April 12, 2010 Class Discussion

Terminating an employee is never a pleasant thing to do. In order to make the best of a bad situation the employer should be prepared.

1. Arrange for a private meeting with the employee who is being terminated.

2. Calmly state the reason for dismissal without giving the employee hope for negotiation and be prepared to give examples of the behavior the employee is being terminated for.

3. Explain the termination process and the exact date the termination will take place.

4. Allow the employee time for his/her input without being wavered.

5. End on a positive note. If possible allow the employee to leave the company immediately to avoid embarrassment and demoralization of the other employee's.

April 5 class discussion

When I receive health care the thing I consider to be quality care are being seen in a timly manner or at least being informed about the extra long wait. A physician who listens and address all of my concerns even the dumb ones. I consider a physician a good physician when he/she knows when to refere me to someone else more qualified to address a particular problem that he/she may not be as well trained in, know it all's do not usually know it all and make mistakes. I also appreciated when one of my childrens physicians said I do not know let me go look it up and returned to the room with the book and information in hand. I have not been in the hospital for anything but having my children years ago, but the care I would expect there should be the same care I provide to my patients.

As a profesional I believe quality care should include respect, promptness, knowledge, knowledge of limitations, how to find out what is not known, attention to details; even the small ones like trash on the floor, patients, kindness, good listening and assessment skills, and the ability to work as a team memeber.

The two are similar we should not expect more than we are willing to give nor should we give less than we want to receive.

March 29 class discussion

I had to think hard to come up with a conflict I was involved in at work because I have not really been part of a big conflict. After pondering for a long time I did remember a conflict I was part of by default.

At the time we did not have specific charge nurses at night the house supervisor would decided who would be put on call and anybody willing would make the patient assignments. I happen to be one of the most experienced nurses working one night so by default I was elected to make the assignments. I evaluated which nurses were coming on and compared them to the patient load and acuity. An LPN was scheduled so I made sure to assign her patients that did not have IV medications. When the day nurses arrived and received their assignments one of the nurses switched her assigned patients with the LPN's patients because she did not want the patients she was assigned. When I explained to her why I had assigned the LPN her patients her response was that is okay I would rather give all of her IV meds for her than have the patients you assigned me. Not really being in charge or having any authority I let it go.

Later I learned that this particular nurse among others often change their assignments around.

If I was the nurse manager I would take time in a staff meeting to explain how assignments are decided upon and that they are not just random. I would make it clear that the nurses are expected to take the assignment they are given unless their is a clear conflict involved. Not wanting to change briefs is not a reason for decling assignments. If the problem continued amoung the few repeat offenders I would make an appointment with them to discusse the problem in private.

March 22, 2010

Class discussion on motivation

Monday's class discussion was enlightening. I discovered something about myself that I had not really considered before. I am usually motivated by positive reinforecment. for example, when someone one tells me I have done something well I try to do better in other areas to ensure continued approval. Another example is if someone puts trust in me to accompish something I will work hard to do a good job.

But guess what. When I want my kids to do something I use negative motivation. For example, I will tell them if you do not get your homework done you will be grounded from video games for a week.

I have set a goal to try using positive motivation with my children, if I prefer positive motivation maybe they do to.

March 15 class discussion

Personal Career Development Plan

• Finish BSN program
• Cross train to the pediatric unit
• Obtain PALS certification
• Apply for clinical supervisor position
• Take advantage of non-formal educational opportunities
• Be open to opportunities that may arise
• Participate on various committee's
• Revise plan as needed.

March 1 clinicals 0900-1600

WHAT: I taught the skills labs again. Employees where told that the labs would take 6 hours. The labs would go from 0900 to 1800 so in order to complete all of the labs they would need to start no later than 1200. Most of the employees waited until 1100 to show up so I had some down time.

SO WHAT: I did some homework. The same thing is happening today and that is why I have some time do be bloging right now.

NOW WHAT: I think I will suggest that employees be assisged a specific time slot so that we do not have the down time that nobody is here and then get a rush. If 5-10 people are assigned at a time every 30min, which is the average time each lab took, the time would be used better.

March 1, Chapter 8 Planned Change

What is my attitude toward change?

I am a creature of habit. I like to have a routine it helps me feel like I know what I am doing and have some control.

Although I am open to changes, especially if the change will make an improvement to the given situation, I do have a hard time adjusting to the change and working it into my routine.

An example of a change at work that many of us are forgeting to do is our shift change hand off. We have been asked to go into each room, say goodbye, and introduce the new person who is replacing you. This change has been in place for several months and we still forget. For me it is just remembering to make it part of my routine.

In the reading I read that most changes will take six months to be fully accepted and everyone compliant. I see this in our shift hand off. Little by little more and more of use are remembering more often to do the hand off, but is taking a while for everyone to adjust.

