Leadership exam 2

The Nurse's Role in Collaborating with the Inter-professional Team

- coordinate the IP team

- have a holistic understanding of the client, the client's health care needs, and the health care system

- provide the opportunity for care to be provided with continuity over time and across disciplines

- provide the client with the opportunity to be a partner in their plan of care

- provide information during rounds and interprofessional team meetings regarding the status of the client's health

- provide an avenue for the initiation of a consultation related to a specific health care issue

- provide a link to post-discharge resources that might need a referral

Speech Therapists

evaluate and treat communication/speech, and swallowing disorders

Occupational Therapists

help clients with their ability to participate in normal daily activities
ex: dressing, cooking, grooming, brushing teeth

Physical Therapists

help clients with movement, function, and exercises to eliminate pain and prevent disability

Pharmacists

do NOT write prescriptions

Dieticians

Manage food service systems, plan menus, and teach special diets.

Stages of Team Formation

process before reaching peak performance
- forming, storming, norming, performing

Nurse Qualities needed for effective collaboration

- good communication skills

- assertiveness

- conflict negotiation skills

- leadership skills

- professional presence

- decision making & critical thinking

Forming Stage of Team Formation

Members of the team get to know each other.

The leader defines tasks for the team and offers direction.

Storming Stage of Team Formation

- Conflict arises, and team members begin to express polarized views.
- The team establishes rules, and members begin to take on various roles.

Norming Stage of Team Formation

- The team establishes rules.
- Members show respect for one another and begin to accomplish some of the tasks.

Performing Stage of Team Formation

The team focuses on accomplishment of tasks.

Behavioral Change Strategies

1. Rational-Empirical
2. Normative-Reeducative
3. Power-Coercive

Rational-Empirical

The manager provides factual information to support the change

Used when resistance to change is minimal.
- giving the "why"

Normative-Reeducative

The manager focuses on interpersonal relationships to promote change.

Power-Coercive

- The manager uses rewards to promote change.
- Used when individuals are highly resistant to change.

What is a case manager?

Someone who collaborates with the IP health care team during the assessment of a client's needs and subsequent care planning, and follows up by monitoring the achievement of desired client outcomes within established time parameters

Goal of Case Management

avoid fragmentation of care and control costs

Principles of Case Management

can be a NURSE, social worker, or other health care professional

case manager nurses do not usually:

provide direct client care (CANNOT be a primary care nurse and case manager simultaneously)

- NOT a HIPAA issue to share info w

- NOT a HIPAA issue to share info w/ a case manager

- coordinate resources and services for clients whose care is based in a residential setting

The Nurse's Roles in Case Management

- coordinating care for clients who have complex health care needs

· Admission, transfer, D/C, post-D/C

· Initiation, revision, evaluation of plan of care

· Reporting stats to other nurses and providers

· Coordinating discarge plan

· Facilitating referrals and use of community resources

- facilitating continuity of care ("nurse liaison")

- improving efficiency of care and utilization of resources

- enhancing quality of care provided

- limiting unnecessary costs and lengthy stays

- advocating for the client and family: protects rights of patients & ensures needs are met

Critical Pathways

- used to support the implementation of clinical guidelines and protocols.

- Based on cost and length of stay parameters mandated by Medicare and insurance companies.

- often initiated by case managers; used for clients that have predictable medical conditions (atypical = document as a variance)

- a way to track patient progress that is specific to a diagnosis type and outlines the typical length of stay/treatments

- also used as a cost containment strategy

What is a consultant?

a professional who provides expert advice in a particular area; provides expertise for client's who require a specific type of knowledge or service
EX: cardiologist for a patient with an M.I; psychiatrist for a suicide risk assessment

What are referrals?

