Transcript Document

Helping Nurses Make Decisions About
Increased Responsibilities at the Bedside
Rosalinda Alfaro - LeFevre, RN, MSN
www.AlfaroTeachSmart.com
© 2008 www.AlfaroTeachSmart.com
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WHAT’S IN YOUR HANDOUTS
Power Point
Clinical Decision Making Tool
Mapping Contributing Factors Tool
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EXPECTED OUTCOMES
1. Discuss nurse’s increased roles related to
diagnosis.
2. Address the importance of teaching how to
make decisions about taking on increased
responsibilities.
3. Identify strategies & tools to improve
novices’ abilities to make decisions related
to diagnosis and care management.
© 2008 www.AlfaroTeachSmart.com
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How Literate Are You?
“The illiterate of the twenty-first century
will not be those who cannot read and
write, but those who cannot learn,
unlearn, and relearn.”
(Alvin Toffler, Author of Future Shock)
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Bus is Leaving the Station &
Now it’s an Airplane
Will you be on it?
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Think, Pair, Share*
* Developed by Professor Frank Lyman at the University of
Maryland in 1981. Read more at:
http://www.eazhull.org.uk/nlc/think,_pair,_share.htm
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EXPECTED OUTCOMES
1. Discuss increasing responsibilities of
nurses related to diagnosis.
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Quotes From The Trenches
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The public needs to know that nurses -- regular,
ordinary bedside nurses, not just nurse practitioners
or advanced practice nurses -- are constantly
participating in the act of medical diagnosis,
prescription, and treatment and thus make a real
difference in medical outcomes. Nurses can help the
public understand that nursing is a package of
medical, technical, caring, nursing know-how -- that
nurses save lives, prevent suffering, and save money.
If nurses wear not only their hearts, but also their
brains on their sleeves. Perhaps the public…. will
finally understand what nurses know and do.”
(Gordon, 2006)
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How are you all dealing with staff “change
fatigue?” Our staff is constantly
bombarded with new JCAHO and other
requirements. They’re already
overwhelmed with work. How do you get
new information to them in a timely way
at a time when they can handle it? How
do you get them to come to educational
programs? (Listserv Posting, 2007)
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I was just asked to "investigate" the
possibility of starting a RN PICC
team. This team would consist of RNs
on various units throughout the medical
center. Our intensive care nursery just
did this, but now the VP wants it to go
house-wide. Any ideas, comments, and
how to's would be much appreciated as
this is not a specialty of mine!
(Listserv Posting, 2006)
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I wouldn’t call this a PICC team and would run
the other direction as fast as I could. For the
past 15 years of training hospitals to place
PICCs, I have seen many, many facilities try
this approach and fail over and over again.
First, PICC insertion is a complex process
that demands an advanced body of
knowledge about vascular anatomy, central
venous catheter technology, and nursing
care and complication management.
(Listserv Posting, 2006)
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In regards to LPNs and narcotics, IVs, etc... as
you know, states have varying regulations
regarding the LPN roles in medication
administration. Besides checking your
nurse practice act for your state, you may
want to log on to a great resource, at the
National Council of State Boards of Nursing
website (www.ncsbn.org) click on to the
Business Book NCSBN Annual Meeting 2005,
Section II, attachment C, Practical Nurse
Scope of Practice White Paper. Good luck!
(Listserv Posting, 2006)
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WORRIED WELL & WALKING WOUNDED
Many patients today are the “worried well” (people
who don’t need a doctor, but think they might)
and “walking wounded” (people who are living
with---or recovering from-- complex injuries or
chronic illnesses at home). Knowledgeable staff
with highly skilled thinking, communication, and
coaching abilities are cost-effective coaches who
help people manage their health at home ,
reducing costs & improving quality of life.
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(Alfaro-LeFevre, 2006,
p. 15)14
CRISIS IN CRITICAL THINKING
Only 35% of new RN graduates, regardless
of educational preparation and
credentials, meet entry expectation for
clinical judgment. Although well-versed in
content, the majority are unable, or have
considerable difficulty translating
knowledge and theory into practice.
(DelBueno, 2005, p 279)
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INCREASED RESPONSIBILITIES
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APNs – RNs – LPNs (LVNs) – Techs
Pharmacy – Radiology – PT – Dietary
Risk Managers – QI – Infection Control
Leaders – Managers – Educators
Triage – Diagnostic Orders
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WHAT DO LAWS SAY?
Unless you’re an Advanced Practice Nurse
state laws prohibit you from making medical
diagnoses independently. (Buppert, 2008)
You are, however, accountable for giving high
priority to assessing for---and reporting--signs and symptoms that may indicate the
need for attention from a professional more
qualified than you are. (Alfaro-LeFevre, In Press)
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INCREASED RESPONSIBILITIES
1. Not expected to make definitive dx
2. Are expected to recognize when signs
and symptoms may indicate a common
problem (Diabetes, MI, CHF, Pulmonary
Embolus).
