I really hate the of subject of Leadership and Management, because (contrary to what the books say) leadership can't be taught to everyone--this is because emotional intelligence is not something that can replicated by book learning. To be a great leader, you need to be able to understand other people's emotions, even when they're hiding their emotions, or unable to express them. You have to anticipate people's needs, whether you are functioning as a transformational leader or a transactional one. And you have to be able to hold your own emotions in check until you have all the facts--and that type of self control is not necessarily trainable in everyone. Life isn't "the Karate Kid."
The books will have you think that leadership and management are separate entities. In my experience leadership is empty without management, and management is tyrannical without leadership. Some people can learn charisma, learn to hear what their people are saying, but to be able to do it in a way that is sustainable, and practical, and attainable, and admirable--that is entirely another matter.
There are
3 leadership styles:
Authoritative: which the books will have you believe works well with employees with little to no formal education (I think that that is insulting--as if a person with no education cannot have common sense and can't be taught, but I digress), and uses coercion. The ATI books says that the work output by the staff is usually high, but then follows it with the caveat that this is "good for crisis situations and bureaucratic settings," but that's exactly why it's a shitty leadership style--and I've had bosses and captains use this as a primary style, and it's not sustainable.
Democratic: motivates group decisions by supporting staff achievements, like a carrot and stick, gold star to maintain cooperation and collaboration.
Laissez-faire: you rely on your individual members to be highly motivated and creative, and usually those members become an informal leader (or manager) to make things happen.
The way this is taught, you would believe that each leader is pigeon holed into one style. That is not the case. You should be able to move fluidly between each when the need arises, but more importantly, I think what makes a great leader is the ability to recognize when each is needed based upon an accurate reading of your follower's emotions and needs.
In order to avoid being an empty "leader" suit, you have to have a formal position of authority and power--which is what a manager has--but, you also have to have the clinical expertise, a good working relationship with your team, and the ability to "coach your subordinate," which sounds an awful lot like leading--doesn't it? I would add, that to be an effective manager (meaning, to not become a tyrant only driven by meeting quarterlies) you have to have a long term vision (which the textbooks put under leadership) for health and sustainability, while also knowing when to enforce a zero-tolerance environment.
As a manager you have to
Plan a path toward a goal,
Organize a power structure/chain of command,
Staff your business with hard-working, willing, instinctive workers,
Direct those staff, and "
Control" your staff (which really means ensuring that everyone on your team is performing adequately to attain your goal--so, if someone is slacking or wandering off task, you have to bring them in line, and if they won't heel, then you got to get rid of them).
Good
time management requires that you have the ability to
prioritize:
Before an accident happens that will require medical treatment, first:
safety/risk reduction: look to eliminate risk (health screens, eating healthy, removing throw rugs, etc.
--------safety detour for random shit that comes up on the test----
double bagging is only necessary if the outside of the bag is contaminated
fire extinguishers: A for paper, B, for liquids eg, grease and gas, C for electrical
for fires: keep emergency numbers near phone, and phone near the bed. No nylon, wool, synthetics with O2 supplementation. Cotton only. No flammable materials.
carbon monoxide with any carbon burning anything--lawn mowers, wood stoves, etc.
burns: 98-99F should be the formula and bath water temperature for neonates. Home hot water heating should be 120F or less
booster for kids up to 40lbs, or until 4'9"
falls happen with skeletal/muscle changes, including pregnancy, aging, and kyphosis
Biohazard /Bioterrorism
Ok, here's the skinny:
airborne anthrax: flu-like symptoms, dyspnea/SOB, meningitis, muscle aches
TX ciprofloxacin+vanco+PCN
cutaneous anthrax: itchy lesions-->vesicular lesions-->necrosis-->eschar fevers, chills
TX ciprofloxacin+doxycycline
botulism: descending paralysis, N/V, kills you when you stop breathing.
TX: airway, antitoxin, eliminate the toxin (dunno how--the ATI book doesn't say. If I find out, I'll post later)
Ebola: Flu-like symptoms N/V/D, with fever, hemorrhage--> shock
NO CURE. Give vaccine.
Pneumo plague: flu like symptoms + chest pain, bloody watery sputum, respiratory failure and shock
bubonic plague: swollen, painful lymph glands with fever, H/A, weakness.
Tx: gentamicin.
Smallpox: fever, rash, vomiting, delirium, severe headache. NO CURE. Give vaccine.
Tularemia: sudden onset chills/aches, dry cough, diarrhea, join pain, progressive weakness.
Gentamicin. MCI: give doxycycline and ciprofloxacin. Give vaccine.
Chemical Terrorism
Undress the client, brush off the chemical. Wash with lots of water--water is the universal antidote--except with dry chemicals such as lye or phosphorus--DO NOT APPLY WATER TO THESE AS THEY WILL CAUSE THE CHEMICAL TO BECOME A GAS/INCREASE BURN AREAS.
Radiation: contain all wash off and wastes. Wear water resistant gowns, double glove, and fully cover body. Cover all air vents and ducts, floors and furniture. Decontaminate with soap and water and disposable towel.