- A formal request for a service by another care provider.
- It is made so that the client can access the care identified by the provider or the consultant.
- care can be provided in the acute setting or outside the facility

To which team members do we refer patients?

discharge referrals are based on the clients needs in relation to actual and potential problems and can be facilitated with the assistance of social services

- Specialized equipment (cane, walker, wheelchair, grab bars in bathroom)

- Specialized therapists (physical, occupational, speech therapists)

- Care providers (home health nurse, hospice nurse, home health aide)

The Nurse's Role Regarding Referrals

- begin discharge planning upon the client's admission
- evaluate client/family competencies in relation to home care prior to discharge
- involve the client and family in care planning
- collaborate with other health care professionals to ensure all health care needs are met and necessary referrals are made
- complete referral forms to ensure proper reimbursement for prescribed services

WhatistheBasis for Referrals

discharge referrals are based on client needs in relation to actual and potential problems and can be facilitated with the assistance of social services (especially if there is a need for specialized equipment, specialized therapists, and care providers)

- knowledge of community and online resources is necessary

Documenting the Continuity of Care

REFLECT THE CARE YOU HAVE DELIVERED so include:

- trending of assessment data (vital signs)

- flow sheets that reflect routine care completed and other care-related data

- nurses' notes that describe changes in client status or unusual circumstances

- client care summaries that serve as quick references for client care information

- nursing care plans that set the standard for care provided (provide a starting point and must be individualized)

- medication administrations

Communication Tools used in Continuity of Care

SBAR, PACE, I PASS THE BATON, 5 P's:

- improve communication & promote client safety

Change of shift reports

- Current health status of client

- Pertinent care information

- Oncoming nurse can ask questions

- Given in private area

Electronic

- EMR's, emails (can be informal, but must be professional, concise, & thorough) & text messaging

Tools necessary to communicate

SBAR (situation, background, assessment recommendation)

PACE (probe, alert, challenge, emergency)

I PASS THE BATON (info, patient, assessment, situation, safety, background, action, timing, ownership, next)

5 P's (patient/project, plan, purpose, problems, precautions)

Hand-Off or Change-of-Shift Reports

- performed with the nurse who is assuming responsibility for the client's care
- describes the current health status of the client
- informs the next shift of pertinent client care information
- provides the oncoming nurse the opportunity to ask questions and clarify the plan of care
- should be given in a private area (a conference room or at the bedside) to protect client confidentiality

What to Report to the Provider?

- assessment data integral to changes in client status
- recommendations for changes in the plan of care
- clarification of prescriptions

Discharge Planning Process

an IP process that is started by the nurse at the time of the client's admission

- with both the client and client's family -> optimal results

- serves as a starting point for continuity of care; as needs are identified, measures are taken for support

- includes review of client information (current health and prognosis, cultural beliefs, mobility status/ADLs, home environment, etc)

- need for additional services can be addressed prior to discharge (home health, pt, respite care) so its in place when client arrives home

Discharge Instructions

- step-by-step instructions for procedures to be done at home. client should be given the opportunity to return demonstration the procedures to validate learning

- medication regimen instruction for home, including adverse effects and actions to take to minimize them

- precautions to take when performing procedures or administering medications

- medication adverse effects or medical complications that the client should report to the provider

- names and numbers of providers and community services the client or family can contact

- plans for follow-up care and therapies

The Nurse's Role in Discharge Planning

Provide a WRITTEN summary of:
- type of discharge (prescribed by provider or AMA)
- date and time of discharge, who accompanied the client, and how the client was transported (wheelchair to a private car, stretcher to an ambulance, etc)
- discharge destination (home, long-term care facility)
- a summary of the client's condition at discharge (gait, dietary intake, use of assistive devices, blood glucose, etc)
- description of any unresolved problems and plans for follow-up
- disposition of valuables, medications brought from home, and prescriptions
- a copy of the client's discharge instructions
- proof that the client understands the teaching

The Nurse's Role in Client Rights

- nurses must ensure that clients UNDERSTAND their rights. & must protect the client's rights during nursing care

- pay close attention to: informed consent, refusal of Tx, advance directives, confidentiality, information security

- Basic tenets are the same for all clients regardless of age:

Each client has the right to the following

- Be informed

- Take an active role in decision making process

- Accept, refuse, or request modifications

- Receive care from competent individuals with respect

The Nurse's Role in Refusal of Treatment

- immediately notify the provider

- if the client is at risk for harm, it is imperative that the nurse explain the risk involved in leaving the facility (possible complications, disabilities, death)

