Transcript Management File - Carolinas College

Management/Leadership
Principles
Nursing 202
Janie McCloskey, RN, MSN
Management Process in Nursing
 Management is a process with both
interpersonal and technical aspects
through which the objectives of an
organization accomplished efficiently
and effectively by using human,
physical, financial and technologic
resources.
 Management does whatever is
necessary to make sure that
employees do their work and do it
well.
How to get the job done!!!
 Leadership
 Clinical Expertise
 Business Sense
Levels of Management
 Top management - administrative
level
 Composed of board of directors
 President
 Vice President
 Nursing has one of these - maybe called
President of Nursing or Chief Nurse, Chief
Executive Officer of Nursing or Director of
Nursing (DON)
 Involved in the nursing department’s
involvement in the organization.
Levels of Management
 Middle Management  Division heads
 Supervisors - evening or night
 This level manages unit managers or
front-line managers. They are usually
over several units that have similar
characteristics.
Levels of Management
 Front Line or Lower-level managers
 Nurse Mangers or Head nurses
 Unit managers
 These people manage unit issues,
staffing, and budgets for their specific
units.

You can make more friends in two
months by becoming interested in other
people than you can in two years by
trying to get other people interested in
you.

Dale Carnegie
Theories of Management
 Two thoughts of management
 Theory X: assumes that people hate
work and as a result have to be
coerced, controlled, and directed by
their supervisors.
 Theory Y: assumes that people take to
work like play and as a result are selfdirected, responsible, and capable of
solving problems
 McGregor (1960)
Management Styles
 Authoritarian- Moves the group
towards the manager’s goals
 Democratic- Moves the group toward
the group’s goals
 Laissez-faire- Makes no attempt to
move the group

The employer generally gets the
employees he deserves.

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Trust men and they will be true to you;
treat them greatly and they will show
themselves great.


Sir Walter Gilbey
Ralph Waldo Emerson
The deepest principle of human nature
is the craving to be appreciated.

William James
Leadership
 Again- The ability to influence other
people.
 You do not have to be a manager to
be a leader but you must be a leader
to be a manager
How to get the job done!
 Develop a sense of direction and
purpose
 Build the groups commitment to it’s
goals
 To face the numerous challenges that
arise in the health care setting
Follower
 Skilled, self directed employee who
participates actively in an activity
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Setting the groups direction
Investing time and energy
Critical Thinking
Advocates for new ideas
How to get the job done!!!
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Identify problems and solutions
Be supportive of change
Disagree
Listen before speaking
Learn from experience
Manager versus Leader
 Formal
 Assigned
 Business
Responsibilities
 Uses a leadership
style
 Informal
 Achieved role
 Everyday
responsibility
 Independent
thinker
Managerial Communication
 Must understand the organization’s
structure and recognize who will be
affected by the decisions made
 Communication will affect other
departments so they must be consulted
with prior to the communication
 Clear, simple, precise
 Seek feedback to see if communication was
accurately received
Communication is the Heart of
all Nursing Care
(Hildegard Peplau, 1952)
Communication
A reciprocal process of sending
and receiving of messages
between 2 or more people
SENDER

Determines what message he wants to
transmit

ENCODES- Converts his thoughts and
feelings into words and gestures resulting in
a message
COMMUNICATION CHANNEL

Medium used to
carry the message
Communication Channels
Sound
 Touch
 Sight
 Smell

Receiver
Deciphers (decodes) the sender’s
transmission to make sense of
the thoughts and feelings
communicated by the sender
Ways To Communicate
Verbally
 Nonverbally
 Metacommunication (paraverbally)


Congruence vs incongruence
I DIDN’T SAY
YOU WERE
INCOMPETENT
Factors Influencing
Communication

Environmental Factors
Arrangement of Furniture
 Climate
 Privacy
 Physical Distance
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Nonverbal Cues
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Facial Expressions
Eye Movements
Vocal Cues

