Lesson 14/15

I presented my case study on Tuesday. This Reflection Journal is now complete!

Blog Week of April 5

This week we got to apply the principles we have learned in class to our case study. We typed up an outline to guide our discussion with the class; each taking responsibility for a section. We have planned to ask for class involvement and then share our ideas we came up with. Dealing with staffing shortages while maintaining a good work environment is a challenge, but we have come up with some creative solutions. Have to wait for the presentation to hear the details. I'm waiting for Lesson 14 to come up on black board, so that's all for now.

Lesson 13: The Future of Nursing Leadership

In your blog (Reflective Journal), discuss where you see nursing leadership moving towards in the next five (5) and ten (10) years.

I hope that in the next 5 years, residency programs become mandatory. I was able to complete a residency program, and it did help me to transition to being an RN. I do not see nursing programs moving toward BSN programs only because the shortage of nurses is too great. Nursing in general I hope in the next 5-10 years will increase its influence on legislation for the better, but I do not think in reality it will happen. For the profession as a whole, I do not see great changes happening in the next 5-10 years. Evidence based nursing was a big recent change, now we have to continually update practices according to research.

Personally, I see my nursing leadership expanding in the next 5-10 years. I will soon take a class to train me to be a clinical coach. Then I will be able to help train new nurses better. I hope to become a charge nurse within the next 5 years. Within the next 10 years, I hope to either complete my DNP or a  masters in nursing so I can teach nursing on the side of my career. Another job I would also like to try sometime within my career is to be a clinical educator. I really liked spending time with my clinical educator and would like to try that. I don't know exactly what opportunities will come my way, but I am excited to see what happens!

UVU Nursing Research Conference

I strongly support evidenced based  practice; however, I do not have any interest in doing the research. Sunny's class killed that for me. I do understand why it is important, and I am glad there are people who like it. It was interesting to know about different people's projects through their education. I wish the conference would have been more about the newest research rather than about old research done and how to do research. It would have been good to know about the resources presented by the key not speaker early on in the program and especially in the research class. When I have more time, I want to look up the AHRQ site to see if there is anything I can learn for my own practice.

Lesson 12: Performance Appraisals and Dealing with Problem Employees

• Come to class prepared to Discuss performance expectations for all employees.
• What are the universal skills expected of the professional nurse?
• ANA standards.
• Expectations should be consistently met.
• Basic assessment, medication, patient care skills, critical thinking, etc.

• Come to class prepared to Role play a performance appraisal with a problem employee.
• What could you say to the employee to help motivate the employee toward better performance?
• In performance appraisals, actual performance, not intent, is evaluated. 
• Make it clear that the appraisal is based on their job description rather than on whether the manager approves of them.
• Expectations of job performance should be clear at time of hire.
• Review expectations of job performance (employee fill out a self evaluation & be peer evaluated) before manager performs an appraisal.
• Treat the employee with trust and professional respect.
• Do not be biased.
• Make statements that are specific not vague and be direct.
• Use coaching techniques.
• Do not make statements that lead towards the halo or horn effect.
• Give credit where credit is due.
• If an employee is lacking in an area, set a measurable goal with the employee for improvement.

• Bring to class, ready to discuss, a copy of the policies governing termination at your place of employment.

Employee Termination Policy

Policy Statement

Intermountain Healthcare will administer all employee terminations (voluntary or involuntary) in a consistent manner and in accordance with all applicable laws and regulations.

Scope

Intermountain Health Care, Inc. facilities and entities.

Definitions

None

Provisions
1 Voluntary Termination
1.1 Employees are requested to give at least 2 weeks written notice of intent to terminate.
1.2 Employees in management and hard to recruit positions are requested to give at least 4 weeks notice.
1.3 All terminating employees should have a termination form completed for placement in employee file.
2 Termination Date
2.1 Generally, an employee's last working day is the date to be used in determining the termination date.
2.2 Unused leave may not be used to extend the length of an individual's employment.
3 Exit Interview
3.1 Each facility's Human Resources Department is encouraged to conduct an exit interview with all terminating employees.
3.1.1 The Human Resource Director should immediately be advised of issues regarding employee relations, legal, or policy identified as the result of an exit interview.
4 Final Pay
4.1 Terminating employees will be paid all compensation owed within legally required time frames.
5 Intermountain Healthcare Debts
5.1 Money may not be deducted from an employee's final pay to satisfy Intermountain Healthcare debts without the employee's written authorization.
5.1.1 Written authorizations should specify the debt incurred, the amount to be deducted, and when the deduction is to occur.
5.2 If any compensation or leave advances have been given to the employee, these may be withheld from the employee's final pay without a specific written agreement.
6 Intermountain Healthcare Property
6.1 All Intermountain Healthcare property, documents, disks, name badges, etc. must be returned to the manager or his or her designate by termination date.
7 Employee Appeal
7.1 If the termination is an involuntary termination the employee has a period of 10 Calendar days following the discharge to initiate an appeal. See Complaint Resolution Policy.

Exceptions

Exceptions to this policy are subject to review and administrative approval by the facility Chief Operating Officer

Unpublished work of authorship. Copyright © Intermountain Health Care, Inc. (Intermountain Healthcare). All rights reserved.

Effective Date: January2004

Confidential and proprietary to Intermountain Health Care, Inc. If Intermountain Healthcare authorizes a person to access policies, procedures, and guidelines (PPGs), it also authorizes that person to disclose information from PPGs – not copies – but only as reasonably necessary for healthcare matters related to Intermountain Healthcare.

Reasonable efforts will be made to keep employees informed of policy changes; however, Intermountain Healthcare reserves the right in its sole discretion to amend, replace, and/or terminate this policy at any time.