- have the client sign a form relinquishing responsibility for any complications that arise from discontinuing prescribed care (Against Medical Advice Form - AMA)

- DOCUMENT EVERYTHING!!!(evenifAMA)

Patient Self-Determination Act (PSDA)

stipulates that on admission to a health care facility, all clients must be informed of their right to accept or refuse care
- must be given information about advance directives
- if a client refuses Tx or procedure = asked to sign an AMA form indicating that they understand the risk involved with refusing Tx
- if client refuses = documented by nurse

Against Medical Advice (AMA)

competent adults have the right to refuse treatment, including the right to leave a health care facility without a prescription for discharge from the provider

- client is then asked to sign a document indicating they understand the risk involved w/ refusing treatment/procedure, and that they have chosen to refuse it

- people may leave AMA for a number of reasons (conflict, insurance, etc)

AHA Patient Bill of Rights(1-7)

1. INFORMATION

2. CHOICE

3. RESPECT

4. PARTICIPATION

5. CONFIDENTIALITY

6. APPEALS

7. ACCESS

AHA Patient Bill of Rights:Information

right to accurate and easy to understand info; accommodation must be made for language & disabilitiesAHA Patient Bill of Rights

AHA Patient Bill of Rights: Choice

right to choose health care providers; can be limited by insurance, the circumstances, etc

AHA Patient Bill of Rights: Respect

right to considerate, respectful care; no discrimination

AHA Patient Bill of Rights: Participation

right to know treatment options and take part in decisions; pt can choose people to represent them if they can't make decisions

AHA Patient Bill of Rights: Confidentiality

right to talk privately w/ providers & to have info protected; right to read and copy own medical record; right to ask provider to change the record

AHA Patient Bill of Rights: Appeals

Right to a fair, fast, and objective review of any complaint (waiting times, operating hours, actions, adequacy) against providers; can be limited by paperwork, urgency of need

AHA Patient Bill of Rights: Access

Right to get the care you need (screened & stabilized) w/o having to pay for the services up front if you believe you're in serious danger

Nursing role in advocacy

THE MOST IMPORTANT ROLE

○ Ensure that clients are informed of their rights and have adequate information on which to base health care decisions

○ Be careful to assist clients with making health care decisions and not direct or control their decisions

○ Mediate on the client's behalf

■ When the actions of others are not in the client's best interest

■ Changes need to be made in the plan of care

○ Situations when advocating may be necessary:

■ End-of-life decisions

■ Access to health care

■ Protection of client privacy

■ Informed consent

■ Substandard practice

■ Vulnerable populations

○ Nurse is accountable for their actions even if they are carrying out a provider's prescription

■ Nurse's responsibility to question a prescription if it could harm a client

○ Support and advocate for legislation that promotes public policies that protect clients as consumers

■ Create a safe environment for their care

Components of Advocacy: skills

■ Risk-taking

■ Vision

■ Self-confidence

■ Articulate communication

■ Assertiveness

Components of Advocacy: Values

■ Caring

■ Autonomy

■ Respect

■ Empowerment

Informed Consent

○ legal process by which a client has given WRITTEN permission for a procedure or treatment to be performed

Informed Consent: Client

■ Reason the treatment/procedure is needed

■ How the treatment/procedure will benefit the client

■ Risks involved if the client chooses to receive the treatment/procedure

■ Other options to treat the problem, including not treating it

■ Risks involved if the client chooses NOT to receive the treatment/procedure

■ Consent is required for ALL care provided in a health care setting

Guidelines for Informed Consent

○ Consent required for all care given in a healthcare facility

○ For most aspects, impaired consent is enough

■ Patient gives this when she follows nurses instructions

● EX: nurse is going to start an IV and patient holds out her arm

○ State laws regulate who can give consent

■ Can vary

○ Signing the form

■ Must be done by:

● A competent adult

● Emancipated minor

● Married minor

■ Individuals authorized to grant consent for another:

● Parent of minor

● Legal guardian

● Court-appointed representative

● Durable power of attorney

● Spouse/closest relative

Implied Consent

The patient complies with the instructions provided by the nurse

■ EX: the nurse is preparing to administer a TB skin test, and the client holds out their arm

