jonas, two RNs, disagree with the best approach to assisting a family that has complex needs. They decide that they will consult with family and together will decide what is best.
b. Jennifer needs to switch a shift to attend a family function. She arranges to trade with Nancy, who wants a day off next to a 3-day break.
c. Alexis asks Melody to stay late for the third day in a row. Melody refuses, stating that she has already helped out for two days by staying late for Alexis.
d. Lara asks Lourdes to switch shifts with her because Lara wants to attend a concert. Lourdes would prefer not to but does to enable Lara, who is new in town, to be with her friends.
ANS: D
Rationale: Accommodating involves neglecting one’s own needs while trying to satisfy the needs of another.
In trying to achieve Magnet status for the hospital, the chief nursing officer establishes a shared governance model to help nurses experience job satisfaction. However, some nurses who have enjoyed working with less autonomy resist this change, which thus creates organizational conflict. Organizational conflict arises from which of the following?
a. Flat organizational structure.
b. Clarity in role responsibilities.
c. Increased autonomy through self-governance.
d. Less participation in decision-making.
ANS: D
Rationale: Organizational conflict arises when discord exists with regard to policies and procedures, personnel codes of conduct, or accepted norms of behaviour and patterns of communication. Some organizational conflict is related to hierarchical structure and role differentiation, in this case, among employees with less autonomy.
Congruence is described as an alignment of one’s real and ideal self, resulting in a greater ability to be authentic and self-actualize/thrive in one’s life roles (Rogers, 1959). Self-compassion is (Select all that apply.)
a. A positive view of one’s self.
b. Clarifying your own values and beliefs.
c. One’s ability to receive and respond constructively to feedback.
d. The ability to get along with others.
ANS: C
Rationale: Self-compassion correlates with one’s ability to receive and respond constructively to feedback and is a necessary element toward attaining congruence. It occurs when one extends kindness to themselves in response to suffering and during times of perceived inadequacy.
There are time when avoiding conflict can be effective. Which of the following are appropriate for avoiding conflict? (Select all that apply.)
a. Facing trivial and/or temporary issues.
b. There is no chance to obtain what one wants or needs.
c. Give time for people to “cool down.”
d. To give up forever.
ANS: A, B, C
Rationale: Avoiding, or withdrawing, is a fear-based approach to conflict management. Most people do not consciously choose avoidance, but rather, from a place of fear they will subconsciously distract themselves from acknowledging the conflict and the impact it has on themselves and others. Not all conflict must be addressed immediately as some issues require considerable reflection before strategies can be selected and action taken. The positive side of withdrawing may be postponing an issue until a better time, or simply walking away from a “no-win” situation.
The way in which nurses respond to conflict has changed very little in the past 20 years. What are the two most often (based on research) ways nurses use when faced with conflict?(Select all that apply.)
a. Collaborating
b. Avoidance
c. Compromising
d. Accommodation
ANS: B, D
Rationale: Professional nurses often avoid conflict when they fear a consequence (Johansen, 2012). Nurses sometimes choose to avoid conflict because they fear that engaging in conflict or even attempting to resolve conflict may jeopardize their career advancement. The stereotypical self-sacrificing behaviour seen in avoidance and accommodation is strongly supported by the altruistic nature of nursing (Blair, 2013). However, it erodes the ability for coworkers to be authentic and to establish relationships of trust.
Nurses entering into the workforce today are faced with which of the following relationships that could create organizational conflict? (Select all that apply.)
a. Nurse–physician relationship.
b. Nurse–nurse relationship.
c. Nurse–patient relationship.
d. Nurse–chief nursing officer relationship.
e. Nurse–auxiliary personnel relationships.
ANS: A, B, C, D, E
Rationale: By nature, conflict has the potential to occur in all interpersonal situations. The nurse manager should create an environment in which differences in staff, physicians, patients, and communities are recognized and valued.
The most important approach that a nurse manager can take with an emotionally troubled employee is to:
a. Act as a therapist for the employee.
b. Adjust the standard of care to assist the employee.
c. Assist the employee in obtaining professional help.
d. Adjust the employee’s work schedule to decrease stress.
ANS: C
Rationale: Emotional difficulties are usually beyond the scope of skills that a nurse manager would normally employ. A referral needs to be made to a professional who is specifically prepared to deal with this kind of difficulty.
The nurse manager knows that the most serious effect that absenteeism has on the nursing unit is that:
a. Using replacement personnel with new ideas may be beneficial.
b. Salary costs are lower because personnel are fewer, and outcome is favourable.
c. Absence on the part of the rest of the staff is decreased.
d. Unacceptable patient care may result.
ANS: D
Rationale: Reduced staffing adversely affects patient care. Employee morale suffers, care standards may be lowered, and additional stress is placed on working staff.
In keeping with guidelines of the organization, the nurse manager documents staff problems. Documentation of disciplinary problems should:
a. Include a plan to correct them and to prevent future occurrences.
b. State a detailed history of past problems that are related to the current one.
c. Be written at the convenience of the manager.
d. Accumulate until the evaluation period begins.
ANS: A
Rationale: In documenting staff problems, it is important to indicate specifically what rules were broken or violated, consequences if behaviour is not altered, employee’s explanation of the incidents,
and the plan of action to achieve and to reach new goals. Accurate and factual documentation
and follow-up actions are key elements in the successful management of all personnel issues.
Before terminating an employee, a nurse manger must:
a. Be an expert in all legal aspects of employment termination and discipline practices.
b. Know the organization’s specific policies for addressing disciplinary problems and employment termination.
c. Function as a counsellor for problem employees.
d. Do everything to assist and protect the employee by adjusting standards and policies.
ANS: B
Rationale: It is important to know the policies of the organization to address disciplinary issues fairly and equitably, and also to know the model that is employed to address employee problems.
A nurse manager understands that the typical first step in handling an employee with a disciplinary problem is to:
a. Provide a verbal reprimand.
b. Prepare a written reprimand.
c. Counsel the employee regarding the problem.
d. Give the employee the day off without pay.
ANS: C
Rationale: The progressive model of discipline advocates that the first step of the disciplinary process is to counsel the employee regarding the problem. The second step is a reprimand of the employee (first verbally, then in writing). The non punitive discipline model advocates reminding the employee of the employment policies and procedures of the agency.
The chief nursing officer understands that clinical incompetence is best prevented by which of the following?
a. A flexible protocol for evaluating competency skills.
b. A standardized clinical skills checklist.
c. A newly established peer review process.
d. A formalized competency program with established standards for practice.
ANS: D
Rationale: The competency program with established standards of practice outlines what the nurse must do to achieve desired competencies in her current position. Competency assessment and goal setting should help the nurse learn how to excel and identify which competencies the nurse wants to achieve in the future.
A nurse manager understands that the second step in handling an employee with a disciplinary problem is to document the incident. Which of the following is best for documentation of personnel problems?
a. Use of the performance appraisal on an annual basis.
b. Notes made immediately after an incident that include a description of the incident, actions taken, plans, and follow-up.
c. A tally sheet of medication errors and other specific problems that will be used at annual review.
d. Copies of reports, placed in the employee’s file, of all unusual occurrences involving the employee.
ANS: B
Rationale: In documenting staff problems, it is important to indicate specifically what rules were broken or violated, consequences if behaviour is not altered, employee’s explanation of the incidents, and the plan of action to reach new goals.