Territory and Personal Space
Crowding
 Size
 Status
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Interpersonal factors
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Developmental
Stage
Language Mastery
Self Concept
Physical Disabilities
Communication
Communication forms the core of a
managers responsibilities
 A critical nursing leadership skill
 A sender, message and receiver is
inherent in all exchanges
 Modes through which the message sent
is verbal, written or nonverbal

Email Communication
Do not send anything that you
would not want published on the
front page of a national
newspaper!!!
Physician Nurse
Communication
Communication Concepts
Identify Yourself
 Don’t Apologize
 State Your Business
 Make Requests
 Clarify
 Finish your request
 Document calls and actions
 Be Professional

Prepare for Contacting the
Physician
Determine the Need
 Have Data at Hand
 Identification

 Nurse
 Physician
 Client
Clarification
 Should I call?

Consolidate Calls
 Notify Unit

Chain of Command
Individual
 Nurse Manager
 Director
 Vice President
 Committee
 Human Resources

Documentation
&
Risk Management Issues
Importance of the Medical Record in Risk
Management
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Best Defense Against Lawsuit
Provides Evidence of Interventions &
Interactions
Source of Information for Risk Identification &
Quality Improvement
Best Defense Against a
Malpractice Claim
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Good Medical Record
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Completeness
Objectivity
Consistency
Accuracy
Purpose of the
Medical Record
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Serves as Basis for Patient Care
Continuity (Evaluation Patient’s Condition)
Documentary Evidence (Evaluation,
Treatment, & Change in Condition)
Communication Tool Between Clinicians
Importance of the
Medical Record


The medical record you prepare today may be
reviewed by others, both within and outside the
hospital.
The accuracy and completeness may be
questioned or discussed and you may be asked
to justify your record-keeping methods and
practices by non-medical personnel.
Common Allegations Against
Nurses
Failure to:
 Interpret & Follow Physician Orders
 Report Questionable Care
 Report Substandard Medical Practices
 Monitor
 Implement Safety Measures
 DOCUMENT CARE
The Medical Record
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Prime Communication Medium
Assists with Obtaining Reimbursement
A “Very Public” Document
Defense Against Malpractice
Basis for “Other” Hospital Activities
What Do Plaintiff’s Attorneys Look
For?
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Omissions
Contradictions & Inconsistencies
Time Delays & Unexpected Time Gaps
Alterations or “Appearance of”
Lack of Supervision
Lack of Informed Consent
Lack of Patient Education Information
What Do Plaintiff's Attorneys Look
For?(cont.)
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Illegibility of Entries By Anyone
Extraneous Remarks
Feuding Among Professionals
Benefits of “Quality
Documentation”
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Plaintiff's Attorney May Not Take Case
Early Settlement
More Reliable Than Personal Recollection
Refresh Memory
Demonstrates Good Communication
Demonstrates Quality Medical Care
What Is Good Documentation?
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Timely, Accurate, & Comprehensive
Legible
Reflects Decision-Making Process
Each Form Completed Entirely
Physician Notification
Always Note:
 Time MD Notified Changed Condition
 Medical Facts Relayed
Telephone Orders
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Only taken by RN or LPN
Read Back for Clarification
Co-signed by Physician (State Law)
Transcribe ASAP
Be Aware!
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Questionable Orders
Working Knowledge of Drugs, Dosage
Meets the client’s needs
Documenting Patient Injuries

IF YOU FAIL TO DOCUMENT THE
OCCURRENCE (I.E., FALL FROM BED), THE
ALLEGATION OF COVER-UP MAY BE EASILY
SUSTAINED.
Documenting Occurrences
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Document Only What You See
Record Vital Signs
Physical Condition
Mental Condition
Subjective Complaints
Physician Notification
Treatments Ordered
Sign Your Notes!

