Decision making process
Includes defining objectives, generating options, identifying advantages and disadvantages of each option ,ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result.
Can
Decision making model (Routine)
If routine,
*Normative, prescriptive approach
*sRely on policies, protocols, standards
Ex: how one hospitals policy differs from others
Decision making model (Complex/non-routine)
If complex/non-routine
*Descriptive, behavioral approach
*Gather information, expert opinion, experience
*Use creativity
*Group process
*Ex: restructuring curriculum
Decision Making Model (Satisficing)
Satisficing
*Minimally meeting objectives
*Used for quick decision making when time is limited
Decision Making (Optimizing)
*Process of selecting options that are best based on analysis of pros and cons
*Takes longer to arrive to decision than satisficing
Authoritarian Decision Making Style
Authoritarian - autocratic - control in one persons position
*Top down decision
*Decision made by one person in authority and passed down
*Appropriate when conflict is likely to occur or when the problem is unstructured
Example: Person uses in a situation
Democratic/Participative Decision Making Style
Group decision made by those involved
*Increases work performance/productivity
*Decreases turnover rates
*Increases job satisfaction
Factors Affecting decision making model
Internal factors:
*Personal beliefs, values, and cultural/social background of those making the decision
*Ethics
*Personal characteristics of the decision maker
*Self esteem
*Self efficacy
*Confidence
*Willingness
*Risk taker
External Factors:
*Conditions
Group Decision Making
* High quality decision making with predetermined goals, outcomes and objectives
*Those responsible for the implementation of the decision must accept the decision
* Individuals must be allowed active input into the process
*Increases quality and producti
Group Facilitator Role
*Create a positive, non-threatening environment
*Encourage participation of all members
*Control aggressive people who try to monopolize
*Encourage passive people to engage with open-ended questions
*Protect those from being attacked
*Provide positive fee
Advantages of group decision making
*Bring together different knowledge, skills and resources that increase the quality of the decision
*Generates more ideas
*Active participation in decision making increases acceptance of the decision and creates a sense of ownership and commitment to the
Challenges of Group Decision Making
*Time consuming to sit down and figure out how to agree to something
*Unequal power between group members
*Dominant personalities
*Passive personalities
*"Group Think"
*Members wish to avoid conflict and maintain harmony rather than engage in active discu
Strategies for group decision-making
**Brainstorming
*Generate ideas
*Creative, "Out-of-the-Box" thinking
*Avoid "Killer Phrases"
"That will never work"
"Administration would not go for that."
"We already tried that before."
**Disadvantages:
*Time consuming
*Getting people together
*Conflict
Focus Groups
*Used in group decision making.
*Identify problems or evaluate the effects of an intervention
*Face-to-face interactions
*May be a disadvantage
*Under supervision od a Moderator/Facilitator
*Objective
*Disadvantages
*Time consuming
*Getting people togethe
Delphi Technique
*Systematically collecting and summarizing judgments from respondents (i.e. expert panels, on a particular issue, through interviews, surveys or questionnaires.)
*Opinions repeatedly fed back to respondents for refining of opinions and rationales
*Between
Decision making tools
*Decision making grid - ranks factors - what's more important to you (cost, quality, etc,)
*SWOT analysis (Strength, Weakness, opportunities, Threats)
**Consequence table
*A summary matrix illustrating the performance of each alternative on each objective
PERT Flow Chart
**Program Evaluation and Control Technique (PERT)
*Key components include:Identifies key activities in a project:
*Sequencing the activities in a flow diagram
*Assigning the duration of each phase of work
*This is your goal, what is your plan, what does i
Decision Tree
*Uses a tree-like graph or model of decisions and their possible consequences
*Including chance event outcomes, resource costs, and utility/satisfaction
Ex: triage
Payoff Table
*A table showing the financial returns minus costs for each of the strategies under consideration
*Ex: 401K
Problem Solving
*Always involves decision making
*Key questions:
*Is it important?
*Do I want to do something about it?
*Am I qualified to handle it?
*Do I have the authority to do anything?
*Do I have the knowledge, interest, time and resources to deal with it?