The nurse manager places a staff member on probation because of reports of chemical dependency. The nurse manager should be aware that which of the following statements is true regarding chemical dependency?
a. The chemically dependent employee usually hides any changes in behaviour.
b. When confronted with the issue, the affected employee is usually relieved to have someone to talk to about the problem.
c. The chemically impaired nurse affects the entire health care organization.
d. Hospital policy, state laws, and nurse practice acts address procedures for the chemically dependent employee in the most general terms.
ANS: C
Rationale: A chemically impaired nurse jeopardizes patient care through impaired skills and judgement. She or he also compromises teamwork and continuity as peers attempt to cover deficiencies in work performance for their impaired team member.
The chief nursing officer reviews the policy about “progressive discipline process.” The progressive discipline process includes which of the following?
a. The manager is a counsellor and friend to the employee.
b. The manager should reprimand and suspend the employee as a last resort.
c. The manager should rehire the employee after a reasonable length of time.
d. The manager should terminate the employee if the problem persists.
ANS: D
Rationale: In some situations, despite best efforts of the manager/leader, the employee’s issue or disruptive behaviour may continue. In such cases, there is sometimes no choice but to terminate the employee.
A nurse manager must be familiar with the agency’s policies regarding employment termination. Termination procedures include which of the following?
a. Following specific procedures at other organizations.
b. Having an attorney present at the termination meeting.
c. Having adequate written documentation to support the action.
d. Having a friend present during the termination meeting.
ANS: C
Rationale: All steps should be followed, including having full, appropriate, detailed documentation and following the procedures of the organization.
Nathan has been on the cardiac unit for 6 months and has found it difficult to adjust to the expectations of his team. Which of the following behaviours are most likely to signal that Nathan is intending to resign from his position on the unit?
a. Increased absenteeism over the past month.
b. Increased attempts to discuss his concerns with his colleagues.
c. Testing of workplace guidelines.
d. Frequent defensiveness.
ANS: A
Rationale: Many employees increase their absenteeism just before submitting their resignation. If the health care worker is experiencing some form of role stress, it might be manifested through absenteeism. Role strain may be reflected by: (1) withdrawal from interaction;(2) reduced involvement with colleagues and the organization; (3) decreased commitment to the mission and the team; and (4) job dissatisfaction. Testing of workplace guidelines and defensiveness are associated with immaturity.
All of the following are grounds for immediate dismissal except:
a. Failing to pursue further medical help for a patient, after which the patient dies.
b. Selling narcotics obtained from the unit supply of narcotics.
c. Restraining a patient in bed for 7 hours, unsupervised, as punishment for hitting a staff member.
d. Grabbing the unit manager and threatening further physical harm after a poor performance appraisal.
ANS: A
Rationale: Situations that may warrant immediate dismissal include theft, violence in the workplace, and wilful abuse of the patient.
Nurses generally experience difficulty in identifying behaviours and actions that could signal chemical dependency in a coworker. Which of the following is not a behavioural change that occurs with chemical dependency?
a. Personality and behavioural changes.
b. Job performance changes.
c. Changes in educational involvement and pursuit.
d. Absenteeism.
ANS: C
Rationale: When suspicions of chemical dependency are raised, a manager needs to be alert to behavioural changes in the affected employee. These changes include mood swings, changes in hygiene and appearance, heightened interest in the pain control of patients, increases in absenteeism, and increases in tardiness.
Aurora, RN, is a self-admitted drug addict and has abused codeine heavily. Aurora and the unit manager decide that changes have to occur. Aurora enrolls in an addiction program, and the manager has her transferred to a drug-free area. What other strategies might be appropriate?
a. The manager could refer Aurora to the human resources department.
b. The manager could assist in monitoring Aurora’s progress.
c. The manager could counsel Aurora if Aurora has formed a trusting relationship
with her.
d. Aurora needs to be asked not to involve her family in the recovery program because this is a work-related situation.
ANS: B
Rationale: Effective management mandates that the organization take an active role in helping employees with chemical dependencies. It is important for the manager/nurse leader to be supportive, caring, empathic, and encouraging with such an employee. Many organizations have employee assistance programs, to which the manager should refer employees.
Incivility is a disruptive behaviour or communication that creates negativity in the environment and interferes with quality of patient care and safety. The manager can implement steps that help to alleviate uncivil behaviour on a unit. Which of the following would not be an appropriate first step?
a. Suspending the staff member from work.
b. Providing written admonishment that is discussed and placed in the employee’s file.
c. Providing verbal admonishment.
d. Terminating the staff member.
ANS: D
Rationale: Dismissal does not enable the organization to attempt remediation of the behaviour and is not consistent with first steps in progressive discipline.
In which order should the strategies below occur in progressive discipline?
a. Suspending the staff member from work.
b. Providing written admonishment that is discussed and placed in the employee’s file.
c. Providing verbal admonishment.
d. Terminating the staff member.
a. A, B, C, D
b. B, A, C, D
c. C, B, A, D
d. C, A, B, D
ANS: C
Rationale: Studies have shown that following this sequence is a fair and effective strategy for discipline and remediation.
When progressive discipline is used, the steps are followed progressively only for repeated infractions of the same rule. On some occasions, the breaking of rules is so serious that the employee is:
a. Transferred to another unit.
b. Suspended indefinitely.
c. Asked to attend a union grievance meeting.
d. Terminated after the first infraction.
ANS: D
Rationale: Situations that may warrant immediate dismissal include theft, violence in the workplace, and wilful abuse of a patient.
You need to terminate Gregory, who has had a long-standing history of conflict with you and the staff and who recently was charged with theft of patient belongings. You consult the human resources department, and together you develop a plan, which includes:
a. A private meeting with Gregory, a human resources representative, and you to deliver the news and deliver the employment termination notice and all other documents that are related.
b. Planning an opportunity for Gregory to return and be recognized at a staff farewell.
c. Calling Gregory at home to tell him that he is fired and that his paperwork will be
sent to him at a future date.
d. Calling him into a meeting in your office on the ward, where assistance is
available, should he become upset or agitated.
ANS: A
Rationale: Employment termination requires careful planning as to timing, privacy, safety, and how to preserve the employee’s dignity and avoid humiliation. Choosing a private location where colleagues are not present and organizing all documentation that is required to be given to Gregory achieves these goals and prevents his having to come to the organization at a future date.
The nurse manager notices that Tia, a staff nurse, has been absent 2 to 3 days per month for the past 3 months. What is the manager’s best response?
a. “Why are you absent from shifts every month?”
b. “I am concerned that you have been absent 3 days this month.”
c. “Your attendance record is not very good. Do you want to talk about it?”
d. “I am changing your shift rotation as it is obvious that you are not able to consistently implement your scheduled shifts.”
ANS: B
Rationale: Nurse leaders must confront persistent absenteeism and discuss the situation directly with the employee by verbalizing their concern, in this case, when they see that a staff nurse has been absent 2 to 3 days per month in the past 3 months. The manager mentions examples of observed behaviour and tells the employee how they makes the manager feel. Asking why the staff member has been absent is not the best response. Although the manager may ask the nurse if she wants to talk about it, the manager would not begin the statement with a value-laden negative response. Changing the shift rotation is based on the assumption that scheduling is the problem, and that assumption may not be correct.