Sign Every Entry
Never Sign Someone Else’s Notes
Countersigning (Only As Verification)

NOT ON THE ONLINE CONTENT
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Sign onto the computer under your login ONLY
Recording of Time
Record Time of:
 Care Entries
 Physician Notification
 Supervisor Notification
 Securing Consents, Authorizations, Releases
 Doctor Order Notification
Documenting Emergencies
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Emergencies, Whether They Occur in OR,
ED, or on the Units, Must Be Documented,
Minute By Minute
Onset of Crisis
Medications
Treatments
Procedures
Protect Yourself
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Never Alter Medical Records
Never Skip Lines
Never Obliterate
Document with Ink
How to Correct a Medical Record
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Single Line Through Inaccurate Material
Date; Initial; Avoid negative words (i.e. error,
mistake, wrong dose)
Enter Correction (Chronological Order)
Questionable Situations (Witnessed By
Colleague)
Documenting Patient Teaching
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Diagnosis
Procedures
Patient Understanding

Health Teaching Reflects that Good Quality
Nursing Care Was Administered
Legible Charting
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Single Most Effective Way to Improve
Medical Records!
Writing Legible Requires No Additional Time
When Defending Malpractice Actions,
Illegible Record No Help
Select Your Words

Avoid
“Unintentionally”
“Inadvertently”
“Somehow”
“Unexplainably”
“Unfortunately”
“Apparently”
Objective vs. Subjective

Charting Must Be Objective & Void of
Conclusions

State Specifically What You:
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See
Hear
Smell
Feel
Objective vs. Subjective (cont.)
Checked on rounds q 2 hours, eyes closed, respiration's regular.
vs
Slept all night.
Less vocal than previous day. Taking medications as prescribed.
vs
Quiet and cooperative.
IV Site Clear, Infusing @ 60 gtts/minute
vs
IV Running Well
Use of Abbreviations

Use Only Formally Authorized
-There are 1402 abbreviations in the database at CHS!
-NO-NO-NO-NO
u, QD, IU, QOD, MS, MSO4, MGSO4

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Submit New Abbreviations
Watch for Dual Meanings
Cx-Cervix
Cx-Circumflex (artery)
(Cx @ 90%)
Extraneous Remarks
Stifle the Urge
Don’t speculate
 Don’t give your opinion on
the cause of the event

