Leadership Exam 1

Characteristics of Leaders

- initiative
- inspiration
- energy
- positive attitude
- communication skills
- respect
- problem-solving and critical-thinking skills
- a combination of personality traits and leadership skills
- influence willing followers to move toward a goal
- have goals that might differ from those of the organization
EX: all nurses are leaders as the play the roles of an expert, educator, advocate, model, and voice

Transformational Leaders

empower and inspire followers to achieve a common, long-term vision
- give clear goals, then steps back and allows members to reach set goals
- risk-taking
EX: chief nursing officers influencing managers

Transactional Leaders

- focus on immediate problem and maintain the status quo

- Uses trade-offs/rewards to motivate followers

- Short-term goals

EX: nurse manager entices staff nurse to work night shift

Authentic (Bureaucratic) Leaders

inspire others to follow them by modeling a strong internal moral code
- empathetic and understanding

Management

the process of planning, organizing, directing, and coordinating the work within an organization
- good managers usually possess good leadership skills and clinical expertise
- have formal positions of power and authority, network with members of the team, coach subordinates, and makes decisions
- major functions: planning, organizing, staffing, directing, and controlling

Leadership

the ability to inspire others to achieve a desired outcome
- effective leaders are not always in a management position; can have formal or informal power afforded to them
- must have followers

Autocratic/Authoritarian Leadership Style

- has a predictable role, makes decisions for the group, and avoids input from other staff
- motivates by coercion
- communication occurs DOWN the chain of command (highest to lowest)
- work output by staff is usually high
- effective for employees with little or no formal education
- "Do This!!"
EX: good for crisis situations and bureaucratic settings; cardiac arrest, disaster management, hostile patient

Democratic Leadership Style

- includes the group when decisions are made
- motivates by supporting staff achievements
- communication occurs UP and DOWN the chain of command
- work output by staff is usually good quality when cooperation and collaboration are necessary
- "What do you think we should do?"
EX: revision of policies, procedures, shared governance structures

Laissez-faire Leadership Style

- makes very few decisions, and does little planning
- motivation is largely the responsibility of individual staff members
- communication occurs UP and DOWN the chain of command AND between group members
- work output is low unless an informal leader evolves from the group
- "Do this or that as you see fit."
EX: effective with professional employees; nursing supervisors, home health, trauma teams

Delegation

the process of transferring the authority and responsibility to another team member to complete a task, while RETAINING THE ACCOUNTABILITY
- RNs delegate tasks to other RNs, PNs (LVN), and APs (CNA)
- RNs delegate tasks so that they can complete higher-level tasks that only RNs can perform; this allows more efficient use of all members of the team

What can RNs NOT delegate?

the nursing process (ADPIE), client education, or tasks that require clinical judgement
- "Never delegate a task you can Evaluate, Assess, Teach, or that requires Teaching, Assessment, Planning, or Evaluation"

What can RNs delegate?

- tasks/functions for stable clients with predictable outcomes
- tasks/functions that involve standard, unchanging procedures
- tasks/functions that are within the education, training, and skill level of the delegate
- tasks/functions that only fall within the agency or regulatory agency policies

The Five Rights of Delegation

a) Right Task
b) Right Circumstance
c) Right Person
d) Right Direction/Communication
e) Right Supervision/Evaluation

Right Task

- identify what tasks are appropriate to delegate for each specific client, and give clear instructions on what needs to be completed
- a right task is repetitive, requires little supervision, and is relatively noninvasive for the client
- delegate tasks to appropriate levels of team members based on standards of practice, legal and facility guidelines, and available resources

Right Circumstance

- assess the health status and complexity of care required by the client
- match the complexity of care demands to the skill level of the health care team member
- consider the workload of the team member

Right Person

- assess and verify the competency of the health care team member: the task must be w/in their scope of practice; the team member must have the necessary competence/training
- continually review the performance of the team member and determine care competency
- assess team member performance based on standards and, when necessary, take steps to remediate a failure to meet standards (communicate)

Right Direction/Communication

Communicate either in writing or orally:
- data that needs to be collected
- method and timeline for reporting, including when to report concerns/findings
- specific task(s) to be performed; client specific instructions
- expected results, timelines, and expectations for follow-up communication

- communicate the patient, room, what needs to be delegated, and reporting back
- reach an agreement with the delegate