Susan, a new graduate, is upset that so many staff members have been absent lately from the unit. She declares to you that all absenteeism could be eliminated with proper management. Your response is based on understanding that:
a. Not all absenteeism is voluntary.
b. High personal control contributes to absenteeism.
c. Direct discussions with employees who have high levels of absenteeism are not
recommended.
d. All absenteeism is related to personal issues and needs.
ANS: A
Rationale: Not all absenteeism is voluntary or preventable, which means that absenteeism can never be fully eliminated. Absenteeism can result from personal issues and needs, work dissatisfaction, and involuntary reasons such as jury duty.
The nursing director calls a meeting with one of the new unit managers. She is very concerned about a report of substance abuse on the manager’s unit, and she reviews the procedures involved in dealing with chemically dependent staff. Which of the following statements would not be included in the discussion?
a. “As a manager, you need to be aware of professional regulatory reporting requirements.”
b. “As a manager, you should check with the human resources department regarding chemically dependent employees and employment practices.”
c. “As a manager, you check the nurse practice acts for the province in which the nurse resides.”
d. “As a manager, you should realize that the nurse is a professional embarrassment and should be kept out of sight of other staff.”
ANS: D
Rationale: As a manager, you need to be familiar with provincial/territorial professional regulatory and reporting requirements regarding chemical use and abuse, and also with the human resources department’s practices and guidelines.
The education consultant for the hospital is presenting a workshop on “Documentation: A Manager’s Responsibility.” Which of the following points concerning documentation of personnel problems would she not include in her PowerPoint presentation?
a. “Documentation cannot be left to memory. A notation must be placed in the personnel file.”
b. “Documentation should avoid discussion of the problem.”
c. “Documentation should include what was done about the problem when it occurred.”
d. “Documentation needs to include date, time, and place.”
ANS: B
Rationale: Documentation of personnel problems is one of the most important aspects of the nursing manager’s role. Through carefully detailed and timely documentation of the problem and plan, the manager decreases the burdensome problems that can ensue from improper or inadequate documentation.
The unit manager discusses absenteeism with the unit clerk. She indicates that it is a serious problem on the unit. Which of the following points would they have probably discussed?
a. Employee morale is at a high level.
b. Care will suffer and standards will be lowered.
c. Existing staff have experienced little effect from the absenteeism.
d. Replacement staff usually needs little supervision.
ANS: B
Rationale: Absenteeism puts a strain on staff, produces morale problems, and can jeopardize patient
safety.
Although the Health Professions Acts and professional nursing standards and competencies
vary across Canada, the underlying expectation is that members of any health care profession
recognized in Canada have on overarching mandate to:
a. Maintain competence.
b. Uphold nursing practice standards.
c. Duty to report.
d. Protect the public.
ANS: D
Rationale: Although all of the answers are correct the nurses’ mandate is to protect the public.
Clinical incompetence is one of the more serious problems facing a nurse manager. Joyce, the
nurse manager, is not aware of the problems of Sarah, a novice nurse. After she investigates, it
is obvious that Sarah’s peers are covering for her. Which of the following might Joyce include in her meeting with the nurses? (Select all that apply.)
a. “It is a nurse’s professional responsibility to maintain quality control.”
b. “All instances of clinical incompetence are to be reported.”
c. “It is not considered being disloyal when one nurse reports another for poor care.”
d. “Patient care is the number one concern. Meeting standards is mandatory and
necessary.”
ANS: A, B, C, D
Rationale: The nurse leader must remind employees that professional responsibility is to maintain quality care, and thus they are obligated to report instances of clinical incompetence, even when it
means reporting a coworker. Ignoring safety violations or poor practice is unprofessional and
jeopardizes patient care.
Role strain can result in which of the following manifestations? (Select all that apply.)
a. Withdrawal from interaction.
b. Feeling of belonging.
c. Job dissatisfaction.
d. Decreased commitment to the team.
ANS: A, C, D
Rationale: If a nurse has a feeling of belonging there is job satisfaction, increased commitment to the team, and a withdrawal from interaction. If role strain continues, there is a likelihood of increased absenteeism and the possibility of changing jobs or leaving the profession.
A nurse’s emotional transference from past trauma may affect their ability to function within a
clinical setting. A manager must be attuned to a nurse’s level of emotional well-being. Which of the following could demonstrate a nurse who is exhibiting signs of past trauma? (Select all that apply.)
a. Hostility toward others.
b. Addictive tendencies.
c. Maladaptive perfectionism.
d. Testing of workplace guidelines.
ANS: A, B, C, D
Rationale: All of the above are a manifestation of personal past trauma. Testing of workplace guidelines
is a derivative of maladaptive perfectionism. If the nurse manager focuses on identifying the root cause of the undesirable behaviour, he or she will be better able to find the right solution and be better prepared to address the issue as a whole.
Many employers have moved from a progressive discipline approach to a nonpunitive
approach. The value of this approach is? (Select all that apply.)
a. Enables both parties to attain their dignity.
b. Takes longer to determine an actable outcome.
c. Minimizes ambiguity related role stress.
d. Shifts the responsibility to act from the manager to the employee.
ANS: A, B, D
Rationale: Nonpunitive discipline minimizes power battles, focuses on objective measures, and puts the
choice in the hands of the employee. The nonpunitive disciplinary process begins with a verbal discussion, whereby the agencies standards and employment expectations that were
agreed to at the time of hiring, or are part of one’s professional nursing requirements, are
reiterated, as is the gap between what is expected of the employee and the employee’s current
performance.
Your health care organization places a high value on workplace safety and integrates this into all aspects of administrative and patient care processes. As a unit manager, you thoroughly endorse this direction, and during the selection and hiring of new staff, you consistently:
a. Refuse to hire applicants who are pushy during interviews.
b. Thoroughly follow up with all references before offering a position.
c. Ask applicants during the interview whether drug or alcohol abuse is a problem.
d. Refuse to interview applicants with sporadic work histories.
ANS: B
Rationale: Sporadic work histories and a “pushy” attitude may or may not be associated with aggression and violence. Thoroughly checking references helps to effectively confirm or rule out impressions obtained during the interview, and may yield useful information about issues related to violence and aggression in previous employment.
Jay, a newly graduated registered nurse (RN), has just begun work on an acute care nursing unit. As a nurse manager, you know that new graduates are most likely to experience:
a. Aggression.
b. Horizontal violence.
c. Physical violence.
d. Vertical violence.
ANS: B
Rationale: Studies indicate that new graduates were likely to experience horizontal violence, which resulted in high absentee rates and thoughts of leaving nursing after their first year.
In which of the following situations would you, as the head nurse, be concerned about potential safety issues?
a. Jordan comes to your office to complain about inadequate staffing on the unit. He says that he is concerned because he attributes a recent incident to the staffing levels.
b. Heinrich, a long-standing RN on the unit, has begun to miss work regularly. He calls in but is vague about his reasons for the absences.
c. Carla, RN, has just ended a relationship with Jake, RN, and he will not leave her alone. You are meeting with Jake today because colleagues on night shifts have reported that Jake seems to have been intoxicated last night and the previous night.
d. Sarah is very quiet and says almost nothing in team meetings. Lately, she has been much more animated since becoming friendly with a couple of other RNs on the unit
ANS: C
Rationale: Jake seems at most risk for violence mainly because of his alcohol use and the end of what may be an obsessive relationship with Carla. In the other situations, Jordan is expressing a legitimate concern and is behaving assertively; Heinrich may have health concerns or other issues that are private and interfering with his work life; and Sarah’s change in behaviour is probably related to a higher level of comfort with work and colleagues.