*Can I d
Steps to Problem Solving
***Define the problem, issue or situation (most critical step)
*Know the facts
*Separate the facts from interpretation
*Be objective and descriptive
*Determine the scope of the problem
*Gather Data
*Separate subjective and objective
*Analyze Data
*Differe
Purpose of cause and effect diagraming
You find out why things happen.
Cause Mapping
People view things different because of the stuff and values they bring to the table
Most common failure in problem solving is improper problem identification
5 Whys" approach
- Nurse injury with patient transfer
� Why?
- No assistive device used
� Why?
- None available on unit
� Why?
- Being used in another department
� Why?
- Sharing equipment due to lack of funds
� Why?
Strategies in problem solving
� Get a new perspective
- Bring in others from the outside
� Try something new
- Avoid practicing out of habit - whats the worse that can happen
� Triage problems
- Address the most urgent problem first
Power definition
The ability to influence others in an effort to achieve goals
**Not corrupt, immoral or negative in nature
Expert Power
*Gained by possession of knowledge and skills
*Ex: charge nurse or manager, leading scholar on EBP.
Perceived Power
*Based on perception of power
*Ex: someone older than you, more experience
Information Power
*Gained by possession of information
*Ex: someone who is less likely to give you information because they would lose power over you
Connection Power
*Gained by association with people
*Money = power, more money, more power
*Ex: its not what you know its who you know
Personal Power
*Based on reputation or credibility
Coercive Power
*Based on the ability to punish
*Ex: what you do to your children
Reward Power
*Based on the ability to reward
*Ex: boss can give you a raise for doing a good job
Charismatic Power
*Gained by having a powerful persona
*Ex: martin luther king, hitler can be someone who is good or bad.
Referent Power
*Based on identification with the leader or what they stand for
*Ex: being associated with someone
Self Power
Power over one's life
Position Power
*Based on status within the organization
*Ex: manager, job description
Influence
Process of using your own power.
Developing a powerful image
*Self image
*Belief that you are powerful
*Grooming and dress
*Neat, clean
*Good manners
*Respectful
*Body language
*Confident, good eye contact, no drama
*Speech
*Firm confident voice, good grammar and vocabulary
*Strong communication skills
Personal Power Strategies
**
Personal power strategies - also important for building political power - get involved
**
***Communication skills
*Verbal versus Non-verbal (90% non-verbal)
*Listening
*Emotional Intelligence
*Networking
*Identifying, valuing and maintaining relationsh
Politics definition
The process of human interaction within an organization
*Shaping policy
*Collegiality and Collaboration
*Empowering Attitude
*Develop Coalitions
*Negotiating
*Collective Bargaining
*Take Political Action
Group definition
A number of individuals assembled together or having a unifying relationship.
Team definition
A number of people associated together in specific work or activities.
Differences between groups and teams
***Not every group is a team and not every team is effective.
*A church congregation is a group not a team. A PTA at an elementary school is a team, but not the student body.
*A group of people does not constitute a team.
*Team is a group of people with a
Leadership in a Team
**Key to holding the team together through supporting the patient care team
**Three essential elements to teamwork:
1) Constant monitoring of the situation to better anticipate the team member needs and manage resources to meet those needs
2) Effective co
Types of Leaders
**Designated Leaders
-->Pre-assigned based on knowledge, skill and attitude to achieve established goals
**Situational Leaders
-->Arise based on a given situation
Example:
First responder to a code
Anesthesia administration
True or false? Leaders have to take responsibility even when its not their fault.
True
Characteristics of team leaders
- Organize a team
- Articulate clear goals
- Make decisions based on input of team members
- Empower team members to speak up and openly challenge when appropriate
- Promote and facilitate good teamwork
- Resolve conflict
Resource Management
*Resource Management
*Actively handling resources available to the team
*Time
*People
*Equipment
*Information
*Goal is to increase situation awareness among team members and decrease the risk of errors
***Delegation
*A method of redistributing tasks or pa
Team Events
****Brief
*Short information session prior to start to discuss team formation; assign essential roles; establish expectations and climate; anticipate outcomes and likely contingencies
****Huddle
*Ad hoc planning to reestablish situation awareness; reinfor
Situational monitoring
Process of continually scanning and assessing what is going on around you to maintain situational awareness
Cross monitoring
*An error reduction strategy
*Monitoring actions of other team members
*Providing a safety net within the team
*Ensuring mistakes or oversights are caught quickly and easily
*"Watching each other's backs
I'M SAFE CHECKLIST
- I - illness
- M - medication
- S - stress
- A - alcohol and drugs
- F - fatigue
- E - eating and elimination
Key components of effective communication
*Complete
1. Communicate all relevant information
*Clear
1. Convey information that is plainly understood
*Brief
1. Communicate the information in a concise manner
*Timely
1. Offer and request information in an appropriate timeframe.
2. Verify authenticit
ISBARR
- Introduce
� Introduce self
- Situation
� What is going on with the patient?