Basic Charting Tips
On Admission, Observe & Record:
 Nursing Observations
 General Demeanor
 Appearance
 Ambulation Ability/Impairment
 Height & Weight
 Vitals
Basic Charting
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General Physical Condition & Mental State
History of Past Hospitalizations
Pull Old Charts
Record Medications Patient Taking
Reason for Admission
Physical Disabilities or Cultural Differences
Discharge Documentation
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Instruct Patient and/or Family
Document
Knowledge of Understanding
Provide Discharge Instructions
Return Demonstration
Booklets
Discharge Instructions
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Discharge Instructions Should Include:
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Diet, Either By the Dietitian or with the Nursing
Staff
Activity, such as Restrictions on Activity,
Importance of Rest Periods, Exercise Programs
Medications with the Name of Medication,
Reason for Taking, Dosage, Frequency, and Side
Effects
Discharge Instructions (cont.)
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Skin Care and Hygiene
Specific Treatment, such as Colostomy Care,
Foley Catheter, Dressing Changes
Follow-up Appointment with Physician,
Appointment with Physical or Occupational
Therapist
Appropriate Agency Referrals
Leaving
Against Medical Advice
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Left AMA
Seen by MD, but refused
treatment/admission
Elopement
Left prior to discharge
Medical Records & Confidentiality
& Security
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Maintain Physical Security
Never Remove Records from the Facility
Release Records Only Through P&P
No Unauthorized Copying of Records
No Access to Records By Unauthorized
Individuals
The Golden Rules
• Poor documentation can make the
competent nurse appear negligent!
• If it isn’t in the medical record,
it didn’t happen!
• Document unto others as you would
have them document unto you!
Types of Nursing
• Functional
• Team Leading
• Primary
Case Management Nursing
• This model created the development of
Critical (clinical) Paths
• Critical paths are interdisciplinary
agreements showing who will provide care
in a given time frame to achieve agreedupon outcomes.
• Critical paths are used to help standardize
care
Case Management Nursing
• Standardizing care allows for better
staffing, lengths of stay and more efficient
use of resources
• Case managers are partners with their
patients, both in the hospital and after
discharge
Case Management Nursing
•
Advantages:
– Nurse has increased responsibility
– Promotes collaboration with other health
professionals
– Cost-effective
– Eases patient’s transition from hospital to
community services
Case Management Nursing
• Disadvantages:
– Requires additional training
– Requires nurses to be off unit for periods of
time
– Time consuming
Shared Governance
• Method of Management that utilized a
committee structure made up of
stakeholders.
• Decisions are committee based instead of
management base.
• Promotes understanding and satisfaction
by employees.
Assignment Making
• Assigning Care: allocating the work
required for a group of clients to the
available staff
• Delegating Care: Allocating specific
tasks to appropriate and qualified
personnel.
Assignment Making
• Pre-Assigning Considerations–
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Assess the client’s needs
Consider staff number and type
Demonstrate trust
Promote continuity of care
Avoid disrupting the logical work flow
Assignment Making
• Assigning–
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Describe assignments in detail
Assign all aspects of care
Consider changes in clients’ condition
Consider changes in plans of care
Assignment Making
• Legal Aspects– Liability: legal accountability for client
risks, danger, and injury caused by
nurse’s malpractice of negligent acts
– Negligence: involves either acts of
• Commission: doing something that harms the
client
• Omission: not doing something that should
have been done to prevent the client from
harm or injury
How to refuse an
assignment
• ASSESS THE SITUATION
CAREFULLY
• Do not jump to conclusions without
exploring all avenues and possibilities
• Base your decision on facts - not
“what ifs”
• Be accountable - professional
-Inform RN in charge, inform RN
supervisor
-Offer alternatives
How to refuse an
assignment
• Be willing to negotiate
• DO NOT LEAVE
• If you have accepted report and
agree to the assignment and you
leave this is ABANDOMENT!
• You may loose your license
Conflict and Change
Nursing 202
Janie McCloskey, RN, MSN
Conflict and Change
The Nurse Manager must guide the
staff through changing situations by
a) Understanding Factors leading to
change. B) Request input for decisions
to plan, implement and evaluate the
change process
Conflict
Types
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Interpersonal
Intrapersonal
Intergroup
Managing Unit Conflict
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Most common sources
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Unclear expectations
Poor communications
Lack of clear jurisdiction
Incompatibilities or disagreements bases on
differences of temperament staffing attitudes
Individual or group conflicts of interest
Operational or staffing changes
Potential sources of conflict
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Competition Between Groups
Increased Workload
Multiple Role Demands
Threats to Professional Identity and
Territory
Threats to safety and Body
Scarce Resources
Individual Differences
Personal Space
Symptoms of Negative Conflict
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Frustration
Anger
Missed or ineffective communication
Very costly on valuable human resources
Complaining
Demoralizing Attitude
Violence
Positive Conflict
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Provides an impetus for change
Helps to understand others jobs
May open communication channels
Energizes people
May redistribute resources
Outcomes
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Win-lose
Lose-lose
Win-win
(Haslin, 2001)
Conflict Resolution Strategies
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Avoiding
Returns
LL
Accommodating
WL
Competing Forcing
WL
Compromising Giving up LL
Negotiating Difficult
WW
Collaborating New goals WW
Analyzing a situation
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Answer these questions:
What do I want to accomplish and what is the
most I will give up
What do I think the other person wants?
What false assumptions or incorrect