Right Supervision/Evaluation

occurs after the delegation occurs

The delegating nurse must:
- provide supervision, either directly or indirectly (assign supervision to another RN)
- provide clear directions and expectations of the task to be performed (time frames, what to report)
- monitor performance
- provide feedback
- intervene if necessary (unsafe clinical practice)
- evaluate the client and determine if client outcomes were met
- evaluate client care tasks and identify needs for quality improvement activities and/or additional resources

Appropriate Tasks to Delegate to a RN

- watching a client with newly diagnosed DM perform a blood glucose check
- administering packed RBCs to a client with CKD
- determining if a PRN pain med improved a client's pain level (evaluation of intervention
- preparing a discharge teaching plan for a client with HF
- measuring the vital signs of a client returning from PACU (pt unstable, just came off sedation)

Appropriate Tasks to Delegate to a PN (LVN)

- monitoring findings (as input to the RN's ongoing assessment)
- reinforcing client teaching from a standard care plan
- performing tracheostomy care
- suctioning
- checking NG tube patency
- administering enteral feedings
- inserting a urinary catheter
- administering medications (NOT IV meds!! - unless licensed to)
- must initiate CPR in the absence of a clear do-not-resuscitate (DNR) order (TX board of nursing)
- completing a focused assessment for clients

Appropriate Tasks to Delegate to an AP (CNA)

- ADLs
- bathing
- grooming
- dressing
- toileting
- ambulating
- feeding (without swallowing precautions)
- positioning
- routine tasks
- bed making
- specimen collection (non-sterile)
- I&Os
- vital signs (for stable clients)
- assisting with postmortem care of a client

What PNs (LVNs) CAN'T Do (TX Board of Nursing)

- cannot pronounce death or accept a verbal order to pronounce death
- cannot insert or remove a PICC line
- should not be responsible for intracatheter management, including administration of drugs via these routes
- cannot administer pharmacologic agents for the purpose of achieving moderate sedation to or monitor patients receiving moderate sedation

The Board of Nursing

sets standards to protect the public and regulates nursing practice
- can guide and RNs decision on what to delegate
- the Nursing Practice Act defines nursing

Client Factors to Consider when Making Assignments

- condition of the client (stable or unstable) and level of care needed
- specific care needs (cardiac monitoring, mechanical ventilation, etc)
- need for special precautions (isolation precautions, fall precautions, seizure precautions)
- procedures requiring a significant time commitment (extensive dressing changes or wound care)

Health Care Team Factors to Consider when Making Assignments

- knowledge and skill level of team members
- amount of supervision necessary
- staffing mix (RNs, PNs, APs)
- nurse-to-client ratio
- experience with similar clients
- familiarity of staff members with unit

Rule for RN assignments

if a RN already has 2 unstable clients, they SHOULD NOT be assigned a third; conversely, if a RN has one stable client and one unstable client, they can be assigned a third client

Types of Disruptive Behavior

incivility, lateral violence, bullying, and cyberbullying

Incivility

an action that is rude, intimidating, and insulting. it includes teasing, joking, dirty looks, and uninvited touching

Lateral Violence

AKA: horizontal abuse or horizontal hostility
occurs between individuals who are at the same level w/in the org; includes verbal abuse, undermining activities, sabotage, gossip, withholding information, and ostracism
EX: a more experienced staff nurse can be abusive to a newly licensed nurse

Bullying

persistent and relentless and is aimed at an individual who has limited ability to defend themselves. occurs when the perpetrator is at a higher level than the victim. it is abuse of power that makes the recipient feel threatened, disgraced, and vulnerable.
EX: a nurse manager can demonstrate favoritism for another nurse by making unfair assignments or refusing a promotion

Cyberbullying

a type of disruptive behavior using the internet or other electronic means

Interventions to Deter Disruptive Behaviors

- create an environment of mutual respect among staff
- model appropriate behaviors
- increase staff awareness about disruptive behavior
- make staff aware that offensive online remarks about employers and coworkers are a form of bullying and are prohibited even if the nurse is off-duty and it is posted off-site from the facility
- avoid making excuses for disruptive behavior
- support zero tolerance for disruptive behavior
- establish mechanisms for open communication between staff nurses and nurse managers
- adopt policies that limit the risk of retaliation when disruptive behavior is reported

Autonomy

the ability of the client to make personal decisions, even when those decisions might not be in the client's own best interest
EX: obtaining informed consent from the patient for treatment, accepting the situation when a patient refuses a medication, and maintaining confidentiality

Beneficence

care that is in the best interest of the client
EX: holding a dying patient's hand

Fidelity

keeping one's promise to the client about care that was offered
EX: following-up on medications, offering support and loyalty to a patient

Justice

fair treatment in matters related to physical and psychosocial care and use of resources
EX: making impartial medical decisions, whether it relates to limited resources or new treatments regardless of economic status, ethnicity, sexual orientation, etc

Non-Maleficence

the nurse's obligation to avoid causing harm to the client; providing a standard of care which avoids risk or minimizing it, as it relates to medical competence
EX: avoiding negligent care of a patient

Veracity

the nurse's duty to tell the truth
EX: timely and accurate documentation

What is the ANA Code of Ethics and what is the purpose of the Code of Ethics?