Intermountain Healthcare is an At-Will Employer. The terms of this policy do not, either directly or indirectly, constitute any form of employment contract or other binding agreement between any employee and Intermountain.

Contact Intermountain Healthcare’s Legal Department for questions.

• In your blog (Reflective Journal), Imagine you are a nurse manager and record ways of terminating an employee.
• It should be done in private. 
• For nonunionized employees, the burden of proof falls the the employee. Union employees the burden of proof for the wrongdoing and need for subsequent discipline falls on management.
• Appropriate steps should be taken prior to the termination (verbal, written, suspension, dismissal).
• Use assertive communication style.
• Remain in control of situation and conversation. Do not allow emotion to take a hold on the manager. 
• Termination is best done in person not over the phone.
• Employees may be given a chance to appeal the dismissal.
• Explain why the termination is necessary (if proper steps have been taken prior, it should not be a surprise to the employee).

Lesson 11: The Nurse Manager’s Role in Quality Control

• Come to class having contemplated the following questions:
• What do you consider elements of quality care when receiving healthcare services?
• What do you consider elements of quality care as a professional nurse?
• Are the two similar or different?
• In your blog (Reflective Journal), Record your opinions concerning the above questions in your reflective journal. 

Steps in auditing quality control (establish control criteria, identify the information relevant to the criteria, determine ways to collect the information, collect and analyze the information, compare collected information with the established criteria, make a judgment about quality, provide information and, if necessary, take corrective action regarding findings, and reevaluation) guide the elements of quality care. It is important to note that quality control should not be implemented solely as a reaction to a problem. Elements of quality should be based around ANA standards and evidence based practices.  Elements of quality care when receiving healthcare services include prompt, informative, accurate, top of the line, evidence based, etc. Elements of quality care as a professional nurse includes providing all the above stated things. The only way that can happen is if the nurse stays up to date on their education and works with management to ensure quality. The goal of quality care should be the same for the nurse and those receiving healthcare services. However, sometimes the way to fulfill quality care is different for how the nurse and patient see it. Depending on different situations quality care for receiving healthcare services and providing healthcare services may be similar or different. 

Reflective Journal Wrap Up: Clinical Perspective

If this is not what you are expecting for the reflective journal, please let me know.

1. Describe why this clinical area was selected and what you initially expected to learn.

• I picked this clinical area because I worked there and knew that it would create a good clinical experience. I initially expected to learn what a manager does; the simple stuff like budgeting, hiring, staffing, etc.

2. Describe what you actually learned through this clinical experience.

• I learned that there is nothing simple about managing; it is much more than just budgeting, hiring, and staffing. It could be said that managers spend most of their time in meetings and answering emails; however, after this experience I would say that a lot of their time is spent thinking and planning (how to resolve this issue, how to improve the unit, how to make this physician happy, etc).There is so much for a manager to remember; there are little things like approving pay roll that many people would be angry if you forgot. Nurse managers are the advocates for the staff and for the patients. They are responsible for keeping the physicians, staff, and patients all happy. Nurse managers can make or break a unit. They set the tone of the unit. It is up to them to create a successful working environment that promotes motivation.

3. Describe how your learning will impact your nursing career.

• My nursing career will be forever (I hope) affected by this experience. I now view management differently. I understand their role much better than before. I respect how hard my manager works for me (the staff). I know that I will be less prone to fighting changes as they come down from corporate; the manager does not make the protocols but is expected to enforce them. I know that I will definitely cut back on my complaining when we are instructed on new protocols; it doesn’t change anything, and it wastes time. Now if there is a legitimate reason why it would not work, I now feel more comfortable in bringing up the issues with my manager. For they do value constructive feedback.
• I also have sat in on interviews; this will hopefully make me a more successful interviewee for future positions.
• I am wearier to go into management than I was before this experience. I struggle with understanding why some people are perfectly fine with doing things mediocre all the time. Why are some more committed than others to service excellence? I try to do the best job that I can every day, while others just do the bare minimum. I know that this would be hard for me to deal with in management. I set a high standard for myself, and I expect others to follow the same standard. Perhaps, that would make people hate working for me? However, I do not believe in micromanaging. My manager sets the standard for service excellence and finds a good balance between accountability and micromanaging. The staff all loves her! Of course, there are still those who do the mediocre job, but the difference can be seen in the raises at the end of the year.

4. Discuss clinical objectives and how you met each of these.

           1. Examine the various roles and responsibilities of a nurse leader and manager.

• See previous entries and above descriptions. A good manager is not only a manager but also a leader. They are respected by their staff not because of the “authority position” that they hold, but are respected by their ability to lead. Recently all floor staff lost the privilege of having internet access; she does have internet but would not do anything that her staff should not be doing. This greatly impressed me, to set the same standards for her as the staff. Another nurse leadership role is to create a motivating environment for teamwork. A manager is responsible for keeping a balanced budget, competent staff, and clear unit expectations. The manager has to have a plan and vision for the floor. The manager is the liaison between administration and floor staff. The various roles and responsibilities of the nurse leader and manager are much more diverse than I would have ever thought.

         2. Manage time in order to effectively complete the clinical hours and expectations.

• Check! I finished all my hours by March 9, 2011.

         3. Demonstrate responsible and professional communication in verbal, nonverbal and written interactions.

• I was able to speak up in meetings as appropriate. I was able to provide valued feedback as a nurse working on the floor. Nonverbal cues helped guide when these comments were appropriate. I also was able to help plan the charge nurse conference.
• I was able to assist in writing up letters to be sent out to physicians and assist in writing emails. I designed and posted staff meeting flyers. I was able to design a template to be used for submitting nurses of excellence nominees.
• I was able to help my preceptor in a variety of ways enabling me to become a true asset to her during my clinical hours.