I do agree with the reading that changes are easier when everyone has some input and the reason for the change is clearly understood with the benifits clearly outlined.

Clinicals February 26th 0830-1700 skills day

WHAT: This was my first day teaching at our hospital skills day. I was very nervous because I knew I would be teaching charge nurses, house supervisors, clinical supervisor, nurses who have been praticing for several years as well as some really great new nurses.

SO WHAT: So what was what I kept trying to tell myself to help me not feel so nervous. So what if they have more experience than me they had to start somewhere too. So what if I am nervous I have survived presentations in class. My so what statements only helped for the brief moment I was thinking them. I was still nervous.

NOW WHAT: Now that my first of three teaching sessions is over. I can honestly say that I am not nervous for the other two teaching days. Everyone was kind. They listened and asked questions, they even acted like they learned something new. I was asked a few questions that I did not know the answers to, but I am looking up the answeres and going to get back to those who asked them.

Chapter readings for February 22
Organiztional structure, power and the role of the nurse leader.

Chapter 13 discusses eight different types of power.
1. Reward power is the ability to grant favors or rewards for their employees to work toward.
2. Coercive power uses fear as the motivator for meeting goals set by managers.
3. Legitimated power is the power gained by a position or title
4. Expert power is gained as knowledge is gained
5. Referent power may be obtained by association with others who have power.
6. Charismatic power is a personal power
7. informational power is obtained when someone has information that other people need.
8. Self power comes with maturity, ego, security in relationships and is gained as a person gains control over his/her own life.

My thoughts about power are that it is good to be well rounded and have some of each of the diffferent types of power to draw from. I think that gaining knowledge, surrounding your self by others who have power, having information that others need, being charismatic, having control over your own life, and being able to recognize others contibutions and reward them for those contributions is what makes a good leader. Coercive power is the least effective for building good relationships with coworkers and family members. Unfortunatly coercive power is what I use too much in my home. For example do your homework or you will be grounded. It may work but nobody is really happy.

I am looking forward to working on increasing my personal power base especially in the self power area. For the past 7 years I have felt like instructors, homework, and time at school have been controlling my life not me. I plan to take my life back by spending more time with my family helping them with their homework not doing mine, and building relationships with them again. I can not wait to have time to plan menues and prepare healthy meals again. Having time for exercise again so I can feel better and think more clearly. I feel that as my self power increases I will be able to increase my confidence and build power in the other areas. One must care for themselves before they can care for others.

Clinical hours 2/11/10 1300-1430 and 1700-0230

WHAT: From 1300-1430 I attended a meeting with my manager and other RN's who will be teaching at the skills labs

SO WHAT: We discussed how to organize the day including how much time would be avaiable for each station. We rescheduled the days for the skills labs. The new days will give the manager time to schedule each RN and education day to attend the skills lab, this will hopfully maximize attendance. The new days will also give those teaching more time to prepare.

NOW WHAT: Now I have more time to do more research and prepare more. I also feel better about how the skills lab day will be presented.

1700-0230

WHAT: I returned to clinicals to meet with my instructor and mentor. I also did an experiment on the PCA pump to determine how long the pump will infuse before it resets. I also did some research for my project. By 0230 I was tired and the hospital had quieted down so Deb sent me home.

SO WHAT: The clinical objective learned was delegating. The PCA pump experiment was delegated to me. By delegating this task to me the supervisor was able to attend to other needs. The ability to delegate is an important skill to have as a supervisor. When someone takes on too many task they usually do not get accomplished to the maximum benefit.

NOW WHAT: I will work on my delegation skills. I do not use my CNA's like I could mostly because I enjoy patient care for example getting the ice water, warming heat packs, offering snacks, ets. When I do all of these things instead of asking my CNA to help I usually get behind on my charting, which is my least favorite part of nursing, therefore my charting is usually not as good as it should be.

February 8th class reading and discussion

1. How does the philosophy of your employer's organization differ from your own?

Timpanogos Regional Hospital mission statement and vision is: Above all else, we are committed to the care and improvement of human life. In recognition of this commitment, we strive to deliver high quality, cost effective healthcare. Timpanogos Regional Hospitals values are: Commitment to patients through compassionate care, clinical excellence, continuous improvement, and cost efficiency.

For the most part I agree with this philosophy. The only part that I sometimes have a hard time with is the cost efficiency. I feel like sometimes there is too much emphasis in this area and patient care suffers. Nurse staffing for example seems to be one of the first things cut back on. When nurse staffing is cut back the patient to nures ratio is higher and nurses have less time with each patient. Patients often interperate this as being less compassionate and caring which defeats the other value of compassionate care.