Delaney, one of your staff nurses, confides that Marjorie, another nurse, has been actively telling others that you are incompetent, you do not know what you are doing in relation to
patient care, and that you lie to the staff about attempts to get more staffing. Through
telephone calls and conversations during breaks, she is recruiting other staff to her position. Delaney confides that most staff members find you fair, honest, and knowledgeable.
Marjorie’s behaviour can best be characterized as:
a. Political action.
b. Bullying.
c. Building alliances.
d. Disgruntlement.
ANS: B
Rationale: Workplace bullying involves aggressive and destructive behaviours such as running a smear campaign and failing to support another nurse.
During coffee and other breaks, Rosalie, the new RN, is excluded from conversations with the other staff. When she approaches other staff on the unit to ask questions, they turn and walk off in the other direction. The behaviour of the staff is characteristic of:
a. Dislike.
b. Lack of trust in Rosalie’s abilities.
c. Horizontal violence.
d. Cultural incompetence.
ANS: C
Rationale: Horizontal or lateral violence and bullying are terms used to describe destructive behaviours
towards coworkers, such as the “silent treatment,” and excluding others from socializing.
Sabotage is an example of which type of violence?
a. Threatening behaviour.
b. Written threat.
c. Harassment.
d. Verbal abuse.
ANS: C
Rationale: Sabotage is harassment, which is any behaviour that demeans, embarrasses, humiliates,
annoys, alarms or verbally abuses a person and that is known or would be expected to be unwelcome. Sabotage includes words, gestures, intimidation, bullying, or other inappropriate activities.
Caroline asks family members to leave while she cares for the 16-year-old victim of a recent
car accident. The father screams at her and tells her that she has no right to ask his family to leave, and that if she continues to do so, he will “throw her out of the room.” Caroline is shaken and tells her head nurse, who tells her that this kind of thing is just part of the job.
The guidance of the head nurse:
a. Is reasonable. No physical violence was involved.
b. Is related to why incidents of violence in health care are probably underreported.
c. Acknowledges the deep distress and fear of the family.
d. Acknowledges the concern of the nurse.
ANS: B
Rationale: A common perception is that incidents such as these, which involve threats rather than physical injury or harm, are part of the job. Because of underreporting, data related to violence and aggression in the workplace may not be reflective of their true incidence.
You are part of a multidisciplinary team that is charged with designing a workplace safety plan for your health care organization. This team has been established in response to increases in reports of violence and aggression. You begin designing the safety plan by:
a. Surveying staff about levels of satisfaction with the workplace and management,
collegial, and patient relations.
b. Offering training sessions in self-defence.
c. Developing a policy that outlines zero tolerance for bullying.
d. Offering education sessions on recognizing behaviours with potential for violence.
ANS: A
Rationale: Violence and aggression and a toxic workplace can lead to staff dissatisfaction and high staff turnover rates. Surveying staff provides a useful starting place in identifying problems such as employee dissatisfaction, bullying, and other forms of violence.
In the emergency department waiting room, you notice a patient sitting, with his head in his hands, who has been waiting for about 5 hours for relief of his headache. When you approach him to ask him how he is doing, he says, “I can’t believe that I have to wait this long for help! Do you know what it is like to be in pain for 10 hours?” Your response to him would be:
a. “It is frustrating to wait when you are in pain and when you are expecting to receive relief right away.”
b. “Don’t talk to me. If you are going to be rude, then you will not receive treatment
here.”
c. “We are very busy and don’t have enough staff to deal with problems such as
yours.”
d. “Perhaps you should go elsewhere. We do not have time for you here, as many
more sick patients are waiting.”
ANS: A
Rationale: Empathizing helps the other person to know and feel that he has been understood and is powerful in deescalating a situation that has potential for aggression and violence.
Communication techniques and body language skills were used to try to deescalate the
situation.
At 3 a.m., a man walks into your emergency department. He paces back and forth in the waiting area before he approaches staff to ask if he can see his wife, who is a patient on another floor. He speaks rapidly, his face is flushed, he glances around often, and he keeps his hand in his jacket pocket. A best initial response would be to:
a. Assess your situation and your surroundings.
b. Ask two or three staff to assist in confronting the individual.
c. Ask what floor his wife is on and remind him that visiting hours are over.
d. Remain calm as there is no potential for violence here.
ANS: A
Rationale: The behaviour of the individual (flushed appearance, furtive glances, speed of speech) and the hand in his pocket suggest the potential for violence or aggression. The first step is to
quickly assess your surroundings for other people who might assist you and for safety alarms.
The Canadian Nurses Association (CNA) cites studies that suggest that intimidating and disruptive behaviours in the nursing profession contribute to:
a. Low morale.
b. Preventable adverse outcomes.
c. An increase in power for leaders.
d. Citations of leaders for not addressing workplace violence.
ANS: B
Rationale: The CNA cites studies that suggest that intimidating and disruptive behaviours in the nursing profession contribute to low patient satisfaction and an increase in preventable adverse outcomes. Although intimidating and disruptive behaviours may contribute to low morale, these were not identified as contributors by the CNA.
Residents in a new long-term care facility attend meals in a large dining hall. In reviewing
reports of aggression and violence, you note that behaviours such as hitting or attempts to hit staff are increasing. Further investigation suggests that this behaviour occurs most often at mealtimes. A possible intervention would be to:
a. Seat residents with the highest potential for violence next to those with the lowest
potential for aggression.
b. Feed residents earlier in the day.
c. Restrain residents who are violent or aggressive during meal times.
d. Establish a smaller dining area that is away from the main area that is for residents who have potential for aggression/violence.
ANS: D
Rationale: Working during periods of understaffing, especially during visiting hours and meal times, is
a risk situation for violence and aggression. Reducing activity levels through interventions such as a separate dining area may reduce incidents of violence and aggression.
Many inaccurately believe workplace violence to be related specifically to:
a. Verbal abuse.
b. Physical injury.
c. Incivility.
d. Harassment.
ANS: B
Rationale: Many people believe workplace violence to refer specifically to physical injury; unfortunately, it is this belief that perpetuates verbal abuse in the health care setting. However, the Canadian Centre for Occupational Health and Safety defines workplace
violence as “any act in which a person is abused, threatened, intimidated or assaulted in his or her employment.”
As indicated by Shield and Wilkins for Statistics Canada (2014), abuse in the health care setting is most often perpetrated by someone who:
a. Is male.
b. Has more experience.
c. Consistently works day shifts.
d. Has high coworker support.
ANS: A
Rationale: Shield and Wilkins noted that abuse was related to being male, having less experience, usually working non-day shifts, and perceiving staffing or resources as inadequate, nurse-physician relations as poor, and coworker and supervisor support as low.
In addressing a high staff turnover rate that results from violence on a nursing unit, you are:
a. Confirming the high correlation between managerial incompetence and violence.
b. Demonstrating awareness that workplace violence, if present, has significant costs.
c. Aware that staff and manager experiences contribute to high turnover.
d. Aware that violence is a rare but present factor in the workplace.
ANS: B
Rationale: Workplace violence and aggression contribute to staff turnover and toxic work
environments. Loss of the organizational investment required to train new staff and departure of experienced staff can increase operating costs and reduce the quality of care.