          4. Organize and complete a project that utilizes the concepts of nursing management to solve a clinical problem. (No longer an objective)

          5. Delegate appropriate tasks or activities to other and self-evaluate delegation style.

• As responsibilities were delegated to me I was able to fulfill the responsibilities. Only a few times was I able to delegate while working on this clinical. Often it was to relay a message to the clinical educator, the assistant manager, or staff. Once I assigned the task to give a staff member a book to read after a dispute between coworkers. The staff member took it really well. I delegate the most when I am a nurse working the floor. After self-evaluating my delegation style I would say it is more of a collaborative style due to the fact that I carefully assess the individual’s skills before I delegate the task. The good/bad thing about this is that I only delegate to those who I feel are truly competent, thus it may be the same people over and over again (excludes some and increases tasks of others).

           6. Identify leadership and management competencies which contribute to optimal organizational climate and culture.

• It is necessary for a good working environment to be in place for an optimal organizational climate and culture to thrive. Judgment must be suspended between all. Opportunities for employee recognize should be available. An environment conducive to creating a motivating atmosphere is key. Micromanaging should be little to none. Everyone should experience respect. Understanding that every floor has their own culture, helps one to better understand the flow of an organization. Staff should practice "being present" to help all feel validated and important. These are just a few of the ways that leadership and management skills contribute to optimal organizational climate and culture.

           7. Examine and evaluate records related to care monitoring, error prevention, incident reporting and quality improvement.

• Managers are responsible for follow up after incident reports and smoothing over upset patients. Calling and intervening for patients and staff as indicated are responsibilities of the manager. The manager sits in on the patient care coordination meeting as a practice of care monitoring. Policies and procedures are reviewed after incident reports to see if there needs to be a system wide change to prevent errors. Managers assure quality improvements by buying assets needed (more phones, better chairs, etc.) and by setting goals and plan to meet the goals. The GALLOP plan measures how satisfied staff is; she created an action plan to improve the scores. Unit goals correlate to National Patient Safety Goals. The staff is divided into charge nurse teams; each team has a different focus for each quarter. This helps the staff focus and improve one area, and then keep adding to it. Care monitoring, error prevention, incident reporting, and quality improvement are all roles of the nurse manager.

          8. Apply leadship and management principles to a variety of health care systems.

• The basics of leadership and management can be applied to any health care system. Principles are universally applicable. Health care systems may be capitalistic (for profit or nonprofit) or socialistic. However, the system does not change the leadership that should be in place, just rules of the business change. Good leadership and management skills are needed in every aspect of health care from the floor nurses in acute care to the home health nurses making follow up calls. Good care cannot be provided without the application of leadership and management principles by the staff. For example, the manager cannot be budget conscious if their staff are not with budget conscious with supplies. The patient cannot expect to receive affordable health care if the above are not doing their jobs. Health care is one big interconnected organization that can only run smoothly when all parties involved work together applying proper leadership and management principles.

5. Discuss your identified clinical goals and how you met each of these goals.

          1. Learn role of manager for the unit.

•  As previously described, I was able to learn the role of the manager for the unit. I was able to listen, observe, and help in delegated tasks to learn the role of manager for the unit (See previous posts and above answers).

          2. Learn about masters/how staffing works.

• Masters are the average number of nurses needed per shift per day. She reviews her masters to make sure she is staffing correctly. After reviewing her masters the last time, she found she was consistently needed more nurses on Wednesdays and Thursdays (heavier surgery days) and increased the number of nurses working that day. She staffs to the average of her masters. Other managers staff their masters to average plus one. She prefers to staff at average to enable her staff to consistently get their hours. The good side is that staff is rarely floated, but the down side is that nurses are often floated to the unit. I learned that she uses a computer program to do her scheduling. All the floor staff has rotating 6 week schedules that just repeat. Cluster staff sign up for days they want to work; their shifts come from needs. Staffing then helps fill in needs as requested the shift before. She always makes it a goal to work towards the staff ideal schedule as it becomes available. I was able to spend time with her trying to adjust staff's schedules to be how they requested them.

          3. Learn about how hires/fires? (What look for in a candidate?)

• I was able to experience interviewing and hiring with my preceptor (see old clinical updates). She conducts her interviews through assessment centers. All applicants give a three minute talk on whatever they want. This helps you to get to know the interviewee and brings out some of their personality. She then tries to get a good feel for how they work with others by doing group interviews and having them do a project together. While they work together, you can assess who are good leaders and team players. Next she asks behavioral based questions to further try to understand how they would react in real life. Then she follows up with 1:1 interviews and asks more behavioral based questions. Last she gives the interviewee time to ask questions. She looks for someone who has the potential of service excellence. Someone who is a team player and passionate about service excellence. She is always wary of someone who is overbearing though. It is difficult because you are always guessing if they are telling and portraying the qualities that you want to see, but then when actually working does not use those qualities daily. I loved participating in these interviews because now I know what it is like to be the interviewer, and it will help me in future interviews.
• Disciplinary action must be taken before firing a person, working with human resources (HR). The proper forms must be filled out. It starts with a verbal warning then leads to written warnings and contracts. Depending on the offense determines how fast the situation may be escalated. Before firing an employee it must go to HR for a committee, if the committee agrees, then the person is easily fired. If the committee does not agree, the manager has to take further action before firing a person. Luckily my manager has only had to do this a few times; when patients are at risk that is when it is escalated very quickly.