The Role of a Provider during Informed Consent

OBTAINS consent by explaining:

- complete description of the treatment/procedure

- description of the professionals who will be performing/participating in the treatment

- description of the potential harm, pain, and/or discomfort that might occur

- options for other treatments and the possible consequences of taking other actions

- the right to refuse

- risks involved if the client chooses no treatment

the provider CLARIFIES questions

The Role of a Nurse during Informed Consent

WITNESSES consent and is responsible for:

- ensuring that the provider gave the client the necessary info

- ensuring that the client understood the info and is competent

- having the client sign the form

- notifying the provider if the client has more questions or does not understand any of the information provided

- nurse documents: reinforcement of info originally given by provider, that questions client had were forwarded, use of language interpreters

The Role of the Client during Informed Consent

GIVING consent

- given voluntarily (no coercion)

- being competent and of legal age, or being an emancipated minor

- receiving sufficient info to make a decision based on informed understanding of what is expected

The Purpose of Advance Directives (AD)

to communicate a client's wishes regarding end-of-life care should the client become unable to do so
- PSDA requires that all clients be asked if they have one (if they don't, they must be given written info)
Includes: Living Will and Durable Power of Attorney

Durable Power of Attorney (POA)

legal document that designates a healthcare surrogate, who is an individual authorized to make healthcare decisions for a client who is unable

- the person should be VERY familiar w/ the client's wishes

- DOES NOT NEED TO BE FAMILY

- can be more effective if used as an adjunct to the living will

- must be periodically revisited to ensure it is up to date

Living Will

a legal document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues

EX: CPR, mechanical ventilation, feeding by artificial means

- legal in all states, most state laws include provisions that health care providers who follow the health care directive in a living will are protected from liability

The Nurse's Role in Advanced Directives

- providing written info regarding advance directives

- documenting the client's advance directives status

- ensuring that advance directives are current and reflective of the client's current decisions

- recognizing that the client's choice takes priority when there is a conflict between the client and family, or between the client and the provider

- informing all members of the health care team of the client's advance directives

The Nurse's Role in Confidentiality

- to be aware of the rights of clients in regard to privacy
- compliance with HIPAA regulations
- knowing and adhering to the policies and procedures

How to Protect Yourself and Others when Using Social Media

- become familiar with facility policies about the use of social media, and adhere to them

- avoid disclosing any client health info online*; be sure no one can overhear convos about a client when speaking on the phone

- do not share photos or videos of a client

- maintain professional boundaries when interacting with clients online

- NEVER post a belittling or offensive remark about a client, employee, or coworker

- report any violations of facility social media policies to the nurse manager

Consequences of breaching confidentiality w social media

- Termination of employment
- Discipline by the BON
- Charges of defamation/invasion of privacy
- Federal charges for violation of HIPAA

Information Technology:Computers provide

- storage for client information

- documentation of treatments and med administration

- referral resources for pathophysiology, meds, procedures, etc

- education materials for sharing with clients and family

- mechanism whereby clients may access their electronic medical records how and where they choose

Information Technology:E-health

- make online appointments

- prescription requests & refills

- review lab results and review billing

- Goal = improved healthcare outcomes due to 24hr access

Federal Regulations of Law

HIPAA
Americans w/ Disabilities Act (ADA)
Mental Health Parity Act (MHPA)
Patient Self-Determination Act (PSDA)
Uniform Anatomical Gift Act (UAGA): sets a regulatory framework for the donation of organs, tissues, & other body parts
National Organ Transplant Act (NOTA)
Emergency Medical Treatment and Active Labor Act (EMTALA)

Criminal Law

relates to the relationship of an individual with the government
Includes: felony (serious crimes [homicide]) and misdemeanor (less serious crime - [petty theft])
EX: falsifying records to cover up a serious mistake = breaking criminal law

Civil Law

protects the individual rights of people
- includes TORT laws

State laws

regulates nursing practice
- each state has statutes that define the parameters of nursing practice & give the authority to regulate the practice of nursing to its state board of nursing (BON have authority to issue and revoke license)