------------end detour---------
Once an injury or disease occurs:
assessment/data collection: to get a whole picture before you make a decision, and
judge whether or not there is survival potential (for example, if a 90 year-old begins to exhibit signs of malignant melanoma, is there a point in taking a biopsy? or, if there's an MCI and this woman has a severe head wound and blown pupils, is there a point to spending time on her? Or do we go to the gaping chest wound?), and whether the patient is
acute or chronic/urgent vs nonurgent/ stable vs unstable. Remember that:
airway>breathing>circulation>disability
Disability really means something that will have a significant impact on quality life in the future, so, not the immediate life and death, but something that is involved in retaining "what makes life worth living." For example, a child was in a massive motorbiking accident, and to save his life we had to apply a tourniquet, however, once we got him into surgery, we want to create a shunt to allow blood flow to continue to his lower limb in hopes that we can save the leg.
- acute trumps chronic
- actual trumps potential
- trends trumps transient (findings)
- emergencies trump expected (unless it violates life vs limb, in which case the expected would itself be an emergency)
- clinical knowledge (aka common sense) trumps procedural standards
- and then there's this listening trumps assuming (which basically means don't be a know-it-all asshole)
And then when you are treating, to treat in a way that is least restrictive and least invasive.
There's a lot of time saving tips, but the ones I found personally pertinent are:
1) completing the more difficult or strenuous tasks first. Their reasoning was that if you attack the task while high on energy, you'll have a higher success rate (whereas my incorrect old reasoning was, that if I take care of all of the annoying, little tasks first I will be unburdened by distractions--but that's just not realistic in nursing, you will always have more distractions and tasks pop up, so yeah, tackle the beast task first).
2) Avoiding interruptions and graciously but assertively saying "no" to unreasonable or poorly timed requests for help. Sorry, not sorry.
3) Setting realistic standards given the constraints of the assignment and the resources. And do use socialization as a break tool
4) Complete one task before beginning another--and document immediately following the completion of a task (man, I really suck at this one).
5) Use a sheet to organize/make lists.
And you have to stick with these tips no matter what your instincts are telling you to do (barring emergencies), because they will save your ass later down the line.
Assigning, Delegating, and Supervising
(Ughhhhh... I just want to bang my head against a wall. I never get these questions right, and part of the problem is the way we use these words colloquially.)
The nurse manager assigns the nurses certain clients to care for. Assigning: transferring authority, accountability, and responsibility to another person for a task. The nurse can then delegate certain tasks to UAPs. Delegating: Transferring authority, and responsibility. YOU STILL RETAIN ACCOUNTABILITY--in other words, you are still accountable for the quality of work and completion of the work. In other words, if your UAP does a shit job, you're still in trouble, so you still need to check in on tasks you delegate.
If a nurse receives an inappropriate assignment she has to bring it to the attention of her superiors and then proceed up the chain of command if the situation isn't resolved. You can't just abandon or refuse to accept the assignment--this is considered abandonment. The order is:
- scheduling/charge nurse
- director of nursing
- file a "Assignment Despite Objection" or "Document of Practice Situation"
Things an RN cannot delegate:
- nursing process (assess, diagnose, plan, intervene, evaluate)
- education
- tasks requiring clinical judgment
Things that an RN can delegate:
- tasks with predictable outcomes (is it a routine, low risk treatment)
- tasks that have a low potential for harm (the patient is stable, and it is unlikely to hurt him)
- tasks that are not complex, and they are legally able to perform the task (so, as shocking as this may seem, insertion of a urinary catheter, trach care and suctioning, g-tube feedings, and checking NG tube patency ARE ALL CONSIDERED ROUTINE, so LPNs can do them; and as crazy as it seems since you could fuck up the procedure for specimen collection, UAPs can take specimen collection. They can also take VS on stable clients--and yes, that includes stable post-op patients)
- task does not require problem solving or innovation (eg, no nursing assessment)
- task does not require teaching
Right task, right circumstance, right person, right direction, right evaluation/supervise.
Informed Consent
Your job is to witness the signing on the consent form for an invasive procedure or surgery. For most aspects of nursing care, implied consent (complying with the nurse's instructions) is adequate. People who can sign consent are: parent of a minor, legal guardian, court appointed rep, spouse/POAHC, emancipated minor/married minor/pregnant minor. --Document the reinforcement of information given by MD, the questions that were forwarded to MD/answered by MD, use of an interpreter.
Advanced Directives
2 parts of the advanced directive: 1) the living will, 2) POAHC. You have to document the advance directives status and you have to update the file so that people will know if there's a DNR or AND.
FYI: Death=irreversible cessation of circulatory and resp. functions. Irreversible cessation of all functions of the brain, including the brain stem.