            4. Implement bedside report and evaluate effectiveness in RN view/patient view.

• (This was my goal until we couldn’t do projects any more for this class; luckily I had picked 6)

            5. Learn what preceptor likes/dislikes about being in management vs. floor nurse.

• She loves how her schedule is a lot more flexible; most of the time she is able to leave by 3ish to be able to be home with her kids. The stress is different than when working the floor, for it stays with all the time. Mostly you have more control over your day. The biggest hard thing that is different being the manager than a floor nurse is that physicians often become your biggest adversary. She has to tell them how to be compliant with Joint Commission (example: date & timing of orders, dc orders by 1000, etc). They do not see her as their equal or partner, nor staff. At times there are conflicts, and she has had to learn how best to make sure the right thing is done without burning bridges.

            6. Learn vision/plan (how to do this) for floor.

• If you can keep the staff happy, then typically the patients are happy. She tries very hard to keep the staff happy; one measure of this is the GALLOP survey. Last year the scores were not as high and she has made an action plan to help improve scores. The company’s mission and values guide what she does. She believes in service excellence, the floor’s plan/vision revolves around that. The yearly goals are set to measure our service excellence; this year the goals are unit goals. The progress will be measured by HCAHPS scores. It might not be obvious to an outside observer that my manager is definitely planning; she does it so second nature.

6. Identify areas of new or enhanced learning with each entry as appropriate.

• See entries.

7. Discuss specific classroom activities as listed in syllabus.

• See entries.

8. Journal should be reflective.

• See entries.

9. Journal will be written and shared with clinical faculty.

• I think that this is you Sean, or is it my preceptor?

Lesson 10: Conflict Resolution Collective Bargaining, Unionization and Employment Law

• In your blog (Reflective Journal), Record an example of conflict you experienced in your reflective journal and describe how you would handle the situation as a nurse manager?
•   A recent conflict occurred when training a new employee. The trainers felt that the trainee was not listening to them. The trainers were not creating an environment conducive to learning, as they got frustrated by the employee. Cultural differences were obvious. The trainee double checked with others, and it irritated the trainers. One trainer got mad because the trainee was acting outside of their scope of practice. One trainer got very upset and used explicit language.  The nurse manager then should interview all involved to complete a clear picture of what happened. The trainers need to be instructed to be patient with new trainee. Everyone is new sometime. The manager should follow up with the trainer and give them a verbal warning. If the problem persists then a written warning should be issued, and the manager and the employee should come up with a contract for how to fix the situation for the future. The manager then needs to follow up with all involved to ensure that all is resolved. The trainee needs a good environment to work in, as does everyone. The problem should be stopped before it is allowed to escalate into a bullying situation. If that becomes the case, then the bully will need to be fired.

• Reflection after reading: 
• I always thought that conflict was bad, it was interesting to read that it is not good or bad. I can now see why too little conflict creates stasis and how too much conflict reduces effectiveness and immobilizes employees. Conflict if handled correctly can promote growth. I think one of the reasons why there is an epidemic in the health care workplace of violence and workplace aggression is because of the high stress environment that health care has evolved to be. I think I often take the avoiding approach than a win-win situation of resolving the conflict. I would rather do it myself, then risk a fight over asking someone else to do it. 
• From what I have heard from co-workers have worked under unionized companies it is extremely unfair to the new employees. Everything in New York was based upon seniority. It is unfair to make the new nurses work every weekend; they also did not have proper staffing. If there was not a nurse to replace them, they were expected to stay. My company I work for does not promote unions, but does have a speak easy forum so issues can be brought to the attention administration. 

Last Clinical Update

This week was a week full of drama. I was able to witness my preceptor handle various difficult situations with the skill an experienced manager. I don't know if I would like being a manager. There is a lot of pressure for the unit to exceed in raising scores. Hiring and orienting staff can be very challenging; the staff have to accept the new staff and train them with courtesy. New protocols and procedures must be enforced; staff are resistant at times. The stress that a manager feels is different than a floor nurse. While it is very intense for the 12 hours of work, the floor nurse gets to clock out and go home. The manager never gets to pass the baton; they have to follow through.

Overall, my experience has left me with a greater appreciation for what my manager does. She is a great advocate for patients and for staff. Sometimes making the staff and the patients happy simultaneously is a challenge. She also has to try to make the doctors and midlevels happy. I don't know if I would like going into management. I struggle with why can't everyone just do their own jobs to the best of the ability. Why are some people perfectly content with doing a mediocre job? I find it frustrating that not everyone is as committed to service excellence. It is so hard because managers can create an environment conducive to motivation, but it is not all up to the manager. Motivation comes from within and you cannot force a person into a higher standard. They must choose to do it themselves.

I have learned so much and am grateful there are people willing to go into management. I am grateful for good managers for they make all the difference in the world. I may choose to go into management someday, but I think I will stick with what I know (being a floor nurse) for a while yet!

Clinical Update Week of 2/28:

I asked my manager how she hires, if she tries to keep the staff at 50% experienced and 50% novice. She stated that she usually doesn’t pay any attention to that. She just hires who she really likes. If she does not like anyone she just starts over and reports the position.