- Background
� What is the clinical background or context?
- Assessment
� What do I think the problem is?
- Recommendation
� What would I recommend?
- Read-Back
� Confirm the co
Call Out
� A strategy used to communicate important or critical information
- Informs all team members simultaneously during urgent situations
- Helps team members anticipate next steps
- Important to direct responsibility to a specific individual responsible to c
Hand Off
�Transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify and confirm.
Examples: Shift change & Patient transfers
Mutual Support
A chain is only as strong as its weakest link. **Collaboration is key
� Team members should protect each other from work overload situations
� Effective teams place all offers and requests for assistance in the context of patient safety
� Team members fos
Two ways in which you can support a team member include:
� Task Assistance
� Feedback
� Timely
� Respectful
� Specific
� Directed towards improvement
� Considerate
Advocacy
� Protect the basic rights of the patient
� Patient has the right to:
� Individualized care
� Their own values, beliefs and customs
� Be informed
� Actively participate in care decisions
� Requires one to be comfortable with conflict
� Ability to mediate,
Common Communication Barriers
a. Distractions
i. Distractions most commonly come through sensory perceptions, such as poor lighting or background noise, including music, talking, ringing phones, and interruptions by others. Papers, reports, and heavy workloads can also be distracting.
Common Communication Pitfalls
1. Giving advice
2. Making others wrong
3. Being defensive
4. Judging others
5. Patronizing
6. Giving false reassurance
7. Asking the "Why?" question
8. Blaming others
Value ineffective communication as the key factor in errors
- Ineffective communication is the root cause of nearly 66% of all sentinel events reported* - things that shouldn't't happen. All comes back to communication
- Poor communication causes conflict
Discuss the importance of team to patient safety and quality
National Patient Safety Goals
- Improved effectiveness of communication among caregivers
� Read-back
� Handoffs
- Accurately and completely reconcile medications and other treatments across the continuum of care
� Address specifically during handoffs
- En
Two Challenge Rule
� It is your personal responsibility to assertively voice your concerns at least TWO TIMES to ensure it has been heard
� The team members being challenges must acknowledge your concern
� If the outcome is still not acceptable:
- Take a stronger course of
CUS
I am Concerned
I am Uncomfortable
This is a Safety concern
Consumer Relationships in Healthcare Delivery
*Refers to the multitude of encounters between the consumer (client, patient, or customer) and healthcare system representatives.
*Includes protecting consumer rights, assessing patient/consumer satisfaction.
*Quality improvement.
*The role of nurses as t
The Consumer Focus Relationship
i. Consumer relationships are constantly changing and thus affect the providers of health services: primary care and public health services, managed care organizations, hospitals, home health agencies, and long-term care facilities, as well as individual
Healthcare Provider-Consumer Relationships
i. These relationships have changed as physicians' typical mode of practice moved from a singe, private enterprise to multi-group practices that also include nurse practitioners, certified nurse midwives, nurse anesthetists, CNS, RNs, etc.
ii. Also includ
Agency Consumer Relationships
i. One solution to containing costs is consumer-directed healthcare plan, which generally has high deductibles with the goal of reducing healthcare costs by providing consumers with information about choices, risks, benefits, and costs.
ii. The goal is gr
Service-Oriented Philosophy
a. A service orientation means delivering services in a manner that is least disruptive.
b. When possible, services should come to the patient and should be easy, comfortable, pleasant, and effective as possible.
