Leadership In Nursing

Leadership In Nursing
Case Study # 20
Maria, a new professional nurse graduate has been asked to participate in her unit’s quality improvement council. Each unit in the hospital has been directed to focus on nursing-sensitive indicators and report the following results to the National Database of Quality Indicators (NDQI) database: hours per-patient-day falls with injury, pressure ulcers, and RN satisfaction. Maria has been informed that over the past year, the hospital has used the results to implement several changes, including decreasing the nurse-to-patient ratio on select units, developing a clinical ladders program, and increasing orientation services for new professional hires.1. Where can Maria find out more information about nurse-sensitive indicators and about best practices in other hospitals?

2. As a new employee, how can Maria possibly contribute something unique?

3. How can Maria approach this challenge in a way that she can learn something from her co-workers can learn something from her?

Case study 20

Tiffany has worked in the Emergency Department (ED) of a regional medical center for the past year. The average length of stay (LOS) is over 4 hours, the number of patients who leave without being seen has climbed to 180 patients/month, and patient satisfaction scores have fallen to 80%. A SIX Sigma, including ED nurses, ancillary department staff, and physicians, has been established to identify opportunities to decrease average LOS and the number of patients that LWBS. Tiffany, a new member of her department’s Practice Council, has been asked to participate. The SIX Sigma team will apply the six steps of the QI process to determine an approach to reduce excessive wait times and improve patient satisfaction. The Practice Council completed the first two steps of the process (identify needs most important to the consumer of healthcare service, and assemble an Interprofessional team to review identified consumer needs and services) before Tiffany was asked to join.

1. Identify the next step in the QI process and an approach the Six Sigma team might take.

2. Describe the six steps for in the QI process. Speculate how communication rounds affect wait times, reduce the number of patients who leave and improve patient satisfaction.

Case study # chapter 2

Thomas, a new nurse is assigned to practice on a unit where are physician centered. He is working on the night shift and knows that eventually he will have to call a physician for advice about a patient. He dreads this experience because he has heard so many stories about how much physicians dislike being awakened in the middle of their sleep. He asks a more seasoned nurse how to present information, how to convey the importance of needing an answer, how to remain calm if the physician is disturbed with him, how to document his oral interchange with the physician, and what the nurse’s first experience was like.

1. Is it true that providers dislike being awakened in the night?

2. Is asking a more seasoned nurse about how to present information a good strategy? What has been your experience with this?

3. How could Thomas use the IOM competencies to practice his communication in advance of actually calling a physician?

Case Study # Chapter 23:

Carlos, a new nurse, has been asked to participate in the hospital-wide initiative go live with an electronic medical record. Carlos understands that nurses and physicians at this institution have long resisted technologic advances, and this conflict has taken 10 years to progress to the point of implementing the EMR with computerized physician order entry. Some work has been completed by the committee to gain buy-in, in an attempt to reduce resistance and reluctance, and plans are now needed to effectively manage conflict after implementation.

1. What strategies can Carlos and the EMR implementation team employs to address conflict management before the go-live date?

2. What strategies can Carlos and the EMR implementation team use to address conflict after implementation?

3. What conflict-handling techniques will be of particular importance during the implementation?

Carmen recently began to question her decision to become a nurse and was considering leaving the profession after only 6 months of licensure. Orientation had left her in tears at least once per week, and she began to question her ability to be a safe and competent nurse. Carmen felt belittled by her preceptor and unsupported by her co-workers, who all seemed too busy to help her. She frequently observed her preceptor roll her eyes and sigh loudly when Carmen asked a question; she observed the same thing from the preceptors of the other two new graduates. Carmen understood that her preceptor was experiencing conflict in her own life because she commonly overheard her preceptor on the phone arguing with her husband.

1. What strategies can be implemented to reduce later violence on Carmen’s unit?

2. What can Carmen and other new nurses do to improve the work environment?

3. How did you handle it when you were new or floated to another unit?

Case study – Chapter 25

I am a recent graduate from a BSN program. After I graduated, I worked for about a year on a busy med/surg unit in a large hospital. I feel that my experience there gave me the solid foundation I needed to be able to work anywhere.
About a year ago, I took a new position working the night shift at ED of a smaller facility. After just a short time working there, I began to notice a big difference between the nurses working the day shift and those working at the night shift. The day shift nurses have at least 15-20 years of working experience and for the most part were educated in associate degree programs. The nurses on the night shift had less than 5 years of experience and were mostly BSN prepared. I began to hear negative remarks from the day shift nurses about those of us with BS degrees and our experience. I would hear them talking and saying some pretty degrading things about the night shift group. I did not pay much attention to the talk. I figured their opinions are too ingrained to change.
After the first month I worked there, I was asked to be in charge. This focused the negativity and criticism on me. The experienced nurses were very verbal about what a bad decision this was since I was a new nurse. I was excited to take on this role and accepted the challenge despite all their grumblings. I loved my new position and was told I was a natural at it. I did not realize that those kinds of negative behaviors would arise within my own group of night shift nurses. There is a nurse on my team that has a terrible attitude and pretends she has been a nurse for a long time but in reality she has not. She is known as the BULLY on the unit. One night I asked her to assist me with inserting a foley in a morbidly obese patient. This nurse made a joke about breaking sterility in front of the patient. I told her I did not appreciate her joke and asked if she would like to take over the procedure. She quickly declined and started laughing about how it was “only a joke” and threatened to leave the room and let me “attempt” to do the procedure alone. It was humiliating and I know the entire episode had caused the patient to lose trust in us. I was very angry. I waited until I felt I could control my emotions and had a clear idea of how to handle the situation. I told her it was inappropriate to say something in front of the patient. I explained there are better ways to offer assistance or simply to take over if there is a concern. Since then, she has never bullied me again and in fact has become my biggest supporter!

Not long after that, I was approached to be the department manager. I have been in training for a month now and I am learning new clinical and leadership skills every day. I feel like I have made progress in dealing with those who previously questioned my abilities. I made it clear to the “veteran” emergency department nurses that I am confident in my ability to lead, but they are my clinical experts and I respect their knowledge. I let them know I would be asking for their opinions and counting on their help. So far I have had nothing but positive feedback. I am now aware how negative talk and bullying can directly impact patient care and will try to keep the same thing from happening to the next new recruit.

1. What kinds of incivility did you identify in this scenario?

2. What interventions were used to address the behaviors?

3. Do you think establishing an environment of mutual respect can diminish incivility?

4. What other things might you recommend to others dealing with incivility or bullying?

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