Leadership Final Notes

Legal:
Ethical:
Cultural:
Delegation:
Other terms to know:
Primary Nursing - Pg. 33, Chapter 3 - in primary nursing, the RN maintains a
patient load of primary patients. A primary nurse designs, Implements, and is
accountable for the nursing care of patients in the patient load for the
duration of the patients stay on the unit. Actual care is given by the primary
nurse and/or associate nurses, (other RNs) - (In other words primary nurses
Will usually be assigned the same patient every day of every shift they work
until the patient is released to go home. This primary nurse creates the
plan of care for this patient.)
Team Nursing - Team nursing is a system that distributes the care of a
patient amongst a team, that is all working together to provide for this
person. (Wikipedia) (In other words, team nursing includes an RN, an LPN
maybe, a PCA/PCT or CNA.)
POD Nursing - Pod nursing is defined by two key characteristics: a division of
one nursing unit into a number of substations with geographic proximity to
patients; and patient assignments that specify a pair of nurses to deliver
care in a team-based approach.
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3968792/) according to miss
Mahoney this type of nursing is considered difficult. Another example of pod
nursing is NICU.
DRG's - diagnosis related groups - a program in the U.S. for billing for
medical and especially hospital services by combining diseases into groups
according to the resources needed for care, arranged by diagnostic category.
A dollar value is assigned to each group as the basis of payment for all cases
in that group, without regard to the actual cost of care or duration of
hospitalization of any individual case, as a mechanism to motivate healthcare providers to cut costs.
(http://www.medilexicon.com/medicaldictionary.php?t=38626) (in other
words, a DRG categorizes diseases into special groups which tell them what
kind of supplies they need for that disease and how much that disease is
worth as far as cost to them based on payments they have received.)
Clinical pathways - Clinical pathways, also known as care pathways,
critical pathways, integrated care pathways, or care maps, are one of the
main tools used to manage the quality in healthcare concerning the

Leadership Final Notes

standardization of care processes. (In other words, clinical pathways are
standardized evidence-based multidisciplinary management plans, which
identify an appropriate sequence of clinical interventions, timeframes,
milestones and expected outcomes for any patient within a homogenous
group such as: DKA patients, Open Heart Surgery/Valve Replacement
Patients, etc. Their care will usually have a protocol to follow and hours or
days of how they will be expected to recover after interventions.)
Pareto & Controls - 80% of rework costs come from 20% of possible
causes. The Pareto principle is one of the most powerful decision tools
available. Among the data that can be plotted on Pareto charts for nursing
services are wasted time, number of jobs that have to be redone, customer
inquiries, and number of errors, accidents, incidents, infections, and
complications. When constructing Pareto diagrams, place the most frequent
cause on the left and arrange the remainder in descending order of
occurrence. The impact on the system becomes obvious, as does the priority
for fixing it.

Chapter 21

Magnet recognition program - recognition by the American nurses

credentialing center that an organization provides quality-nursing care.
o Promoting quality in a setting that supports professional practice
o Identifying excellence in the delivery of nursing services to
patients and residents
o Disseminating "best practices" in nursing services
It is said that patient safety is improved when nurse staffing meets
magnet standards
These types of systems involved participatory management and
shared governance.
This type of atmosphere creates organizational environments that
reward decision-making, Creativity, independence, and autonomy.
Organizations that empower nurses to make decisions for better meet
consumer requests.
At the healthcare environment continues to evolve, more and more
organizations are adopting consumer sensitive cultures that require
accountability and decision-making from nurses.
Common characteristics of a magnet hospital include:
o Higher ratios of nurses to patients (like 2:1 2 patients for every 1
nurse vs 5:1 (5 patients for each nurse)
o Flexible schedules

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o Decentralized administration (meaning administration is not in
one location, the authority is redistributed to many areas)
o Participatory management
o Autonomy and decision-making
o Recognition
o Advancement opportunities
Chapter 22
Types of emergencies
Natural disasters
Man-made disasters
Floods, hurricanes, earthquakes,
Accidental - structural collapse of
Landslides and mudslides, wildfires
buildings or bridges; industrial spills;
Power outages
Epidemics and pandemics (influenza, Intentional - explosive or incendiary
the Ebola virus, AIDS, Antibiotic
device; sniper or mass casualty
resistant bacteria, SARS, H1N1)
shootings; release of toxins
(chemical, physical, biological,
radiological, nuclear)
Arson fires

Natural disasters - any disaster that is not man-made such as floods,

Hurricanes, tornadoes, volcanoes, heat waves, and blizzards.
o Location is the key element in preparing for natural disasters
such as with hurricanes and coastal areas, like the Mississippi
River towns to prepare for flooding and planes of vast land
should prepare for tornado disasters.
o Health disasters are also natural disasters. Epidemics of disease
that can spread rapidly through the population and pandemic
that spread disease around the globe are health disasters.