c. Meeting emotional, psychosocial, and sp
Consumer Relations
� Media coverage surrounding medical errors has heightened consumer awareness and increased involvement of patients as active members in their care
No longer "Patient in the middle"
� Health Literacy
- The degree to which individuals have the capacity to
Nurses' Relationships
- Spend the most time with the patient and family
- Have personal encounters
- Are the liaisons between the consumer and the complex healthcare system
- Ensure well coordinated care
- Have four responsibilities in promoting a successful relationship:
� Se
Role of Advocate and Advocacy
� Advocate:
- Defends and promotes the rights of others
- Changes system to meet the needs of others
- Empowers and promotes self-determination in others
- Promotes autonomy of diverse cultures and social groups
- Ensures respect, equality and dignity for
Role of Leadership in Nursing
� Leadership
- Influencing mission, vision, values, philosophy of the organization
- Patient satisfaction
- Empower others
- Perform and use evidence based practice to form standards of care
Conflict
A disagreement with a belief or value within oneself or with others that cases harm or has the potential to cause harm
*Conflict is a fundamental human experience
Types of Conflict
Intrapersonal - within self
*Conflict with ethics, priorities or values
Interpersonal -between two or more people
*Differences of opinion, priority or approach
Organizational
*Disagreement on policies, procedure, personnel codes of conduct or accepted nor
Avoiding
- Withdrawal (unassertive)
- "No Win" solution
Accommodating
- Neglect own needs, goals, and concerns, while trying to satisfy others (unassertive)
- "Lose-Win" solution
Competing
- Pursue own needs and goals at the expense of others (assertive)
- "Win-Lose" solution
Comprising
- Each person give something up, negotiation is key (assertive and cooperative)
- "Lose-Lose" solution
Collaboration
�Collaboration - most ideal
- Develop a common goal (assertive and cooperative)
- "Win-Win" solution
Effective Leadership Strategies in Conflict
Leaders in conflict
� Participation in decision making
� Encourage a positive workplace
� Encourage effective communication
� Encourage active listening
� Respond promptly to concerns
� Do not delay or cancel important meeting
� Do not address conflict in
Categorize the types of violence/incivility that may occur in the workplace
Lateral/horizontal
Bullying: Perceived power differential between the instigator and the recipient of the bullying
Verbal abuse
Most common sources:
1. Other nurses
2. Patient family members
3. Physicians
4. Patients
What is STAMP and what does it do?
Identify potentially violent people
*
STAMP
*
- Staring
- Tone and volume of voice
- Anxiety
- Mumbling
- Pacing
Assess the most appropriate approaches to conflict in potential and actual situations
De-escalating
� Allow them to have control
- A stressful event can be magnified if the person feels they do not have the resources to handle the situation
� Improve communication
- Decrease frustration due to ineffective communication
- Listen
� Allow the
Aftermath of a violent episode
� A violent event does not just effect the victim
- Decrease morale
- Increase turnover
- Lead to loss of work time
- Decrease productivity
� Nurse leaders role
- Support staff
- Provide counseling **
- Take immediate efforts to prevent reoccurrence
Guidelines for preventing workplace violence
� No national legislation or federal regulation to address workplace violence
� OSHA
- Published voluntary guidelines for workers in healthcare
- Some states have enacted laws, standards or recommendations related to healthcare workplace security and safe
Types of Violence
Types
� Type I
- Criminal Intent
� No relationship with employees or organization
� Ex: Robber, criminal trespassing
� Type II
- Customer/Client
� Relationship with organization and employees
� Becomes violent when served
� Ex:
� Type III
- Worker-to-Work
Toxic work environments
Prolonged high stress environment
� Causes:
- Tolerance to bullying
- Lack of trust among workers
- Lack of trust between workers and management
- Frustration
- Anger
- High stress work
- Rapid changes
- Hiring freeze, layoffs
- Changes in schedules or wo
Aggressive and destructive behavior or psychological harassment of nurses against each other
10 most common:
� Non-verbal innuendo
� Verbal confrontation
� Undermining
� Withholding information
� Sabotage
� Infighting
� Scapegoating
� Backstabbing
� Failure to respect privacy
� Breeches of confidentiality
Lateral/Horizontal Violence and Bullying lead to:
- Psychological and physical stress
- Underperformance
- Professional disengagement
- Increased turnover
- Decreased quality of care
Nurse Burnout
� New nurses are most vulnerable
- Start their positions feeling undervalued
- Too much responsibility with too little support
� "A syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment which happens as a result of the c
What can be done about burnout
Reframing
- Humor
- Leisure activities
- Vacations
- Social support
- Meditation
- Limit caffeine
- Take time for self
- Counseling (employee assistance programs)
- Time management techniques
- Effective leadership/management
Self Management
The ability of individuals to actively gain control of their lives, components include stress management, time management, meeting management, and the ability to delegate.