perceptions might the other person might
have?
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Which strategy should I use?
What are my “hot buttons” and what should I
do if they are pushed?
Resolving Conflict
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Identify the Problem
Generate Possible Solutions
Evaluate Suggested Solutions
Choose the Best Solution
Implement the Solution
Is the Problem Solved?
Key Concepts
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Communication is the most important aspect
of conflict resolution
Some conflict resolution is growth producing
and revitalizes efforts to meet client care
goals
Performance Appraisal
Adult Health 202
Performance Appraisal
The process of giving and
receiving evaluative feedback
Why have an appraisal
process?
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Reinforces constructive behavior
Discourages unproductive
behavior
Develops and improves
performance
Provides input into key decisions
about employees
Improve the quality of manager
and employee relationship
Principal criteria for determining
a pay increase
Merit Increase
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Budget Goal
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Overall Performance
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Monies allotted at the beginning of the year
Superior, Exceeds Expectations, Meets
Expectations, Below Expectations, Not Acceptable
Position within the range
Internal Pay Equity
Date of Last Pay Increase
The Appraisal process shapes
the system
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System’s vision
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Observe employees effectiveness
How well are we meeting the mission statement of
CHS
Identify how well departmental objectives are met
Performance information provides the opportunity
to make adjustments to the “model”
The Appraisal process shapes
the system
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Does serve as a controlling and
auditing mechanism
Useful in organizational prevention and
corrective maintenance
Internal and external factors impact
the growth and profitability
Effective Guidelines
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Both positive and negative feedback
Immediate Feedback
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Fix the problem
Remember the event
Decreases frustration and anger
Frequent Feedback
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Motivates
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Privacy for negative feedback
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Embarrassment
Avoids misconceptions
Objectivity
Actively Listen
Non-threatening
Objectivity and Consistency
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Legally defensible
Demotion
Failure to promote
Job elimination
Termination
Performance Appraisal Cycle
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Managerial responsibility
Sequential one that requires day to day
managerial input.
Begins by determining the tasks, priorities
and outcome of a position
Managers define the functions
Manager coaches and communicates to the
employee moving forward to success
Appraisal Schedule
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New employees
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90 day appraisal
12 month appraisal
All employees, after problem on annual
review
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Interim six-month review to address areas of
concern
Performance Appraisals
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Timely in presentation
Meeting time and place, no
interruptions
Know the system prior to the
review
Stick to the facts
Use direct and understandable
language
Review, discuss and set goals
Performance Appraisal
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Based on the job description
Based on goals and objectives
Ongoing evaluation of goals
Input form multiple sources
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Manager
Employee
Peers
Work related issues
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Stress- Nonspecific response of the body to
any demands made on it
Burnout-Progressive deterioration in work
and other performance resulting from
increasing difficulties in coping with high and
continuing levels of job related stress and
professional frustration
Stress Response
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Alarm- Body’s initial response with a slight
decrease in resistance to a trigger
Resistance- The body adjusts and tries to
restore balance
Exhaustion-Resistance continues to decrease
and an illness may occur
Physical response (sympathetic)
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Increased HR
Increased BP
Increased RR
Increased blood sugar
Dilated pupils
Dry mouth
Frequent Triggers
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Workload
Role conflict
Supervisor
Wrong job fit
Fear
Discrimination
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Technology
Downsizing
Policy changes
Violence
Home conflicts
Stress Management
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Awareness
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Be Honest
Believe in yourself
Commit to stress relief
Stress Relief
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Deep Breathing
Good posture
Rest
Guided Imagery
Nutrition
Exercise
Burnout Implications
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Financial
Physical
Emotional
Social Implications
Workplace Safety
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Disease exposure
Professional Issues
Ergonomic issues
Sexual Harassment
Substance Abuse
Violence
Bioterrorism/Disasters
Bioterrorism!
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The use of microorganisms with the deliberate
intent of causing infection to achieve political
goals.
Easy to use with results taking a period of
time
Spreads before you really know it!
What can a nurse do?
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Early recognition
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Large epidemic
Large numbers seeking care from EDs and MDs
High mortality rates
Highest risk
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Smallpox
Anthrax
Plague
Hemmorhagic fevers
Disasters
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Know the evacuation routed and procedures
in your facility
Develop your knowledge of the most likely
and dangerous biochemical agents
Know the backup systems available for
communication and staffing for emergencies