Man-made disasters - can be accidental or intentional.

o Industrial hazards, structural collapses of buildings or bridges,
and power outages are examples of accidental hazards.
o Subways, sports stadiums, and airplanes may be attacked.
Chemical, physical, biological, radiological, or nuclear toxins may
spread to the population causing illness and death. Anthrax, a
bacterial toxin, and asbestos, a physical toxin, are examples of
poisonous substances that can cause environmental disasters
which may fall under accidental or intentional.

Levels of disasters (Level III being the worst)

a. Level I: local level response and containment suffices
b. Level II: regional level response is necessary
c. Level III: State wide or national assistance is needed

Leadership Final Notes

Mass casualty incidents (MCI) - can be defined as an incident that has

produced more casualties than a customary response assignment can
handle, such as: Multi vehicle collisions, collapsed buildings, Mass
transit accidents (plane crash, train crash, etc.), Hazmat 911's, CO 911,
mass shooting victims, chemical exposure, weapons of mass
destruction, (WMD).

Disaster triage - similar to the triage system used by the military in war
situations, Hospitals must reverse their usual triage method of treating
the most seriously injured person first. Instead, they must prioritize
scarce resources to those who can benefit the most. The simple triage
and rapid treatment (START) System is an example. The goal is to treat
as many injured people as possible in the shortest time possible.
Because of time parameters police areas injured it's first before the
most seriously injured.

THE EMERGENCY OPERATIONS PLAN (EOP) - includes preparation,

education and training, and implementation of the hospitals response
to emergency situations.

THE NATIONAL EMERGENCY PREPAREDNESS EDUCATION COALITION

established core competencies for nurses to prepare for mass
casualties. These include: Critical thinking, Assessment, Technical
skills, and Communication.
o Critical thinking - Because most casualties may inundate the
facility, the triage system is reversed, nurses should be able to
prioritize, demonstrate clinical judgment, and make decisions
(which are key to successful emergency responses.)
o Assessment - include self-assessment and situational
assessments; patient assessment includes physical injuries as
expected, but also emotional injuries and family assessments.
During a disaster such as SARS, the hospital may become
inundated with psychological casualties or people who think they
have the symptoms. Triage must decide how to address and treat
these casualties as well.
o Technical Skills - in addition to therapeutic skills, nurses must be
able to implement appropriate therapies, arrange for
transportation, maintain patient safety during the incident, Etc.
The nurse must also be aware of hazardous substances, and
isolation techniques necessary such use PPEs
o Communication - when dealing with mass casualties,
Communications within the hospital and with local officials is
essential. A system to track patients rather stay is necessary for
staff follow-up to their families can be kept informed.

Leadership Final Notes

Epidemic - a widespread occurrence of an infectious disease in the

community any particular time.
Pandemic - a disease public over a whole country or the entire world,
an outbreak of a pandemic disease.
Chapter 23

Workplace violence - is any violent act including physical assaults

and threats of assault, directed toward persons at work or on duty.
o Most assaults and healthcare are by patients, But attacks are
also made by disgruntled family members, coworkers, Vendors,
employers, or even colleagues.
Violence includes:
o Threatening actions such as waving fists, throwing objects, or
threatening body language
o Verbal or written threats
o Physical attacks, including slapping, hitting, biting, Shouting,
Kicking, Pushing, beating
o Violent assaults, Including rate, Homicide come and attacks with
weapons come Such as knives, fire arms, or bombs
Incidents of workplace violence in healthcare occurs more often than
any other workplace settings.
Consequences of workplace violence- violence can range in
intensity and caused physical injuries, temporary or permanent
disability, psychological trauma, or death. In healthcare, violence is
more likely to occur in psychiatric settings, emergency rooms, waiting
rooms, and geriatric units, while clinics are reported to be less likely
sites of violence.
o In addition to harming employees violence in the workplace can
affect worker morale, Increase staff stress, cause a mistrust of
administration and may exacerbate a hostile work environment.
o Furthermore absenteeism and turnover are expensive, and the
organization may incur additional health costs for care of
insurance for injured workers.
Factors contributing to violence and healthcare - working with the
public carries with it inherent risks, and the added stress by staff,
patients, and families in healthcare settings increases that risk.
o Hospitals have an "open door" policy from visitors. Visiting hours
are not restricted, and visitors are often not required to check-in
when they enter.
o Patients with head trauma, seizure disorders, dementia, alcohol
or drug withdrawal, or who are homeless may lash out in
violence.