Serves the following purposes: It is a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession. It is the profession's nonnegotiable ethical standard. It is an expression of nursing's own understanding of its commitment to society.
- a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession

Overview of the ANA Code of Ethics Provisions

Codes 1-3: the basic values and commitments of the nurse

Code 4: nurse's accountability to practice

Codes 5-6: ethical issues related to duty & loyalty; Healthy Self and Workplace

Codes 7-9: ethical issues beyond patient encounters
- nurse's obligation to address social justice issues through direct action and involvement in health policy
- responsibility to contribute to nursing knowledge through scholarly inquiry and research

ANA Code of Ethics: Provision 1

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
- ethical connection: autonomy, beneficence, veracity, fidelity

ANA Code of Ethics: Provision 2

The nurse's primary commitment is to the patient, whether an individual family, group, community, or population
- ethical connection: nonmalficence, justice, veracity

ANA Code of Ethics: Provision 3

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient

ANA Code of Ethics: Provision 4

The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and take action consistent with the obligation to promote health and to provide optimal care

ANA Code of Ethics: Provision 5

The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

ANA Code of Ethics: Provision 6

The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care

ANA Code of Ethics: Provision 7

The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy
- know and tell EVP; develop institutional practice standards; nursing & health policy development/revision

ANA Code of Ethics: Provision 8

The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities
- human rights & health disparities

ANA Code of Ethics: Provision 9

The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain integrity of the profession, and integrate principles of social justice into nursing and health policy
- unified voice, create global policy change, personal awareness of professional documents, responsibility to address the unjust

The Nurse's Role in Ethical Decision-Making

- An agent for the client facing an ethical decision
EX: Caring for a teen wanting an abortion enough through her parents think it's wrong.
- A decision maker for health care delivery
EX: witnessing a surgeon discuss only surgical options with a client and not alternative options
- have a responsibility to be advocates, and to identify and report ethical situations

Steps in Ethical Decision-Making

1. Identify whether the issue is an ethical dilemma.
2. State the ethical dilemma, including all surrounding issues and individuals involved.
3. List and analyze all possible options for resolving the dilemma, and review implications of each option.
4. Select the option that is in concert with the ethical principle applicable to this situation, the decision maker's values and beliefs, and the profession's values set forth for client care. Justify why that one option was selected.
5. Apply this decision to the dilemma and evaluate the outcomes.

Priority setting requires that decisions be made regarding the order in which:

- clients are seen
- assessments are completed
- interventions are provided
- steps in a client procedure are completed
- components of client care are completed

Priority setting decisions are made based on evidence obtained:

- during shift reports and other communications with members of the health care team
- through careful review of documents
- by continuously and accurately collecting client data

Recognize and respond to trends vs. transient findings

Trend: consistent findings over time

Transient: “fluke” that lasts for only short time and sets inconsistency Gradual deterioration in LOC rather than a random GCS of 14, back to 15, back to 14, etc

Systemic before local (“life before limb”)

Patient in shock over one with a localized limb injury

LISTEN and do not assume

Do not ask yes or no questions about s/sx

- “Where are you hurting?” not “Do you have chest pain?” -

- Determining what the patient feels is most important to learn about disease management

Acute vs Chronic Prioritization Example

Patients w/ chronic diseases have had time to physiologically adapt

Prioritizing care of a client who has a new injury/illness (mental confusion, chest pain) or an acute exacerbation of a previous illness over the care of a client who has a long-term chronic illness

Prioritizing Actual vs. Potential Problems

- If the current problem is not fixed now, the future possible problem does not matter

- Prioritizing administration of medication to a client experiencing acute pain over ambulation of a client at risk for thrombophlebitis

Prioritizing Unexpected vs. Expected Problems

Knowing expected findings in a disease process vs. complications’