A patient who has a history of involvement with drugs and weapons comes up to you in the hallway and asks you a question regarding directions in treatment. When you respond, he moves closer in to you and puts both hands up on either side of your neck. No one else is in the hallway. Your best response at this point is to:
a. Yell at him to stop.
b. Calmly ask the patient to remove his hands.
c. Hit the patient in the midsection.
d. Use pepper spray.
ANS: B
Rationale: In a potentially violent situation, it is important to look and behave in a calm and confident manner, even if you do not feel calm or confident. The person whose behaviour you are deescalating will notice and take his or her cues from you.
Canadian knowledge of the scale of workplace violence in health care remains incomplete because:
a. Collected data are inflated.
b. No consistent system of data collection for workplace violence exists.
c. Data is collected only in relation to physical injuries.
d. The classification of workplace violence is unclear.
ANS: B
Rationale: Knowledge of the scale of workplace violence remains incomplete in Canada because no consistent system of data collection exists. Data regarding the less severe forms of workplace violence are particularly sparse.
Reza, RN, works as a staff nurse in the mental health department; Sharon works as a data entry clerk in the admissions department; Sarah is an emergency room physician; and Donna is a housekeeper in the geriatrics department. Which of these four is most at risk for violence: and aggression?
a. Reza.
b. Sarah.
c. Sharon.
d. Donna.
ANS: A
Rationale: Nurses are the primary target of violence in health care settings. Hader (2008) found that nurses were the primary targets of violence in 79.7% of such incidents.
Reza, RN, works as a staff nurse in the mental health department; Sharon works as a data entry clerk in the admissions department; Sarah is an emergency room physician; and Donna is a housekeeper in the geriatrics department. Which of the four is most likely to be a perpetrator of violence?
a. Reza.
b. Sarah.
c. Sharon.
d. Donna.
ANS: A
Rationale: According to Hader (2008), the perpetrator was a patient in 53.2% of violent incidents; a nurse colleague, in 51.9%; a physician, in 49%; a visitor, in 49%; and other health care workers, in 37.7%.
A safety and security plan is important to a health care organization because it:
a. Specifies preventive measures in relation to violence.
b. Provides direction as to changes in facilities that protect staff.
c. Establishes expectations in relation to behaviour and tolerance of violence.
d. Establishes policies and practices that guide prevention of violence and
expectations in the workplace.
ANS: D
Rationale: Nurses need to know how to access the workplace safety plan in their areas of practice. A safety plan provides overall direction in relation to what is expected, how violence is
prevented, and what will occur when violence happens.
Aishwarya is involved in intervening when a patient attempts to harm herself on the unit. During the interaction, the patient slaps Aishwarya across the face. It is important that the head nurse:
a. Offer Aishwarya immediate education and training in self-defence.
b. Assist with follow-up documentation and offer access to counselling.
c. Provide access to a lawyer.
d. Encourage Aishwarya to perceive the incident as a normal part of care.
ANS: B
Rationale: If nurses are the victims of or witness workplace violence, they have a duty and right to report the situation and to seek support to address the incident. When violence occurs, it is important to foster an environment that offers open communication, support, assistance with documentation, and psychological and other supported therapies.
Various descriptions of types of violence are available. Which form includes the use of power which differentiates itself from other terms?
a. Horizontal violence.
b. Bullying.
c. Lateral violence.
d. Interpersonal conflict.
ANS: B
Rationale: Other terms associated with this type of violence include bullying, which is a practice closely related to lateral or horizontal violence, but a real or perceived power differential between the instigator and recipient must be present in bullying.
According to the Government of Ontario, Ministry of Labour health care report (2017), workplace violence “accounted for what percentage for all lost-time injuries in the health care sector?
a. 10%
b. 20%
c. 12%
d. 5%
ANS: C
Rationale: This data was drawn from Workplace Safety and Insurance Board (WSIB) data published in 2016. In a 2014 analysis by the WSIB regarding claims, it is noted that there was an increase of 6.4% in reports of workplace violence from 2013-2014 in the health care sector.
A poll conducted by the Canadian Federation of Nurses Unions (CFNU) there were 16, 617 claims between the years 2006–2015. This is over double the rate reported by police and
correctional service officers in the same time period. The two most often reported incidences of violence are? (Select all that apply.)
a. Verbal by physician.
b. Verbal by patient.
c. Verbal by nurse colleague.
d. Verbal by family member.
ANS: B, C
Rationale: It is troubling that the rates of violence do not appear to have decreased, as is evidenced by a review conducted by Hader (2008). One survey found that 80% of the 1377 nurse respondents from the United States and 17 other countries reported having experienced some form of violence within the work setting.
Many theories exist as to why horizontal violence takes place in nursing. Which of the following are thought to be contributing factors to violence in nursing? (Select all that apply.)
a. Worker burnout.
b. Hierarchical structure.
c. Feminism.
d. Lack of supports.
ANS: A, B, C, D
Rationale: Historically, horizontal violence in nursing was considered to be a result of nursing’s traditional hierarchical structure, the oppression of nursing as a profession, or feminism (Farrell, 2001). More recently, bullying in the workplace has been linked to worker burnout and decreased access to empowering structures in the work environment, including access to information, resources, supports, and opportunities (Laschinger, Grau, Finegan, et al., 2010).
In designing a new health care facility, it is particularly important to pay close attention to safety elements related to violence and aggression in which of the following settings? (Select all that apply.)
a. Emergency.
b. Psychiatry.
c. Gerontology.
d. Maternity-pediatric.
ANS: A, B, C
Rationale: Although the potential for violence and aggression exists in all health care settings, emergency, psychiatric, and geriatric settings are at particular risk for violence.
The manager in the coronary care unit believes that the most important ethical considerations in performance evaluations are that they include the employee’s good qualities and that they give positive direction for professional growth. This belief is an example of:
a. Justice.
b. Fidelity.
c. Beneficence.
d. Nonmaleficence.
ANS: D
Rationale: Nonmaleficence refers to “doing no harm.” By focusing only on good qualities, the manager seeks to do no harm to the employee.
Normative ethics is concerned with the:
a. Broader theory and meaning of morality.
b. Foundation and scope of moral values, words, and practice.
c. Standards that most people use to guide their behaviours.
d. Relationship of ethical principles to real-life moral issues.
ANS: C
Rationale: Normative ethics is concerned with the standards that most people use to guide their behaviours (e.g. “murder is wrong”) and how they are determined. Metaethics concerns the
broader theory and meaning of morality and the foundation and scope of moral values, words, and practice. In applied ethics, ethical principles are studied in relation to real-life moral issues, such as how to provide nursing care and how to conduct research on human subjects.
A patient refuses a simple procedure that you believe is in the patient’s best interest. The two ethical principles that are directly in conflict in such a situation are:
a. Fidelity and justice.
b. Veracity and fidelity.
c. Autonomy and beneficence.
d. Paternalism and respect for others.
ANS: C
Rationale: Autonomy refers to the freedom to make a choice (e.g., to refuse a procedure), and beneficence refers to doing good (performing a procedure that will benefit the patient).
Three gravely ill patients are candidates for the only available bed in the intensive care unit. As the supervisor, you assign the bed to the patient with the best chance of recovery. This decision reflects which of the following ethical principles?
a. Beneficence.
b. Autonomy.
c. Veracity.
d. Nonmaleficence.