2. How is your employer's philosophy the same as your?

The parts Timpanogos Regional Hosptials philosophy that is the same as mine is the commitment to the care and improvement of human life, compassionate care, clinical excellence, and continuous improvement. As an Registered Nurse at Timpanogos Hospital I strive to always give compassionate care to all of my patients. I also strive to make improvements in my nursing practice by seeking advice from mentors and participating in educational opportunities when even I can.

3. Where are the areas of conflict and how do you resolve them?

As stated earlier the area of conflict for me comes when cost efficiency involves nurse stafing. On my unit we are working with our nurse manager reguarding this issue by offer suggestion for her to consider. We will see how it turns out in a few months.

February 1st reading on advocacy

Advocacy is speaking up for a patient when they are not able to speak for themselves.

I have not been in a situation where I have had to be a big advocate for a patient, but I have had several small expereince of little things I have done. Sometimes I think that as nurses doing our jobs we do not think that the small things we do every shift count as having been an advocate. For example every shift it is my job to do chart checks. These chart checks include reviewing the patients medications and making sure there is an order for each medication on the patients E-MAR. I also check to make sure that all orders for labs and any other test have been ordered, and that any other orders for the day have been compleated. A patient can look at their chart if they want to but because they may not understand all of the medical jargan it would not make sence to them. Therefore I feel that this simple part of my job is being an advocate for my patient.

Another time when nurses are being advocates and may not think much of it because they do it all of the time, is when we call the doctors. For example when our patients are not getting their pain controlled and there is a need to try something different. The patient can tell you about their pain but they can not call the doctor, and most patients do not have the knowledge about pain medication to know what to ask for.

I know that somtimes as a night nures we will debate about calling a doctor because sometimes they are just so darn cranky when you call at night. This is an area that I can improve on. Just because the doctor is cranky our patients should not have to suffer in pain all night.

Clinicals 1/28/10 - 1/29/10 1800 - 0700

WHAT: I learned a little about the budget and staffing. I do not know if I can really explain it, but I will give it a try. The staffing budget has actual dollars involved, but that is not really what is looked at. What they look at is the census. The manager is allowed to have a certain number of employees per patient, but she does not have to worry about what wage each nurse makes. If all of her top payed nurse are scheduled and the census justifies the need for the number of nurses on it is okay. Employees are allowed to be scheduled an extra shift if they want but if the census is not high enough they are the ones who will be called off first then part time employees next.

The rest of the time I worked on my project. I got all my signs made and put up around the units and made my poster. Now all I have left to do is the teaching. I hope that counts for clinical hours so I can be done following Deb like a lost puppy. Just kidding she has been good.

SO WHAT: The clinical objective I meet was budgeting. I was also able to meet one of my goals. the goal was to learn what the budget is and how it affects staffing.

NOW WHAT: I feel better now about staffing and the budget because I understand that the census plays a bigger part in the decision making than just the money. Of course there could always be more money allowed per patient to keep the patient nures ratio down. That would probably be to much to ask for.

Clinical 1-27 -10 - 1-28-10 1800-0700

WHAT: Deb and I discussed a project I could do. The project we came up with was to research urinary catherter aquired urinary track infections and how to prevent them, then teach my findings at the skills labs in February. Medicade's new law that they will no longer pay for hospital aquired UTI's is what inspired this project.

NOW WHAT: I obtained a copy of a prevention reminded on catheter care and made copies and hung them on the doors of the break rooms and bathrooms for all staff to see. I worked on my teaching posted. I will do more research and continue preparing for the class.

SO WHAT: The goal I meet was to have a project. This project is important because reseach shows that a hospital aquired UTI increases a patients hospital stay as well as increased risks for furthur complications and even death.

Chapters 1-3 thoughts

I have learned about the three main management styles, authoritarian, democratic, and laissez-faire, but I had no idea there were so many different management theories. I was relieved in class when our instructor Dena said she was mostly concerned with the three main styles because I know I would never be able to remember all of the theories.

I see myself as more democratic to laissez-faire because I always like to get other peoples opinion and have my idea confirmed as a good one. But I do not like confrontations so I find myself saying whatever a lot to unless it is something I really feel will would be a big mistake if not done my way. I call it choosing your battles wisely.

Clinical 1/24/10 - 1/25/10 1800 - 0700

WHAT: A rapid response was called. A patients o2 sats were droping and he was having a difficult time breathing. The nurse was concerned about him. The respiratory team, Deb the house supervisor, the clinical supervisor for the floor came. It was good to watch how they all work together asking questions to the patient, nurse and the family about how the patient had been when he began having trouble ets. Respiratory quickly drew blood gas levels. a non-rebreather mask at 10L o2 was placed on the patient. Chest x-rays were done. All of this was done quickly and smoothly and the patient reported feeling better with just the O2.