3. They are the first in the chain of
command and a lot of responsibility
goes with this.
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EXAMPLE
If the patient has signs and symptoms of an
MI (chest pain--shortness of breath),
you’re accountable for:
• suspecting that this could be the problem
• recognizing that it’s a high priority,
• doing what you can to address the
problem (e.g. raise the head of the bed)
• reporting it immediately
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ACTIVATING THE CHAIN OF COMMAND
•
•
Follow policies and procedures for
getting help
Be persistent---stay with the problems
until the patient gets the qualified help
they need.
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INCREASED RESPONSIBILITIES
 Health promotion: smoking cessation,
obesity management
 Screening: Depression, diabetes
 IV management
 Outcomes management (eg. Airway
management)
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DISEASE MANAGEMENT
Arthritis
Asthma
CHF
COPD
Depression
Diabetes
Hypertension
Kidney Disease
Wounds
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PATIENT ASSESSMENT
Identifying
Reportable
Problems, Risks,
Signs & Symptoms
Identifying
Problems, Risks,
Signs & Symptoms
Requiring
Independent
Management
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OLD vs NEW THINKING
Old Thinking
 We must be creative
 Staff must remember
 Tools are crutches
New Thinking
 We need more
evidence
 Staff will forget
 We ALL need tools
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CLINICAL WORKSHEET
Name______________ Room_____
Age____ Religion___ Culture____
Diet____ Activity_______________
Neuro:
Resp:
Oxygen:
Cardiac:
Circ:
Skin:
GI:
Medical Dx_____________________
Dr.____________________________
Allergies_______________________
Medications/IV’s:
Potential Complications:
Nursing DX/problems:
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Digoxin 0.25 mg po OD
CIPRO 500 mg po BID
KCl Elixir 20 mEq po OD
Multivitamin po OD
Ambien 5 mg po hs
MOM 30 cc po hs
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2000
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QUICK PRIORITY ASSESSMENT (QPA)
Start with patient “snap shot”:
 Allergies – Meds – Medical Problems
 Age - Height – Weight – Hydration
 Risk for Infection – Injury
 Breathing – Comfort – Communication
 Other Relevant Specialty Data
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CARE MANAGEMENT
Interventions aimed
at the disease
Interventions
aimed
at the person
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SOLUTIONS
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Mentor-Preceptor-Teacher
Independent learner
Needs Assessment
Tool Development
Informatics
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Think, Pair, Share*
* Developed by Professor Frank Lyman at the University of
Maryland in 1981. Read more at:
http://www.eazhull.org.uk/nlc/think,_pair,_share.htm
© 2008 www.AlfaroTeachSmart.com
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Summary
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EXPECTED OUTCOMES
1. Discuss nurse’s increased roles related to
diagnosis.
2. Address the importance of teaching how to
make decisions about taking on increased
responsibilities.
3. Identify strategies & tools to improve
novices’ abilities to make decisions related
to diagnosis and care management.
© 2008 www.AlfaroTeachSmart.com
32
Bibliography
Alfaro-LeFevre, R. (In Press). Applying nursing process: A
tool for critical thinking (7th ed.). Philadelphia: LippincottWilliams & Wilkins
Alfaro-LeFevre, R. (2008). Giving and Taking Constructive
Criticism in: Critical Thinking and Clinical Judgment: A
practical approach to Outcome-focused thinking, 4thed.).
Philadelphia: Elsevier-Saunders
Alfaro-LeFevre, R. (2008). Evidence-based Critical Thinking
Indicators. Available at http://www.alfaroteachsmart.com/cti.htm
Buppert, C. (2008). The legal distinction between the practice
of medicine and the practice of nursing. The Journal for
Nurse Practitioners, 4(1), 22-24
© 2008 www.AlfaroTeachSmart.com
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Class, P (2006) The Walking Wounded. Nursing
Spectrum (FL ED), 9(21), p. 3
Henneman, E., & Roche, J. Eight ways to nurture a
new student. Retrieved June 2, 2002 from
http://community.nursingspectrum.com/MagazineArticles/article.cfm
?AID=5948
Rich, P. Giving and receiving feedback. Retrieved
2/20/2008 from
http://www.selfhelpmagazine.com/articles/growth/feedback.html
Walters, J. The 4-1-1 On Constructive Criticism.
Retrieved 2/20/2008 from:
http://www.inc.com/articles/2001/08/23257.html
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NP Book (2006)
Lippincott
www.lww.com
USA: 800-638-3030
CANADA: 800-223-2300
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CT Book (2008)
Saunders/Elsevier
USA: 800-325-4177
www.us.elsevierhealth.com
CANADA: 866-896-3331
www.elsevier.ca
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