ANS: A
Rationale: Beneficence refers to doing what is good for the patient; in this situation, doing what is good means providing care to the patient with the best likelihood of recovery.
Which ethical principle is primarily involved in informed consent?
a. Veracity.
b. Autonomy.
c. Beneficence.
d. Nonmaleficence.
ANS: B
Rationale: Autonomy refers to the right to choose freely, which is inherent in informed consent.
Which of the following is a key area of ethical nursing practice?
a. Nursing process.
b. Therapeutic relationship.
c. Decision-making model.
d. Embodied knowledge.
ANS: B
Rationale: A key area of ethical nursing practice is the therapeutic relationship between the nurse and the patient.
Which question reflects the essence of relational ethics?
a. “What can I do to maintain my professional practice?”
b. “What should I do for others?”
c. “What techniques can I use to empower my colleagues?”
d. “What ethical decision-making model will work best for me?”
ANS: B
Rationale: Relational ethics involves asking not only “What should I do?” but also “What should I do for others?”
The nurse manager organizes interprofessional team meetings on a weekly basis. This action is demonstrating which aspect of relational ethics?
a. Embodied knowledge.
b. Interdependent environment.
c. Engaged interactions.
d. Mutual respect.
ANS: D
Rationale: Nurse managers show respect for students, nurses, and the health care team by facilitating interprofessional team meetings to discuss and plan patient care. Team meetings provide an opportunity to value everyone’s contributions and foster mutual respect, which is a critical aspect of effective teamwork.
According to relational ethics, what is critical in the development and maintenance of the roles and actions of the nurse manager?
a. Time management skills.
b. Professional relationships.
c. Understanding of biomedical ethics.
d. Comprehension of the Quebec Nurses Association’s Code of Ethics for nursing.
ANS: B
Rationale: A relational ethics perspective can help nurse leaders realize that relationships are critical in
the development and maintenance of the nurse managers’ and leaders’ roles and actions.
Which of the following is a criticism of the principle of autonomy?
a. It is not culturally sensitive.
b. It can lead to focus on the needs of one person at the expense of the needs of
others.
c. It is not applicable with entire groups.
d. It can be viewed as advancing professional directives rather than patient desires.
ANS: B
Rationale: One criticism of the principle of autonomy is that it can lead to a focus on the rights or needs of one individual at the expense of the rights or needs of others (including entire groups).
Autonomy is best promoted through which of the following, in taking a relational approach to autonomy?
a. Specific roles within the relationship.
b. Social change.
c. Protecting an individual’s freedom of choice.
d. The necessity of treating everyone fairly.
ANS: B
Rationale: A relational approach to autonomy suggests that autonomy is best promoted through social
change rather than through protecting an individual’s freedom of choice.
Sue, a staff nurse, consistently arrives 15 minute late for her shift, and the nurse manager has talked to her about it several times. Sue does not take the comments seriously because
there are two other nurses who also arrive late all the time, and the unit manager does not reprimand them. In this situation, the nurse manager is violating the ethical principle of:
a. Beneficence.
b. Nonmaleficence.
c. Justice.
d. Autonomy.
ANS: C
Rationale: Nurse managers who apply the principle of justice in their nursing practice and managerial
decision-making ensure that workload is fairly distributed among the nursing staff.
Performance appraisals by nurse managers ought to be guided by the principle of justice. For example, if one nurse is disciplined for being late, then all nurses who are late should be disciplined in the same way.
Which element of the Code of Ethics of the International Council of Nurses is reflected in the following statement: “The nurse manager sets policies and procedures to guide ethical nursing practice?”
a. People.
b. Practice.
c. Profession.
d. Coworkers.
ANS: C
Rationale: The element of the Code of Ethics of the International Council of Nurses that is reflected in the question statement is the element of profession.
Which element of the Code of Ethics of the International Council of Nurses is reflected
when the nurse manager establishes a system for performance appraisals?
a. People.
b. Practice.
c. Profession.
d. Coworkers.
ANS: B
Rationale: The element of the Code of Ethics of the International Council of Nurses that is reflected in
the creation of performance appraisals is the element of practice.
What is reflected when a nurse feels a lack of clarity or is unable to know even what the moral problem is, whereas at the same time feeling uneasy or uncomfortable about the
situation?
a. Moral distress.
b. Moral uncertainty.
c. Ethical dilemma.
d. Ethical distress.
ANS: B
Rationale: At the simplest level, an ethical experience is a situation that creates a sense of moral uncertainty: when a nurse feels indecision or a lack of clarity or is unable to even know what the moral problem is, while at the same time feeling uneasy or uncomfortable.
A patient’s husband asks to speak with the nursing manager. He is visibly upset and tells the nursing manager that while at the corner store, he overheard two nurses discussing his
wife’s health issues and is certain that others around him also heard the discussion. This is an example of:
a. Ethical distress.
b. An ethical violation.
c. Moral inappropriateness.
d. An ethical dilemma.
ANS: B
Rationale: Ethical violations reflect a nurse’s neglect of moral obligations and a breach of duty (e.g., when a nurse discusses patient information in the cafeteria).
Sally, a fourth year nursing student, was assigned to a maternal child unit. Upon reporting for an assignment she was informed her patient would be having an abortion because of severe medical issues with the unborn child. She approached her preceptor immediately and
asked to be reassigned to another patient because Sally was opposed to abortion for any reason. This is an example of:
a. Competent nursing care.
b. Staffing availability.
c. Conflict of conscience.
d. Fatigue.
ANS: C
Rationale: In case where the nurse’s personal values do not allow for moral acceptance of practices of
the patient, a nurse is permitted to step back from the situation that involves a “conflict with their conscience” (CNA, 2017, p. 35) to work with the team and allow another nurse to take
over care.
Michael a novice nurse has been assigned to four medically ill patients. There is a nursing staff shortage on his unit and more experienced nurses have as highly acute a workload as
he does. As the shift progresses he becomes more distraught and unable to provide the type of care he knows his patients need. Michael is experiencing:
a. Moral distress.
b. Moral fatigue.
c. Values conflict.
d. Therapeutic relationship.
ANS: A
Rationale: There are a number of both internal and external factors that can interfere or threaten the
integrity of the nurse-patient relationship. External factors such as high rates of turnover or casual nursing staff, staff shortages, consistently high workloads, unhealthy or hostile work environments, or poor staff morale might make it difficult to establish and sustain nurse-patient relationships. Internal factors might include fatigue, moral residue, moral distress, or a values conflict.
Mr. and Mrs. Bennett are attending a consult for reproductive assistance. Although there is a positive chance the method will result in a pregnancy, they are not able to cover the cost of the procedure. This situation denies which of the following ethical principles?
a. Autonomy.
b. Nonmaleficence.
c. Justice.
d. Beneficence.
ANS: C
Rationale: Justice refers to the principle that addresses how we treat others out of a sense of what we consider to be fairness. The Canadian Nurses Association (CNA) considers the principle of
social justice to be a key policy initiative, and considers it an organizational priority, noting clearly that the value of social justice is aligned with the professional values outlined in the CNA Code of Ethics.
To perform treatment on a patient not requiring a formal written consent a nurse must conduct which of the following? (Select all that apply.)
a. Asking permission to do a treatment.
b. Explaining the procedure.
c. Stopping the procedure if patient is uncomfortable.
d. Confirming understanding of the treatment.