Recognizing indications of increasing intracranial pressure in a client who has a new diagnosis of a stroke vs findings expected following a stroke

Priority-Setting Frameworks

-Maslow's Hierarchy
-Airway, Breathing, Circulation (ABC) framework
-Safety/Risk reduction
-Assessment/Data Collection First
-Survival Potential
-Least Restrictive/Least Invasive
-Acute vs. Chronic/Urgent vs. Nonurgent/Stable vs. Unstable
- Evidence-Based Practice

Maslow's Heirarchy of Needs

1. physiological needs: breathing, food, water, shelter, clothing, sleep (bottom)
2. safety and security: health, employment, property, family and social ability
3. love & belonging: friendship, family, intimacy, sense of connection
4. self-esteem: confidence, achievement, respect of others, the need to be unique
5. self-actualization: morality, creativity, acceptance, purpose (top)

Airway

- identify an airway concern (obstruction, stridor)
- establish a patent airway if indicated
- recognize that 3 to 5 mins w/o oxygen causes irreversible brain damage secondary to cerebral anoxia

Breathing

- assess the effectiveness of breathing (apnea, depressed RR)
- intervene as needed (reposition, administer naloxone)

Circulation

- identify circulation concern (hypotension, dysrhythmia, inadequate CO, compartment syndrome)
- institute actions to reverse or minimize circulatory alteration

Diability

- assess for current or evolving disability (neurological deficits, stroke in evolution)
- implement actions to slow down development of disability

Exposure

- remove the client's clothing to allow for a complete assessment or resuscitation
- implement measures to reduce the risk for hypothermia (provide warm blankets and IV solutions or use cooling measures for clients exposed to extreme heat)

What do you prioritize care based on?

client care needs and priorities
- determine what's immediate (administering an analgesic/antiemetic, assessing an unstable client, STAT orders)
- determine what needs to be done at a specific time (routine med admin, V/S, blood glucose monitoring)
- determine what needs to be done by the end of the shift (ambulating a client, discharge, dressing changes)

Time Savers (Long AF)

- Documenting nursing interventions as soon as possible after completion to facilitate accurate and thorough documentation.
- Grouping activities that are to be performed on the same client or are in close physical proximity to prevent unnecessary walking.
- Estimating how long each activity will take and planning accordingly.
- Mentally envisioning the procedure to be performed and gathering all equipment prior to entering the client's room.
- Taking time to plan care and taking priorities into consideration.
- Delegating activities to other staff when client care workload is beyond what can be handled by one nurse.
- Enlisting the aid of other staff when a team approach is more efficient than an individual approach.
- Completing more difficult or strenuous tasks when energy level is high.
- Avoiding interruptions and graciously but assertively saying "no" to unreasonable or poorly timed requests for help.
- Setting a realistic standard for completion of care and level of performance within the constraints of assignment and resources.
- Completing one task before beginning another task.
- Breaking large tasks into smaller tasks to make them more manageable.
- Using an organizational sheet to plan care.
- Using breaks to socialize with staff.

Time Wasters (long sorry)

- Documenting at the end of the shift all client care provided and assessments done.
- Making repeated trips to the supply room for equipment.
- Providing care as opportunity arises regardless of other responsibilities.
- Missing equipment when preparing to perform a procedure.
- Failing to plan or managing by crisis.
- Being reluctant to delegate or under-delegating.
- Not asking for help when needed or trying to provide all client care independently.
- Procrastinating: delaying time‑consuming, less desirable tasks until late in the shift.
- Agreeing to help other team members with lower priority tasks when time is already compromised.
- Setting unrealistic standards for completion of care and level of performance within constraints of assignment and resources.
- Starting several tasks at once and not completing tasks before starting others.
- Not addressing low level of skill competency, increasing time on task.
- Providing care without a written plan.
- Socializing with staff during client care time.

The Cyclic Process of Time Management

- Time initially spent developing a plan will save time later and help avoid management by crisis
- Set goals and plan care based on established priorities and thoughtful utilization of resources
- Complete one client care task before beginning the next, starting with the highest priority task
- Reprioritize remaining tasks based on continual reassessment of client care needs
- At the end of the day, perform a time analysis and determine if time was used wisely

Safety/Risk reduction

“What is the risk to my patient?” and “How significant is it compared to other risks?”

Assessment/Data Collection First

Gather information before making a decision ■ Ex: determine if additional information is needed before calling provider to ask for pain medication for a patient

Survival Potential

Reverse triage

Only used in mass casualty/disaster events