For my project I did the education on bedside report; now I get to track the results. I was so sad to see that after March 1 the mandatory bedside report date, my mini survey only had 50% doing bedside report on the am shift from 3/2. The noc shift exchange was much better. I encouraged all the shift working to do it and instructed them on what they need to chart. Then the manager was there listening in from a distance to watch people do bedside report. The couple of people that were still being resistant started giving report in the back.  My manager just went and sat in the back, and the staff left to finish with a bedside report. One nurse in particular would how much she didn’t like it, but was open. So if you are really open try it! She could not be at the staff meeting and did not receive the education, so that was her excuse. I told her that the video was in the educator’s office and that she could watch at any time. However, she did not make an effort to watch it and was resistant when report came. After a little teasing from the manager she tried it and it was not that bad. Once people try it, they usually like it, but it takes doing it to actually realize it is not this great and terrible thing. Managing is so hard! The staff often resent you, who are just the messenger telling them what corporate has made the new standards. I am a nurse on the floor, I know how hard it is to already do everything that they are asking and now you want me to do more stuff? It is very frustrating. One nurse states that she is going to retire early because it is just too hard to do everything that you are supposed to do. I often feel I want a new job because I cannot do everything they want me to. I worry about not being protected in court because I did not follow the protocol but neither does anyone else on the floor. I take good care of the patients, but my charting is crap! Nursing is a very hard industry, and I do not envy the managers position!

Lesson 9: Creating a Motivating Climate Organizational, Interpersonal and Group Communication

• Come to class prepared with Three (3) ways that could motivate nurses on your unit.
• Lead by example-set a high standard. Project positive energy & a drive for excellence.
• Create an environment conducive to the development of human potential.
• Create opportunities for high job satisfaction.
• Do not over manage!
• Fast bucks for good deeds! (Positive reinforcement)
• Charge Nurse highlights nurse in report, then give a note to that nurse explaining appreciation.
• Raises by peer evals, attendance at staff meetings, etc.
• Come to class prepared to discuss the difference between assertive and aggressive communication.
• Assertive and aggressive are not synonyms.
• Assertive communication is not rude or insensitive behavior; rather, it is having an informed voice that insists on being heard. It always a people to express themselves in direct, honest, and appropriate ways that do not infringe on another person’s rights. Uses I statements.
• Aggressive communication is when people express themselves in a direct and often hostile manner that infringes on another person’s rights. “Winning at all costs” or demonstrating self-excellence. 
• In your blog (Reflective Journal), Record your thoughts concerning motivation. Include an example of when you felt motivated/not motivated as a result of a manager’s actions. Thoughtfully record a personal career development plan.
• Motivation is one of the hardest things to achieve in management because motivation can only happen within an individual. Managers can help create situations that are conducive to motivation. I really like how my manager has a system to recognize good work. She highlights the nurses that are highlighted by the Charge Nurses during a shift by placing a note in their box. I know that these notes make a huge difference to me after an especially hard shift it helps me want to continue to work hard. My personal motivation is usually based on a personal high standard. I uphold myself to a high standard and expect others to too; sometimes I get frustrated when others are not as committed to service excellence. See my career development plan in the last post.

Clinical Update for the Week of February 21

Managers sure go to lots of meetings! If you are not in a meeting, then you might be planning one! I got to go the managers meeting. It was interesting, they have it once a month; they also meet with corporate once a month. In this meeting, we reviewed scores, the budget, and speed rounding with the axillary services. The focus this year is service excellence. I was glad it was not my first budget I had ever seen. I still don't really understand them very well. I did learn that FTE means full time employee, they kept talking a lot about that. I got to help plan and present at the staff meeting today. It had a really good turnout. I was so happy to see the nurses start supporting bedside report. Looks like the unit is matching what the literature is saying. Managers are also problem solvers. They answer lots of emails, and help the staff and patients any way they can. My favorite thing about management so far, is that it has a greater flexibility for a work schedule. However, you have a different higher stress. You are constantly thinking about your unit & what you need to do to improve it. It is not a job you clock out and not think about until you clock back in, which I suppose is good and bad. Can't wait to see what I learn about next week!

Lesson 8: Nurse Manager’s Roles and Functions in Hiring, Team Building and Staffing, Career Development Stages and Personal Career Development

In your blog (Reflective Journal), thoughtfully record a personal career development plan.

I definitely viewed my job as a job not as a career until recently. Lately, I have been trying to increase my perspective. I definitely fall into the category like most new professionals who neglect long term career plans. I have big broad ideas. I know I do not want to stay on my floor forever. There are too many things in nursing that I want to try. I have always wanted to in pediatrics; I loved my clinical experience there. Right now, I am not sure what to do with my life. I'm not married and don't have any kids. I don't have all the pieces of the puzzle right now. I could be perfectly happy, working only 1-2 days a week, so I can be home with my kids. However, I don't know if this will ever be an option for me. I have applied to the University of Utah's DNP Family Practice program. I don't know if I really want to do it or not. I know that if I have to work full time and be a real bread winner, I would not like being a floor nurse forever. There already are parts of me that desires that next step up. I would like to be a DNP either on a Trauma Team or at a private clinicians' office. However, if I get to only work a little, I don't think I would get burnt out on being a floor nurse. Right now, I am happy being a floor nurse, there is still so much for me to learn. However, it feels so stressful that I want to do something else! If I am going to become a DNP, there is no better time than now. I have applied to keep my options open. Part of me really wants to get in, and the other part of me wants to just work and buy a newer car. I do know that I have to learn to make the job that I have now, more than a job, a step on my career ladder. I enjoy taking care of patients, but I get so sick of being the middleman with all the responsibility and at times it feels no back up from the docs. Nurses are the middleman that are greatly under appreciated. The patients do not have a clue as to what goes into organizing their care, and the docs often get frustrated with the nurses because of they do not like the way the system works.