ANS: A, B, C, D
Rationale: For many type of routine nursing procedures, written informed consent is not necessary but
consent should still be obtained from the patient, in a less formal way. Each time a nurse approaches a patient to administer a medication, to check vital signs or to change a dressing, the nurse should always first check in with the patient that they understand what is about to
happen and that the immediate plan of care is acceptable to them at that point in time. Respecting patient autonomy means always ensuring that patients are not passive recipients
of care, but rather that they are as involved as possible in all decisions that are part of their own health care experience.
Nursing management actions and decisions are guided by (Select all that apply.)
a. The law.
b. Ethical principles.
c. Leadership style.
d. Professional accountabilities.
e. Staff preferences.
ANS: A, B, D
Rationale: Nursing management decisions and actions are guided by three elements: ethical principles,
professional accountabilities, and the law.
Which of the following are core elements of relational ethics? (Select all that apply.)
a. Mutual respect.
b. Justice and beneficence.
c. Informed consent.
d. Interdependent environment.
ANS: A, D
Rationale: The core elements of relational ethics are engaged interactions, mutual respect, embodied knowledge, uncertainty and vulnerability, and interdependent environment.
According to Leininger (2002), “cultural imposition” is a major concern in nursing because
nurses have a tendency to impose their values, beliefs, and practices on people of other cultures. The discussion topic most likely to be without cultural imposition would be:
a. Abortion.
b. Wound management.
c. Blood transfusion.
d. Advance directives.
ANS: B
Rationale: Abortion, blood transfusion, and advance directives are heavily imbued with values, beliefs, and practices that may be different between patients and nurses.
Cultural diversity is the term used to describe a vast range of cultural differences. Events
have symbolic meanings for the nurse manager and the staff. The event that would be most
likely to provide symbolic meaning to a nurse manager and staff is:
a. The formation of a task force to commemorate a New Year’s celebration in the Western tradition.
b. A project to provide Christmas gifts to the children in a daycare program.
c. Celebration of National Nurses’ Week with the focus on cultural care.
d. The formation of a task force to develop a poster for the unit depicting religions of the world.
ANS: C
Rationale: Symbols define and reflect a culture. National Nurses’ Week, with a focus on nursing interests, reflects the culture of nursing.
One of the staff nurses on your unit makes the comment, “All this time I thought Mary was
Black. She says she is Jamaican.” The best response would be:
a. “Who cares what she is?”
b. “What did you think when you learned she was Jamaican?”
c. “Why did you assume she was Black?”
d. “We have never had a Jamaican on this unit before.”
ANS: B
Rationale: The response of the nurse manager invites cultural awareness, which involves self-examination and in-depth exploration of the nurse’s own biases, prejudices, and assumptions.
As a nurse manager, you notice that Sharon, an Aboriginal licenced practical nurse aide, is
visibly upset. When you ask her if something is wrong, she becomes tearful and says, “Why
is it that when Nick and I work together in giving patient care, he jokes about my being ‘a
little fat Eskimo’?” The nurse manager’s best response is, “Do you think he
a. Is sensitive to your culture?”
b. Wants to learn more about you?”
c. Has been hurt and wants to hurt others?”
d. Is stereotyping you without thinking?”
ANS: D
Rationale: Stereotyping and prejudice enable people to predict behaviours and make sense of situations, but they constrain people’s understanding and development of new insights.
The nurse manager of a unit is asked by a family member of a dying Inuit patient if it is
possible to for the patient’s eight-member family to recite the rosary by the patient’s
bedside. The manager responds affirmatively. The nurse manager is most likely exhibiting behaviour related to:
a. Acculturation.
b. Ethnocentricity.
c. Cultural diversity.
d. Cultural sensitivity.
ANS: D
Rationale: Cultural sensitivity involves the capacity to feel or react to ideas, customs, and traditions unique to a group of people.
A 66-year-old native Chinese patient, hospitalized for a myocardial infarction, asks the
nurse manager about seeing his “acupuncture doctor” for treatment of his migraine
headache. The best response to this patient would be:
a. “How long have you been using acupuncture treatment?”
b. “Do you think acupuncture relieves your pain satisfactorily?”
c. “What have you told your heart specialist about your migraines and treatment?”
d. “Have you tried nonprescription pain medication or been given a prescription drug for your headaches?”
ANS: A
Rationale: Acknowledging the patient’s use of acupuncture demonstrates cultural sensitivity through acknowledgement of treatments that would be consistent with the patient’s cultural interpretation of illness and responses to it. The other responses indicate lack of cultural sensitivity and cultural imposition, in that the nurse diverts the line of inquiry toward interventions that would be common to the nurse’s experience of health care in Western cultures.
Maintaining a culturally diverse staff is an important function of a nurse manager who works in the hospital of a large medical centre. According to Health Canada (2008), which cultural group represents about 2% of registered nurses employed in Canada? The chapter states 3% p. 11.
a. Men.
b. Aboriginal.
c. French Canadian.
d. African Canadian.
ANS: B
Rationale: Fewer than 2% of health care providers in Canada are of Aboriginal ethnicity; about 6% of the 8% in nursing work force is male.
Because an increasing number of Aboriginal patients are being admitted, a nurse manager
designs a staff-development program for her staff to help them understand Aboriginal
culture. A nurse should understand that culture is determined by which of the following?
a. Behaviour.
b. Love for people.
c. Shared vision.
d. Rapid time passage.
ANS: A
Rationale: Culture is determined by behaviours and beliefs, and it develops slowly.
The nurse manager for a unit’s culturally diverse staff creates a staff-development program
so that the professional nursing staff members can enhance their understanding of cultures
on the basis of published literature. The literature reveals that what characteristics are
inherent in a culture?
a. It develops over time.
b. It maintains a strong work ethic.
c. It changes easily.
d. It develops quickly.
ANS: A
Rationale: Culture is a patterned behavioural response that evolves slowly as times change. The culture may or may not maintain a strong work ethic.
Which principle of The Canada Health Act is frequently not upheld in rural and remote areas of the country?
a. Comprehensiveness.
b. Public administration.
c. Accessibility.
d. Portability.
ANS: C
Rationale: Accessibility to health care in Canada is based on the Canada Health Act principles of
universality and accessibility. However, such principles are not always adequately upheld.
For instance, individuals living in rural or remote areas might not have ready access to health care or might have access to only limited amounts and types of care.
Within the deaf community, there is considerable disagreement about the use of SEE (Signed Exact English) and ASL (American Sign Language). This is indicative of:
a. Dominant versus nondominant behaviours.
b. The need to recognize diversity within groups.
c. The effect of cross-culturalism.
d. How language separates subgroups.
ANS: B
Rationale: When a nurse is working with people of various cultural groups and diversity, it is important to recognize that diversity also exists within groups.
When interviewing a candidate for a nursing position who has an Aboriginal background, a
non-Aboriginal nurse recognizes that the candidate’s lack of eye contact reflects the
candidate’s:
a. Lack of confidence.
b. Professional behaviour.
c. Cultural sensitivity.
d. Ethnicity.
ANS: D
Rationale: Ethnicity refers to the classification of people according to common racial, tribal, religious, linguistic, or cultural backgrounds.
