Chapter 2 Leadership Flashcards

Patient-Centered Care

Care that respects and responds to a client's preferences, needs, and values while ensuring those values guide clinical decisions.

Eight Principles of Person-Centered Care

Access to healthcare advice, trusted providers, continuity of care, family involvement, clear communication, respect for preferences, empathy, and attention to physical/environmental needs.

Client Rights

Legal guarantees that protect a client's ability to make decisions about their healthcare and receive respectful, competent care.

Nursing Role in Client Rights

Ensure clients understand, exercise, and have their rights protected during care.

Right to Be Informed

Clients have the right to receive information about all aspects of care and participate in decision-making.

Right to Refuse Treatment

Competent adults may refuse any treatment, procedure, or hospitalization.

Refusal of Treatment

A client's legal right to decline medical care after being informed of the risks and consequences.

Patient Self-Determination Act (PSDA)

Federal law requiring healthcare facilities to inform clients of their rights to accept or refuse treatment and create advance directives.

Against Medical Advice (AMA)

Leaving a healthcare facility before provider discharge after being informed of potential risks.

Nursing Action for AMA

Notify the provider, explain risks, document discussions, and ask the client to sign an AMA form.

Advocacy

The nurse's role in protecting client rights, ensuring informed decisions, and promoting the client's best interests.

Nurse Advocate

A nurse who supports and protects clients, especially when they cannot speak for themselves.

Nursing Role in Advocacy

Provide information, protect rights, assist with decision-making, and intervene when care is not in the client's best interest.

Situations Requiring Advocacy

End-of-life decisions, informed consent, access to care, privacy concerns, and substandard practice.

Essential Advocacy Skills

Risk-taking, vision, critical thinking, self-confidence, communication, and assertiveness.

Essential Advocacy Values

Caring, autonomy, respect, and empowerment.

Informed Consent

Legal process in which a client voluntarily agrees to a treatment or procedure after receiving necessary information.

Requirements for Informed Consent

Explanation of procedure, benefits, risks, alternatives, and consequences of refusing treatment.

Implied Consent

Consent inferred from a client's actions, such as holding out an arm for a blood pressure reading or injection.

Written Consent

Required for invasive procedures and surgeries.

Provider's Responsibility for Informed Consent

Explain the procedure, risks, benefits, alternatives, and answer client questions.

Client's Responsibility for Informed Consent

Voluntarily consent, be competent, and understand the information provided.

Nurse's Responsibility for Informed Consent

Witness the signature, verify understanding, and notify the provider if clarification is needed.

Competent Adult

An individual who can understand information and make informed healthcare decisions.

Emancipated Minor

A minor legally permitted to make independent healthcare decisions.

Medical Interpreter

A trained professional who assists communication when language barriers exist.

Individuals Authorized to Give Consent

Parent, legal guardian, healthcare proxy, court-appointed representative, spouse, or closest relative according to state law.

Advance Directives

Legal documents that communicate a client's wishes regarding healthcare if they become unable to make decisions.

Living Will

Written document outlining desired medical treatments and life-sustaining measures at the end of life.

Durable Power of Attorney for Healthcare

Legal document naming a healthcare surrogate to make decisions when the client is unable.

Healthcare Surrogate

Individual designated to make healthcare decisions on behalf of an incapacitated client.

Do Not Resuscitate (DNR)

Provider prescription directing healthcare professionals not to perform CPR if cardiac or respiratory arrest occurs.

Allow Natural Death (AND)

Provider prescription focusing on comfort measures rather than resuscitation.

Nursing Role in Advance Directives

Provide information, document status, ensure directives are current, and communicate wishes to the healthcare team.

Confidentiality

Protection of private client information from unauthorized disclosure.

Health Insurance Portability and Accountability Act (HIPAA)

Federal law protecting privacy and security of health information.

Protected Health Information (PHI)

Any identifiable health information that must remain confidential.

Privacy Rule

HIPAA regulation requiring protection of written, verbal, and electronic client information.

Nursing Role in Confidentiality

Protect records, discuss client information privately, and follow HIPAA regulations.