Discharge Planning
(the reason why this is in Leadership and Management is because discharge planning for complex cases requires interprofessional coordination)
Normal discharge:
-plan with both the client and family/caretaker in the room
- give step by step instructions for for procedures to be done at home, with return demonstration
- medication instruction including adverse effects and preventative actions
- contact info for doctors and community services
- follow-up plans and therapies
-additional services need to be coordinated and in place so that the continuity of care isn't broken
Against Medical Advice discharge (only if the patient is mentally competent):
1) immediately call the provider
2) explain the risks
3) have the patient sign the AMA form
4) document all communication including the advice provided for the client
Documentation of discharge:
type of discharge (ordered by provider or AMA), date & time, discharged with whom (accompanying the patient), how accompanied out of the hospital (w/c, stretcher, etc.) to destination (home, long-term care facility), summary of condition at discharge (VS, "patient is stable at this time"), description of any unresolved problems for follow-up, list of valuables and prescriptions that were taken upon discharge, copy of discharge instructions.
Patricia Brenner's 5 stages of nursing ability
- novice nurse (obeys the rules and guidelines--had minimum clinical experience)
- advanced beginner (can make clinical judgement based on sufficient clinicals)
- competent (practicing for 2-3 years)
- proficient nurse (significant experience, well-developed critical thinking, holistic conceptualization, able to react to unexpected changes)
- expert nurse (does not need rules to comprehend a situation and take action)
If there is a need for an educational program (eg, to update competency training):
1) identify the problem (can be taken retrospectively, concurrently, or prospectively):
- structural audits: analyzing the setting (eg., the building), and the available human and material resource
- process audits: review the relationship between the nurses (education, training, level of commitment) and the quality of care provided
- outcome audits: results of the nursing care provided
- root cause analysis: what variable contributed to an outcome, often done for sentinel (unexpected e.g. death, serious injury) events
2) analyze what needs to be taught
3) research EBP regarding that subject
4) plan a teaching program
5) implement (teach)
6) evaluate
Performance Reviews
I have to remember that these books were written for people who may be in BSN, BA-MSN bridge programs because there's little chance of me becoming a supervisor and giving a performance appraisal or disciplinary action as an Assoc. RN., however, the day when I do become a supervisor (shudder), I guess I'll have to know this.
Performance appraisals are used to give the nurse an opportunity to discuss personal goals and to receive feedback on their performance, not only deficiencies and discipline, but also praise. There should be data and observed behavior documented/used as evidence, including anecdotes and peer view. The appraisal should be done in private, by the unit manager, at a time convenient for the staff member's attendance. And if the staff member does not agree with the evaluation, she should have the opportunity to make written comments on her evaluation and appeal the rating.
Disciplinary Action
- deficiencies should be presented in writing, with evidence
- correction should be based on policy
- unless the offense is mistreatment of a client, or use of alcohol or drugs (p.s., I didn't know this before, but preferring to work the night shift when supervision is less on controlled substances are more frequently given is a sign of possible drug use), there should be progression in discipline:
- first- informal meeting, discuss the issue and suggest correction
- second-manager meets with the employee and give a written warning to review exact violations of policies, and discuss the potential consequences
- third-suspension without pay to give the employee time to examine the issue and consider alternatives
- fourth-terminate
Civil laws-protect the individual rights of people
torts=unintentional, quasi-intentional, or intentional
-Unintentional: Negligence & Malpractice (professional negligence):
negligence must be proved by:
1) prove there was a standard of duty
2) prove there was a breach of duty by failing to meet a standard
3) prove there was a possibility to foresee the harm that would be caused
4) prove there was there was a direct relationship between the breach of duty and the harm
5) harm actually occurred in direct causation of that breach of duty
-Quasi-intentional: breach of confidentiality and defamation of character
-Intentional torts: assault, battery, false imprisonment
Mandatory Reporting
- Abuse of children
- Abuse of elders and dependent adults
- TB
- foodborn outbreaks (Hep A)
- diseases that have immunizations
Restraints
Prescription within 1 hour of seclusion or restraint, refreshed q24hr: specify reason for, type, location, how long it may be used, and type of behaviors that warranted application.
neuro checks q2hr: circulation, sensation, mobility, with 2 finger give.
Other q2hr: food and fluids, toilet, VS, ROM
Document: behavior precipitating, and attempts to redirect/control leading up to restraint, leve of consciousness, type of restrain, etc., education of the client and family, exact time of application and removal and behavior while restrained, all the q2hr checks, response when the restraint was removed, and medication administration.
Ethics
Deontology--judging the morality of an action based on whether or not that action was in line with a society's rules (eg., duty, obligation, or rule based morality).
Utilitarianism--the morality of an action is based on whether the outcome benefits the most people or if the effect is overall good, e.g., "ends justify the means."
Negotiating Strategies
- avoiding
- smoothing
- coercion (just fyi, you can risk being terminated by refusing an assignment--depending on how asshole your boss is--but listen, if it's the difference between losing your job and losing your license, lose the job, you know? And here's the thing: you need to refuse to practice beyond your legal scope or outside of your area of competence regardless of whatever reason your superior tells you. They may say "there's not enough people," or "there's no one else to do it," but whatever, it's your license.)
- cooperating/accommodating
- compromising--even when there is compromise, if one side had to give up more than the other it can be a win-lose situation
Grievances
But, like, if you're that fucking difficult to work with, you're probably going to get canned. Or, if it's that unbearable to work where you're working, then you should just leave.
- formal presentation of complaint with chain of command
- formal hearing
- professional mediation