Recognizing that the Aboriginal candidate’s lack of eye contact is different from her own, the non-Aboriginal nurse is exhibiting
a. Acculturation.
b. Cultural sensitivity.
c. Ethnocentrism.
d. Transculturalism.
ANS: B
Rationale: Cultural sensitivity is the affective capacity to feel, convey, or react to ideas, habits,
customs, or traditions unique to a group of people. In this situation, acknowledgement of the patient’s background in relation to eye contact demonstrates cultural sensitivity.
A non–English-speaking patient arrives at the nursing unit. The nurse knows that when patient communication is hampered by the inability to communicate in the same language, it may lead to:
a. Inequities in accessing health care services.
b. Inability to obtain health insurance.
c. A decrease in patient morbidity.
d. Lack of portability with health care coverage.
ANS: A
Rationale: When communication with a patient is hampered, the patient may have difficulty accessing
needed health care services, which might lead to negative health outcomes.
At Health Centre XYZ, staff members on the rehabilitation unit have a head nurse who is
intolerant of error and publicly chides anyone who makes a mistake. Over time, the rules on the unit dictate that mistakes are hidden and that areas of concern related to the functioning of the unit are discussed in privacy and are never openly discussed during periodic meetings. New staff members are quickly made to realize that silence is expected. The situation described is an example of:
a. Ethnicity.
b. Work environment.
c. Work culture.
d. Marginalization.
ANS: C
Rationale: Culture develops over time, is essential to survival, is learned and shared by members, and changes with difficulty.
Which of the following enables people to make sense of situations that they may encounter that differ from their circle of familiarity?
a. Paradox.
b. Prejudices.
c. Power.
d. Position.
ANS: B
Rationale: Prejudices enable people to make sense of the situations in which they find themselves, but prejudices also constrain understanding and limit the capacity to develop new or different ways of understanding.
During performance appraisal, you praise Xia for her attention and care to nursing details.
You suggest that her care would be further enhanced by greater acknowledgement of
patients’ feelings. Xia bursts into tears and leaves the office. Later, you learn that in Xia’s
culture, criticism is perceived as akin to failure. You reflect on how you could modify your
approach in the future to acknowledge different cultural interpretations of feedback. Your response is indicative of:
a. Bias.
b. Cultural awareness.
c. Cultural diversity.
d. Ethnocentricity.
ANS: B
Rationale: Cultural awareness involves self-examination and in-depth exploration of a person’s own cultural and professional background, such as biases, prejudices, and assumptions, including assumptions about thinking modes and decision-making.
Individuals living with asthma, who also live in poverty, are much less likely to seek early
care than to go to emergency rooms for assistance. This example reflects:
a. Stereotyping.
b. Cultural diversity.
c. Ethnocentricity.
d. Transcultural care.
ANS: D
Rationale: Transcultural care involves consideration of health beliefs and practices between genders among races, ethnic groups, and people with different socioeconomic status.
Serena, RN complains to you that a male nurse from a different culture sits very close
during charting and leans toward her when speaking. In responding to Serena, you consider that differences across cultures that are relevant to this situation include:
a. Eye contact.
b. Personal space.
c. Harassment.
d. Expressions of feeling.
ANS: B
Rationale: Spatial differences (closeness or distance) are inherent within and across cultures.
A new graduate registered nurse joins your unit. After a few weeks, she complains about some of her peers on the unit and compares their practices negatively to what she learned in her nursing program. She also is vocal about how she has learned so much here that she did not in her program. She is best described as:
a. Having cultural sensitivity.
b. Experiencing cultural diversity.
c. Experiencing cultural marginality.
d. Experiencing acculturation.
ANS: C
Rationale: The new graduate is caught between two cultures at this point—work and education—and expresses feelings of belonging to neither.
In caring for a patient from an East Indian culture, staff members express frustration that many friends and family members are in the room at any one time, which interferes with care. As the nurse manager, you provide leadership in understanding that this behaviour of the family and friend network reflects:
a. Lack of understanding of the seriousness of the patient’s illness.
b. Lack of communication between family members.
c. The social organization of friendships and family networks in East Indian culture.
d. Lack of caring about the hospital environment by the friends and family.
ANS: C
Rationale: The Giger and Davidhizar Transcultural Assessment Model identifies six phenomena to assess provision of care to patients who are from different cultures, including social organizations, which include how relationships are formed and expressed in different cultures.
Monique, one of your registered nurses, tells you that she cannot understand why Jim, an Aboriginal patient, wants to have a smudge ceremony. Monique’s response is based on her:
a. Cultural marginality.
b. Circle of familiarity.
c. Cultural understanding.
d. Acculturation.
ANS: B
Rationale: The circle of familiarity refers to constrained interpretation on the basis of a person’s values, attitudes, and beliefs.
In coaching Monique to become more culturally sensitive when a patient has requested a smudge ceremony at the bedside, you suggest which of the following?
a. “Explain to Jim that there is no smoking in the hospital.”
b. “Inform Jim that fires are not allowed in the hospital.”
c. “Insist that he give you his tobacco because it is unhealthy for him.”
d. “Ask him what he means by a ‘smudge ceremony’ and what meaning it has for him.”
ANS: D
Rationale: Finding out more about Jim’s traditions helps Monique to step out of her circle of familiarity.
A constructivist perspective of culture recognizes which of the following influence an individual’s understanding of culture? (Select all that apply.)
a. Social context.
b. Is changeable.
c. Political understanding.
d. Economic status.
ANS: A, B, D
Rationale: Although social context, political understanding, and economic status influence a constructivist perspective, the essentialist perspective maintains that culture is unchangeable and based on the “norm” culture in Canada that is white and moderately affluent.
To ensure cultural safety regarding the use of language it is essential to address which of the following? (Select all that apply.)
a. Uses common points of reference in practice.
b. Count on a word for word translation.
c. Ensure linguistic equivalence in both languages.
d. Think any translator is adequate.
ANS: A, C
Rationale: Translation of illness or disease conditions and treatment can be complex and requires a qualified translator with an understanding of medical terminology as a translator who translates word for word does not convey the complexity and understanding of medical terminology. For common points of reference and linguistic equivalence language clarity is important for cultural safety.
New immigrants to Canada have a limited understanding of the Canadian health care
system. Nurse leaders must ensure that staff use effective communication to ensure patients have the knowledge to understand their rights to health care. Good communication can be
achieved through which of the following? (Select all that apply.)
a. Understanding one’s own prejudices.
b. Allowing time for interpreting and clarifying information.
c. Presuming openness exists between people of different cultures.
d. Recognizing providing care to diverse groups is a dynamic and complex experience.
ANS: A, B, D
Rationale: Interpreters must be trained to decode words and ensure the right meaning in the translation. Nursing care is complex and the patient population is diverse. Knowing how one’s own prejudice influences recipient care, to receive more than adequate support. Presuming openness exists between different cultures may prevent the right implication and understanding of care provided.
As a nurse manager, you have to be effective in managing a culturally diverse staff. Which
of the following attributes of a nurse manager would assist you in addressing the cultural
needs of your staff? (Select all that apply.)
a. Stereotyping of others.
b. Respect for others.
c. Positive reinforcement.
d. Knowledge about your staff.
e. Age bias.
f. Disrespect for others.
ANS: B, C, D
Rationale: Cultural competence involves knowledge of diverse cultural and ethnic groups, including knowledge of staff members and respect for other people and their cultural differences.