SO WHAT: The clinical objective I learned was analyzing and managing resources. The patients status was analyized using his family, the RN, clinical supervisor, house supervisor, and respiratory therapist as resources.

NOW WHAT: I learned what a great resource rapid response is any time you are concerned about your patient. And that we should probably use it more often.

Clinical 1-21-10 - 1-22-10 1800-0700

WHAT: When I arrived at clinical Deb had been frantically working on staffing. She had gotten there and there was a note from the executive secretary asking her to do all of the staffing for the whole hospital for the 1800 shift. She was just finishing when I arrived.
After all of the placing people on call at the beginning of the shift nurses had to be called in. A doctor called to have his pediatric patient admitted. The problem is that we did not have any pediatric patients so the unit had been closed. Deb had to call in two nurses because our policy is that one nurse cannot be on peds alone.

And of course the usual stuff: rounds, blood draws, problem solving, and helping out where needed.

SO WHAT: One of my clinical objectives was to learn how the staffing is decided for the morning shifts because that is Debs job, but since she had been doing for the night and it is the same she went over what she had done with me so I could complete my goal. The patient census is the deciding factor for how many nurses will be needed. Who gets put on call is determined by part time or full time status, with part time being called off first.

NOW WHAT: Staffing is a big job and can take a long time. I know Deb starts early in the night getting the census so she can figure staffing for the morning because she gets interupted a lot. I will not complain any more.

clinicals on 1/19/10 - 1/20/10 1800 to 0700

WHAT: Deb taught me about interqual reports. Interqual reports are done on all new admits as soon as possible. The interqual report is then given to a case manager who uses the report to determine if all criteria has been meet for the patients admit. If the criteria is not meet the insurance and medicaid will not pay for the patients hospital stay. The report has to include the admit diagnosis, vital signs on admit, if patient is a medicade patient, and of course the patients name ets.

Some other cool stuff she did was fix the elevator. When they said nurses do everything they were not kidding.

She also had to make sure that respiratory and other staff was available for twins being born with possible low apgare scores.

She was called by a med/surg nure to look at a picc line. The patient said that it was hurting and and she could feel the line. I have never been able to feel a line, but this one you could feel, it was very superficial. The line had just been put in that day it was drawing and flushing fine. Deb said it would be okay and had the nurse put a warm pack on it and given something for the pain.

Deb was called to help with lab draws. She is really good at the hard sticks, I have called her to help me on occations. If the patient had not already been pocked so many times I would have tried, but I have compassion on patients and know that Deb usually gets it her first time.

SO WHAT: One of the clinical objectives meet was organizing. Deb made sure that everthing and everone was organized and ready for the birth of twins. I was also able to complete one of my objectives which was to learn about the interqual worksheets.

NOW WHAT: Organizing is not just making sure you can find things when you need them it is making sure everone and everything is in place in the event they are needed. I have now made a sticker for the back of my badge that has the phone numbers of who I might need for example: lab, clinical supervior, house supervisor, pharmacy, respiratory therapy, and rapid responce. This way I can call them without having to go back to the nurses station to look up numbers not yet memorized. I feel more prepared and organized now.

clinical

Clinical on 1/13/10 to 1/14/10 1800 to 0700

WHAT: I met with our night house supervisor and ask her if she would be willing to let me follow her for 90 hours. She agreeded and asked if I wanted to start right then. I let my family know I would not be home untill the morning and started my clinical hours. I am glad my instructor approved my plan or I would have just wasted 13 hours. I guess it was not wasted I did get a feel for what she does.

We did a lot of running around getting material and supplies for the different units. I even got to go buy diapers for our pediatric unit because we were compleatly out in the whole hospital.

We made rounds and checked on all of the units to see if they needed anything.

It was a pretty calm night. I hope next time we have some admits so I can accomplish one of my goals.

SO WHAT: Well since I am editing my post I thought this might be a good place to put that I was able to accomplish my goal of learning how bed assignments are made for admits. Fist the patients diagnosis and aquity level is evaluated. Then staffing is considered. For example if a patient has a stable medical diagnosis that did not require the ICU the medical unit under the med/surg umbrella would be considered. It the medical unit was full or there was not enought nurses to cover the additional admit another unit may be considered. If the diagnosis is not contagious and the staff and room is avaiable the patient may be admitted to the orthopedic unit. If the patient must be on the medical unit a nurse will be called in even if it is just for one patient.

NOW WHAT: Sometimes I have complained about getting a medical admit when I was working on the orthopedic unit. Now I have a better understand of when and why they do it I do not complain. After all we can not turn a patient away just because our 12 medical beds are full.

Nursing Leadership

I have no idea how to blog. My nursing instructor is making me do this. I hope this is what I do.