So with all of this indecisiveness, how am I supposed to thoughtfully record a personal career development plan? Here it goes... I do have mentors on my floor; there are some really good nurses on the floor that I want to be like. I have set a goal not to grumble over education pieces, but to take every opportunity to learn that I can. I do keep a professional portfolio, which contains a career statement and personal goals. I want to be a good clinical nurse, but also a nurse who cares for the individual. Thereby practicing holistic nursing and evidence based nursing. I don't exactly know where my career will take me, but I can take these principles with me where ever I go. I also want to teach nursing someday. I never thought I would, but after working with my clinical educator I knew I would love teaching. My current plan if accepted to the DNP program, is to become a DNP now and also get a teaching certificate. Thereby, I will be able to fulfill both dreams. If I don't get in, I haven't decided whether or not I will try again next year or if I will wait maybe another 5-10 years and then try again. The good news is that I do not have to decide today. My personal career plan has some holes in it currently, but I am learning and growing everyday. I may or may not become a nurse practitioner ever, but it is up to me to turn my job into a successful, meaningful career.

Lesson 7: Managing Healthcare Resources

I find that I use my time much more effectively when I am busy than when I have all day to do a project. You waste a lot less time procrastinating. I think it is very easy to fall under the traps of whatever hits first, the path of least resistance, squeaky wheel, managing by default, and waiting for inspiration instead of actually prioritizing what you need to do. Sometimes a task seems so overwhelming, but when broken down into small manageable tasks it becomes much more "doable." Often we think we are wasting our precious time by writing down a list of what needs to happen and prioritizing that list. However, in the end it will save you time, and it will help you to accomplish truly what is most important first. Prioritizing has to happen all the time. Maybe what was most important 2 hours ago, is not currently the most important thing if something else comes up, so you have to be flexible. The manager I follow, usually starts the day by trying to clear off her desk of papers that people have left for her. This helps her see what things she didn't know about need to be done. One of the most challenging things for prioritizing in management is that you are constantly interrupted.  If you feel you do not have enough time to do everything you need to do, then looking at your internal time wasters will help you know how to reevaluate how to properly spend your time.

One thing that I do not understand is that Medicare and Medicaid are the largest purchasers of managed care in the U.S, but they do not pay 100% of the bill. Why are they allowed to choose what they will reimburse? Legally you can't deny care, so the hospitals have no choice but to charge everyone else more. In reality we already are mostly socialistic when it comes to payment. A little needs to happen here...

I can't wait to ask my manager more about the budget. From reading the book it looks complicated and tricky. The three major types of budgets are personnel, operating and capital. The two most common budgeting methods are incremental and zero-based. I can't wait to see how this works in reality by following my manager more! I can see how budgeting would be stressful, for you have to do so much usually with so little!

I know I am guilty of often under-delegating. I feel bad to ask someone to do something that I am perfectly able to do myself. However, my aid cannot do everything I can do, so I do have to prioritize and delegate when needed. I have gotten better at it, compared to when I first starting being the RN, but there is always room for improvement. Delegation must follow the "5 rights" (task, circumstance, direction & communication, supervision & evaluation, person, )! Delegation for the manager is a necessity. My manager has an assistant manager and a clinical educator to help her. Often she delegates appropriate tasks to them. They also are very useful in covering for her when she is on vacation. My manager often states she is so grateful for the nursing team she gets to work with, for she couldn't do her job without them! Good management often leads the way to good teamwork.

A little side note...

Last week I took the textbook into the clinical educator and showed him the chapter about change. After skimming it, he did get some good insight. He stated that we definitely need to work on educating people on the benefits of bedside report. It was going to be very important to not allow the charge nurse meeting to not turn into a griping session. When the meeting did start heading in that direction, he was able to steer it away from that through his excellent leadership skills!

Clinical Update

Change is very hard. I was able to help present at the charge nurse meeting about the benefits of changing to bedside report. I made a poster board for it, and it will be left in the break room for more people to read. We are having a special staff meeting next week on bedside report. I also made the flier for the special staff meeting and I even made a banner last week encouraging staff to do bedside report. The charge nurse meeting was very hard because it is more of an informal meeting with very strong personalities. There was one charge nurse (one of the most experienced on the unit), who was very supportive about the change. She stated how in most of the changes she had fought now she wouldn't have those any other way, and this very well may be one of them. Another charge nurse was very discouraging and had the attitude of well they are making us do this so it doesn't matter what I think. Others were worried about the logistics of it all, but were willing to try it. I think after the meeting we will able to change the feel from complete resistance to let's try it and figure out how to make it work. It was hard to get out of the discussion mode and more into a presentation mode with it being more informal. We needed to teach people about why it was good before they could buy into it. The charge nurses are the leaders on the floor. Once we get them behind it, others will also be behind it due to the simple fact that they will follow their peer leaders. A unit must have leadership in management members but also in the leaders on the floor. It would not work without both sides. You don't have to be a "charge nurse" to be a good leader on the floor. Others follow good leaders, but that good or bad. Hopefully the leaders on the unit are also those behind you/management. Change is hard, but it can be very beneficial. We just have to not be afraid of new ideas and willing to try new things before we form an opinion about them, which can be very challenging!

Lesson 6: The Nurse Leader’s Role in Managing Change

What is your attitude toward change? Record your attitude in your blog, Reflective Journal.

No one likes change. We all resist against. But it is like the Who Moved Your Cheese? book, you can either starve or venture out into the maze in hopes of finding cheese! In health care, things are constantly changing. Often I feel, I just got one thing mastered only for it to change again. Sometimes change is for the better and other times it feels just like a major pain! Often we do not see the benefits of change until much later.  Other times it is only through statistical analysis that we are finally able to see the positive effect. As a new nurse, I feel I am more likely to be less resistant to change because I have not done it "that way" for years. Everything is new and I have to learn it. So what is one more thing to learn? But I can see how it would be very frustrating to a nurse to have to change her system after she has found a way to make it work efficiently for years only to have to learn another way.