Leadership Final Notes

o Crime victims in the perpetrators might be admitted to the same
hospital, and gang violence could spill over into the hospital.
o Family members stress and fear as well as long waits can
contribute to the possibility of violent actions
o Absence of visible, armed, and adequately trained security
personnel may make the settings less secure
o Additional risk factors for potential violence in healthcare
organizations include:
Working understaffed, especially at meal times and visiting
hours
Long waiting times
Overcrowded waiting rooms
Working alone
Inadequate security
Unlimited public access
Poorly lit corridors, rooms, and parking lots
Preventing violence
o Zero tolerance policies - healthcare organization should cultivate
a culture of intolerance to violence and set its violence
prevention policies to reflect that position. Appropriate
personnel policies must stay clearly what Will happen if violence
or the threat of violence occurs
Policies regarding patients and visitors must do the same;
specifically anyone who becomes violent or who exhibits
threatening behavior must be removed from the settings
and the authorities contacted.
o Reporting and education - employees must be educated to
recognize the warning signs of violence and potential assailants
agitators come and be taught conflict resolution skills and deescalation tactics. They should also be a T use care when storing
health instruments (stethoscopes, Hemostats, and scissors) as
these could be used as weapons. Once policies are in place,
employees must be informed about them so that they are
prepared in case of an eventful crisis. They will also need to
know how report and who to report to as well as how to
document problem situations. Employees should be reassured
that reporting threatening behavior will not result in reprisals (act
of retaliation).
o Environmental controls - the organization should institute
environmental controls to ensure patient, Visitor and employee
safety. These include:
Adequate lighting

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Security devices
Bullet resistant barriers in the emergency department
Curved mirrors in the hallway
o In addition, Safe work practices should be implemented such as:
Escort services
Adequate staffing
Judicious use of restraints or seclusion
A learning staff about patients with histories of violent
behavior, dementia, or intoxication
Dealing with violence
o Verbal intervention - verbal threats often preceded physically
violent event; bus Colin please need to know technics for
reducing aggression and people who are making verbal threats.
When faced with a potentially violent situation, try to keep
calm even with another person screaming threats or abuse.
Try to get the person away from others. A crowd might
encourage the abuser, or the person might be afraid to
"lose face" in the presence of others.
Nonverbal communication is more powerful than your
words so watch your body language and keep a distance
from the person
Use clear and direct words: anxiety could make it difficult
for the person to comprehend what you are saying
Reflect the person's words back; this let the person know
that you will hear him or her
Silent is often effective because it forces the person to
think about what is being said and maybe calming itself
Finally keep your tone of voice calm, keep your volume
normal, and slow your rate of speech, as these strategies
may reduce the person's anxiety and aggression
Verbal Intervention Strategies
Remain calm
Keep it simple
Isolate the individual
Use reflective questioning
Watch your body language
Embrace silence
Maintain moderation in speech
o A violent incident - despite all that you try to do the individual
aggression may escalate. In the event that this occurs the
organization should make certain that all employees are
prepared. Each employee should:
Recognize the signs of escalating violence
Know the organizations violence policies

Leadership Final Notes

Be prepared to protect their patients, their visitors, and

themselves
Law enforcement personnel recommend watching for
these behaviors:
o Clenched fists
o Blank stare
o Fighting stance (one foot back with an arm
pulled back ready to strike)
o Arms raised in the fighting position
o Staying too close to advancing toward you
o Holding anything that might be used as a
weapon, such as a pen, letter opener, heavy
objects, or actual weapons such as a knife or
gun
o Overt intent saying that they intend to "kick
your ass," or other similar statements
o Movement towards the exit to prevent you
from leaving

How to Handle a Violent Incident

Notify security immediately
If not armed, enlist staff help
in restraining a violent person
Never try to disarm someone
Put a barrier between you and
with a weapon
the violent person
o Other dangerous incidents - infant abduction, , a bomb threat or
a gun on the unit are some examples of other dangerous
incidents that could occur. Most organizations now have a
specific code to alert staff to potential or real infant abduction
such as Code Pink, And many hospitals now also place security
bands on babies and parents to prevent a baby being abducted
from the nursing unit
Policies are usually in place in hospitals to address bomb
threat or going on the unit and the procedures to follow,
and the staff are trained to call the hospitals 911 number.
Other threats also use specific codes for alerting security
and obtaining assistance.
In addition, drills for infant abductions, bomb threats, and
firearms on the unit are practiced on a routine basis and
included in the yearly competency test for employees.
Keeping patients safe as always the focus.
o Post-incident follow-up - after a violent incident, everyone
involved will suffer some degree of emotional, if not physical,
trauma. 94% of the emergency department nurses experienced

Leadership Final Notes

at least one symptoms of posttraumatic stress disorder (PTSD)
following an incident of violence, With 17% diagnosed with
probable PTSD.
o Post -ncident follow-up is essential for the well-being of patients,
visitors come and staff members.
1.
2.
3.
4.

How to handle post-incident follow-up

Be certain that everyone is safe having a violent event
Arrange an immediate treatment for the injured
Complete injury and instant reports
Follow up with human resources regarding the Worker's
Compensation process for the injured employees

5. Contact security to determine if a police report should be

filed
6. Contact the injured employee at home to expressed
concern for the person's well-being and follow up with any
questions the person may have