Job Stressors
Feelings of being trapped by conflicting expectations:
- Positive patient outcomes
- Being caring and nurturing
- Cost effective
- Efficient
- Cutting edge, evidence based
- Quality
- Patient safety
� Within the work environment
- High acuity
- Workload
-
Evaluate common barriers to effective time management
� Too much to do
� Inability to say "No"
� Procrastination
� Perfectionism
� Interruptions
� Disorganization
� Too much information
Stress Management
-The emotional and behavioral control, perseverance and challenge in the face of a stressful event
-Does not necessarily remove stress
Barriers to time management
� Too much to do
� Inability to say "No"
� Procrastination
� Perfectionism
� Interruptions
� Disorganization
� Too much information
Time Management
Time management
� Three primary areas of practice that consume the time of the registered nurse are:
1. Professional
- Assessments, plan care, coordinating efforts
2. Technical
- Catheterization, injections, venous cannulation
3. Amenity
- Service oriente
Monochronic
Do one thing at a time
Polychronic
Do 2 things simultaneously
Identify factors that contribute to time-wasting
1. Telephone interruptions
2. Socializing
3. Meetings
4. Lack of information
5. Poor communication
6. Lack of feedback
7. Lack of adequately described policies and procedures
8. Incompetent co-workers
9. Poor filing system
10. Paperwork and reading
11. Co
Avoid time wasters
1. Telephone interruptions
2. Socializing
3. Meetings
4. Lack of information
5. Poor communication
6. Lack of feedback
7. Lack of adequately described policies and procedures
8. Incompetent co-workers
9. Poor filing system
10. Paperwork and reading
11. Co
What is delegation?
Achieving performance of care, care outcomes, for which an individual is accountable and responsible by sharing activities with other individuals who have the appropriate authority to accomplish the work
� Transfer of authority and responsibility of a tas
Errors in delegation
- Over delegation
- Under delegation - trying to do it all
- Improper delegation- asking someone to do something they are not allowed to do
Steps to Effective Delegation
� Plan Ahead
� Identify necessary skills and levels
� Select the most capable person
� Communicate goal clearly
� Empower the delegate
� Set deadlines and monitor progress
� Role model and provide guidance
� Evaluate performance
� Reward accomplishments
Never Delegate
� Patient Assessment
� Nursing Diagnosis
� Care Planning
� Patient Teaching
� Patient Outcome Evaluation
Barriers to delegation
� Diversity
- Culture
- Age
- Gender
- Ethnicity
- Generational Variations
Supervision
� Key to ensuring proper delegation
� An active process of directing, guiding, and influencing the outcome of the individual performance of an activity
� Is interpersonal and goal directed***
� Requires:
- knowledge of own scope of practice, role dimensio
Resistance (Ability vs. Willingness)
Subordinate resistance
� Most common causes:
- Failure of the delegator to see the subordinate's perspective
� Workloads assigned to UAPs are highly challenging both physically and mentally
� Rapidly changing priorities
� More than one delegator
� Inappro
Apply the 5 Rights of Delegation
1. Right Task
2. Right Circumstances
3. Right Person
4. Right Directions and Communication
5. Right Supervision and Feedback
Delegation responsibility
� Delegator responsible for prudent (cautious) action
� Failure to delegate and supervise within acceptable standards may extend to the institution for liability
Non-nursing functions
�The RN must be aware of the job description, knowledge base, and demonstrated skills of each person
�CNAs have 75 hours of theory and practice and successful completion of examination in both areas (Omnibus Budget Reconciliation Act of 1987)
�No federal
Discuss the role of unlicensed care providers and the responsibility of supervision by registered nurses
o Any unlicensed person trained to function in an assistive role to the Registered Nurse in the provision of patient activities
UAP function under the license of the institution, not of the professional nurse
o The institution is responsible for consisten