The hardest thing about change is that usually it stretches people's comfort zones. Some people are better than others at trying new things and not getting stuck in a rut. I like consistency and have to fight the getting stuck in a rut phase! I am all for the change if I can see the positive benefits for it. I have a really hard time if I cannot see the "why" we need the change. You make me a believer of the "why," and I will full heartedly make the change.

This has been very interesting to watch in clinical. The hospital is switching to bedside report. When I first heard about it, I thought this is so stupid! It will take so much time! I hate it when administration gets an idea, and we all have to suffer! But as I have done my research I have found how beneficial it is. When I actually tried it, I realized it was really painless. I just have to get used to it.

Other nurses on the floor have had a similar response. Others are stuck in the anger phase right now. Others have been onto the denial phase, replying that they will "bite the bullet come March" (when it becomes mandatory). I think it will help once the staff meeting comes, where the reasons for bedside report can be taught. The best way to  motivate change is through knowledge. The power of education is great. This is what I was discussing with the educator. I loved reading about rational-empirical strategy because that is what I was telling him basically (the resistance to change comes from a lack of knowledge and humans are rational beings who will change when given factual info supporting the need for change). The book states that before any change can occur, people must believe the change is needed. Right now that is definitely the problem! If the educator can help people see it is needed, then we will be able to transition to bedside report successfully. I do believe that it will take a good 3-6 months (like the book says) before people start seeing the difference and truly become comfortable with the change.

I also really like how the book says that change should not be viewed as a threat but as a challenge and a chance to do something new and innovative. I want to be like that!

In my clinicals I have got to go to a lot of meetings. It is impressive to see all that the administration does to keep the hospital striving for excellence. Attending these meetings has made me more grateful for the company that I work for. I am so glad that I get to work for them! I even got to be involved in a planning meeting for a charge nurse conference. I love how much strength there is when you pull people with lots of experience together!

All my experiences following my manager has made me think more about how to take my nursing from just a job to a career. There is a real difference. Right now I treat my job just as a job. Between work and school that's how I have coped, I guess. I need to change my ways.... oh that word change again!!!

Lesson 5: Organizational Structure, Power and the Role of the Nurse Leader

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  • Discuss in your blog, “reflective Journal”, the patient care models used in the organization where you are employed. What works well in the model? What doesn’t work so well?
  •  I work under a functional method to deliver nursing care. I work in a team with a Patient Care Tech (PCT). On days, the RN is assigned 1 PCT to help deliver care. The PCT is responsible for bringing me vitals, doing I/Os, hygiene, ADLs, etc. What works well is that this is cheaper. It is nice to have to 2 people assigned to the team, to help reposition/walk often takes 2. What doesn't work so well, is if the PCT is not very good. For example, if they do not tell the nurse that a BP is low or high/the RN does not find out about it until later, which can be problematic. Overall, I really like this team approach.
  • In your blog, “reflective Journal”, Differentiate among the different types of power and identify strategies to increase your personal power base. What are your thoughts about power and how it is used? 
  • Reward power is gained by grant favors/rewards. Coercive power is punishment power,  which is based on the fear of punishment (transfer, layoff, demotion, or dismissal). Legitimate (authority) power is obtained by a title or official position within an organization. Expert power is power through knowledge, expertise, or experience. Referent power is gained when others identify with that leader or with what that leader symbolizes. Charismatic is personal power. Informational power is gained when people have information that others must have to accomplish their goals.  Self-power (feminist power) is the power a person gains over his or her own life, which comes from maturity, ego integration, security in relationships, and confidence in one's impulse.
  • The five driving forces to increase nursing's power base are: timing, size of the nursing profession, increasing knowledge base and education for nurses, nursing's unique perspective,  and desire of consumers and providers for change. Strategies to increase my personal power base include stop acting like a victim, build coalitions within and outside of nursing, support nursing leaders, pay attention to mentoring future nurse-leaders and leadership succession, and promote greater research to strengthen evidence-based practice. Personally I can maintain my personal energy, increase professional skills and knowledge, use experts and seek counsel, be flexible, maintain a sense of humor, empower others, & learn the language and symbols of the organization.
  • I have a hard time under an authoritarian power. I need to know the why before I am willing to follow. I do not do well under the I told you so regime. I need a manager who is good at empowerment; luckily my manager is!I thought that the struggle over power is a major cause of burnout in the nursing field. The power struggle is between the doctor, the nurse, the patient, and time. They often conflict at times. The best way I can increase my power base is to number one have confidence in myself, two stay up on my education, three laugh when it becomes overwhelmingly stressful, etc. No one thrives when they feel complete suppressive power. The best to increase your power/confidence is by empowering others. It will also build you up. Power hungry people often eat up power unnecessarily. Power must be used appropriately!!!
  
  Clinical Update:
  
  Started my clinicals this week. I got to sit in on interviews and help pick who to hire. It was very difficult but a good experience! I do not envy the manager's job of hiring! I also got to see how she forms schedules and comes up with the masters. We also got to play around with schedules to try to work up to the employee's ideal schedule.

Lesson 4: Operational and Strategic Planning, CH 7

I wonder how many nursing managers are good at planning. Do they really plan out things or are they mostly reactive to problems? Do they have a long term vision for the floor? Where do their goals come from? I'm sure  a lot of goals come from trying to improve patient scores.  Planning evolves from values. I had never thought about a true value vs. a value indicator. I bet many people's "values" are really value indicators due to not actually actively living the value. Again, the things in the text make perfect sense in textbook land, but how are they really applied in the real world? It will be interesting to follow a manger and see....