Electronic Health Record (EHR)

Digital version of a client's health record accessible by authorized healthcare providers.

Informatics

Use of technology and computers to manage healthcare information and improve client outcomes.

E-Health

Electronic access to healthcare services, records, appointments, prescriptions, and laboratory results.

Telehealth

Use of technology to provide healthcare services remotely.

Health Information System (HIS)

Computerized system used to manage administrative and clinical healthcare information.

Clinical Information System (CIS)

Component of the HIS used to coordinate and manage client care.

Information Security

Protection of electronic and written health information from unauthorized access.

Information Security Protocols

Log off computers, protect passwords, secure records, and shred unnecessary client information.

Social Media Confidentiality

Nurses must never share client information, photos, or identifying details online.

Interprofessional Team

Group of healthcare professionals from different disciplines working together to provide care.

Collaboration

Cooperative process in which healthcare professionals work together to achieve client goals.

Benefits of Collaboration

Improved communication, quality care, client outcomes, and efficient use of resources.

Qualities Needed for Collaboration

Communication, assertiveness, leadership, conflict resolution, and critical thinking.

Nurse's Role in Collaboration

Coordinate care, communicate client needs, facilitate consultations, and involve clients in planning.

Centralized Hierarchy

Decision-making occurs primarily at the management level.

Decentralized Hierarchy

Staff nurses participate in decision-making processes.

Rational-Empirical Change Strategy

Uses facts and evidence to support change.

Normative-Reeducative Change Strategy

Uses relationships and education to encourage change.

Power-Coercive Change Strategy

Uses authority, rewards, or consequences to enforce change.

Planned Change

Structured process used to implement evidence-based improvements in healthcare.

Lewin's Change Theory

Three-stage model consisting of unfreezing, change, and refreezing.

Unfreezing

Recognition that change is needed.

Change (Movement)

Implementation of strategies to create change.

Refreezing

Stabilization and acceptance of the new change.

Precontemplation

No intention to change behavior.

Contemplation

Considering behavior change.

Preparation

Planning to make a change.

Action

Actively implementing change.

Maintenance

Sustaining the new behavior over time.

Forming Stage

Team members meet and learn their roles.

Storming Stage

Conflict occurs as members express opinions and establish roles.

Norming Stage

Team develops cooperation and mutual respect.

Performing Stage

Team works effectively toward goals.

Case Management

Coordination of healthcare services from the beginning of care through completion.

Goal of Case Management

Prevent fragmented care, improve outcomes, and reduce costs.

Case Manager

Healthcare professional who coordinates care and monitors progress toward goals.

Nursing Role in Case Management

Coordinate care, improve efficiency, enhance quality, advocate for clients, and facilitate continuity.

Critical Pathway

Standardized plan outlining expected treatments, length of stay, and outcomes for a diagnosis.

Variance

Deviation from the expected critical pathway.

Continuity of Care

Consistent, coordinated care provided as clients move through different settings and levels of healthcare.

Nursing Role in Continuity of Care

Coordinate transfers, referrals, discharge planning, and communication among providers.

Consultation

Request for expert advice from a specialist regarding client care.

Consultant

Specialist who provides recommendations for a specific healthcare issue.

Referral

Formal request for additional services from another healthcare provider or agency.

Nursing Role in Referrals

Assess needs, initiate referrals, complete documentation, and coordinate services.

Transfer

Movement of a client from one unit, department, or facility to another.

Transfer Report

Written and verbal communication containing essential information needed for continued care.

Discharge Planning

Process that begins on admission and prepares the client for care after leaving the facility.

Goals of Discharge Planning

Promote safety, continuity of care, and successful recovery at home or another facility.

Discharge Instructions

Written and verbal information about medications, treatments, follow-up care, and when to seek medical help.

Hand-Off Report

Communication provided when responsibility for client care transfers from one caregiver to another.

Sentinel Event

Unexpected client death or serious injury associated with healthcare delivery.

Documentation

Accurate recording of client assessments, care provided, responses to treatment, and outcomes.

Purpose of Documentation

Promote communication, continuity of care, legal protection, and quality improvement.