Good Samaritan laws

protect nurses who provide emergency assistance outside of the employment location
- the nurse must provide reasonable and prudent care

Unintentional Torts: negligence

practice/misconduct that does not meet expected standards of care and places the client at risk for injury (a nurse fails to implement safety measures for a client at risk for falls)

Unintentional Torts: malpractice

failure to act in a "reasonable and prudent" manner; PROFESSIONAL NEGLIGENCE in which the patient is harmed (a nurse admin a large dose of medication due to a calculation error and client has cardiac arrest and dies

Elements Necessary to Identify/Prove Negligence

1. Duty to provide care as defined by a standard (complete fall risk assessment)

2. Breach of duty by failure to meet the standard (nurse doesn't perform fall risk assessment)

3. Foreseeability of harm (nurse should know failure to do fall-risk assessment can endanger pt)

4. Breach of duty has potential to cause harm (combines elements 2 and 3, relationship must be provable) (if fall risk assessment not performed, client risk for falls is not determined and needed precautions are not put in place)

5. HARM OCCURS! (pt falls out of bed and breaks hip)

Nurses can avoid malpractice by

- following standards of care
- giving competent care (using equipment in a responsible way)
- communicating effectively w pt
- developing caring rapport with pt
- fully documenting

Quasi-Intentional Torts:invasion of privacy

intrusion into a client's private affairs or a breach of confidentiality (a nurse releases diagnosis of a pt to the press)

Quasi-Intentional Torts:defamation

false communication or communication with careless disregard for the truth w/ the intent to injure an individual's reputation

slander (defamation w/ the spoken word)(a nurse tells a coworker that she believes a client has been unfaithful to their spouse)

libel (written word or photograph)(a nurse documents in a clients record that a provider is incompetent)

Intentional Torts

- assault: threatening

- battery: actual physical harm (restraining a client and admin an injection against their wishes)

- false imprisonment: a competent person NOT AT RISK FOR INJURY TO SELF OR OTHERS is confined or restrained against their will (using restraints on a competent client preventing them from leaving the facility)

The Nurse Licensure Compact (NLC)

allows RNs to have one license yet practice in other compact member states

Standards of Care

legal requirements for nursing practice that describe minimum acceptable nursing care

Standards of Care(1-8)

1. Nurse Practice Act: governs nursing practice, & legal guidelines for practice are established through state board of nursing (vary from state to state)

2. Published standards of nursing practice

Developed by:

- professional organizations: American Nurse Association (ANA) & National Association of Practical Nurse Education & Services, Inc

- Specialty organizations: American Association of Critical Care Nurses (AACCN) & Oncology Nurses Society

3. Accrediting bodies (The Joint Commission)

4. Originally mandated quality assurance programs into quality improvement

5. Sentinel event reporting: unexpected death or injury

6. Failure mode & effects analysis: examines all potential failures, including event sequencing risks, vulnerabilities, & improvement areas

7. National patient safety goals: augments core measures & promotes client safety through client ID, & preventing wrong-site surgery

8. Healthcare facility policies & procedures

Working with an Impaired Coworker

has a duty to report the coworker to appropriate management as specified by institutional policy
- At time of infraction -> report should be made to immediate supervisor (charge nurse) to ensure client safety

The Nurse's Role in Mandatory Reporting

- attempt to get the client alone to ask questions in an attempt to determine if the stories match up or not
- report the appropriate situation to the proper source (charge nurse, local or state health department, etc)
- JUST REPORT IT! even if you didn't get the chance to collect all the facts

Which situations REQUIREDreporting?

Child abuse
Older/dependent adult abuse
AND communicable diseases (TB, Hep A, Ebola, etc)

Guidelines for Organ Donation

- regulated by federal and state laws

- donations can be stipulated in a will or designated on an official card

- federal law requires health care facilities to provide access to trained specialists who make the request to clients and/or family members and provide info regarding consent, organ and tissues that can donated, and how burial or cremation will be affected

- THE NURSE ONLY ANSWERS QUESTIONS AND PROVIDES EMOTIONAL SUPPORT!! (it's not your job to OFFER donation)