Ethical Decision Making

I think we often come into situations where we face with ethical dilemmas without really realizing that they are.  The most common practice of unethical behavior that I see on a regular basis is doing things without an actual order. Usually it is simple things, and things that the doctor would not care about, but you don't have an order for one so the nurse either just writes one, or just provides it to the patient. Have I done this? Of course, but mostly for very simple things like ordering a CPAP/patient uses one at home and RT won't allow it without an order. But where do you draw the line? I've had patients slipped a dose "contraband tylenol" after a fever of 38.8, in reality the doctor should have been called, but the night nurse did not want to disturb the doctor's sleep. Or another...the doctor admitted a Same Day surgery patient for observation for possible pain control problems and did not order their home meds, the night nurse told the patient just go ahead and take your normal medications. One of which was Kadian (basically oral morphine), so the patient did have good pain control. So what is the problem? Number One..no doctor order, and patients are not allowed to take their own meds without pharmacy reviewing them. The nurse is then practicing medicine by telling the patient its okay to take her medications. Number two: The medical record has no record of her taking her any medications. Number Three: The scheduled substances should be locked up down in pharmacy. Now have I ever looked the other way when a patient wanted to take a home med supplement that we don't carry and is not ordered, sure but this seems over the line. Ethical decisions often may have no right answer, and what is best varies from person to person. Why are we so scared to call the doctors? That is our job. We are the patients advocate, and should follow protocols or we cannot be protected in court. Ethical decision making happens everyday on the job...whether we choose to recognize it or not.

Lesson 3: Ethical and Legal Responsibilities and the Role of the Nurse Leader as Advocate

So it appears that complaining actually works! Well sometimes... Blackboard has decided to give me 2 sections right now so currently I can view the modules!

Well, these chapters were not particularly insightful (maybe it was because I read them while waiting for my mom's surgery to finish or maybe because they are blah blah blah).  I've taken an Ethics & Values, so it wasn't really anything new.  Theories are great, but in the real world I have a hard time seeing how they are actually used. Usually what I see in practice is the managers personal values applied in action. In general, I think the values match that of the company, but if this were not the case then problems would result. If it were simple, then we would not be discussing it in class. Life is not black and white, there is a lot of GRAY! And what is right and wrong changes according your standards/values.

One of the most challenging things for the nurse leader is that they are responsible for the actions of others, but do not often have very much control of the actions of others. The fear of being sued is always at the back of everyone's mind. In text I think utilitarianism is the best method, but when actually applying it is difficult.  For what creates the best common good is not always agreed upon and who wants to be the individual that gets the shaft for the greater good? I loved what we talked about in class, it is not best to try to be fair (as it is impossible), but to strive for consistency (hard to do but the best policy!). Sometimes what is most ethical is definitely not the best legal option (like the case study of allowing the life partner at the  bedside when she had no legal authority to be there). I think often managers are faced with many decisions that need to be discussed at length (for 2 heads are always better than one), but often are left to make the decision quickly by themselves. One of the best ways that manager's are effective in ethics & legal responsibilities is by being an advocate for patients, subordinates, and the organization. They help make policy decisions that have a great affect. Keeping the perspective as an advocate helps guide good decisions. It is easy in a manager position to forget what it is actually like on the floor. One day my manager had to take a team on the floor, she laughed and said that she thought all managers should have to do this! But don't quote me! Maybe that really would yield the best management!

Technical Difficulties...

SO it sounds like we get to start 2011 off with lots of problems... Clinicals are difficult to set up. The book store is out of books, fortunately I do have one. But I did end up buying an extra book since it was listed in book match, but it is not on anyone's syllabus... guess doing things early sometimes bites, but works out at other times... Blackboard hates me... every time I try to be good and want to look at the modules and actually stay caught up; it disappears! So I was going to blog about what I read from chapters 4-6... ethics in management... but i can't get in to see the questions... so hopefully things will start improving after a good complaint!

Lesson 2: Successful Leadership and Management

There are many styles of leadership and management....

I think that is is very important to be an authentic leader. Without authenticity, how can the employees ever be expected to also uphold the values of the company?  If the values of the leader are not congruent with the company, then problems definitely will result.

I think it would be hard to always be a good transformational leader, but it is very important to look beyond the day to day to the future with a vision of where the unit/company is going. Most employees I think are on the transactional level, but need to be brought up to the transformational level; the manager is the key person who can lift them up to that level.

Managers are not always good natural leaders, but leadership is a necessity to be a good manager. My favorite leaders are servant leaders.  Just knowing that management has your back and is willing to help you however they can helps to boost the morale of the employees.  Sometimes my manager cannot do anything to help me, but just having her ask me if there is anything she can do for me helps me get through a crazy shift.

I do not work very well under an authoritarian leadership style.  Just because you are the boss and you say it is that way is not motivating for me.  I have to  know why ... changes are needed.  If I understand the importance, then I will follow completely. 

I think some people have very little emotional intelligence, but understanding emotional intelligence is a very important characteristic in the workplace. 

Management can be key player in the role of cultural bridging.We definitely have generational issues.  The younger generations have an attitude of entitlement, which does not mesh well at all with the older generations. It is also damaging to the company when they show little patience with difficult clients. 

Thought leadership is very intriguing to me; by being an example of how risk taking and vision leads to innovation and others then can follow suit by example. Intermountain  Health Care is a good example of a company set upon good thought leadership. We need more thought leaders in the world.  Quantum leadership although a new theory, has clear application as management/environment definitely have an impact on productivity.

The future of nursing is dependent upon good leaders and managers. Health care has changed and will continue to change as it adapts to its needs.  The guarantee for good outcomes always starts with good leaders and managers with extraordinary vision.