© 2008 1 Helping Nurses Make Decisions About Increased Responsibilities at the Bedside Rosalinda...

© 2008 www.AlfaroTeachSmart.com 1

Helping Nurses Make Decisions About Increased Responsibilities at the Bedside

Rosalinda Alfaro - LeFevre, RN, MSN

www.AlfaroTeachSmart.com


WHAT’S IN YOUR HANDOUTSWHAT’S IN YOUR HANDOUTS

Power Point

Clinical Decision Making Tool

Mapping Contributing Factors Tool


EXPECTED OUTCOMESEXPECTED OUTCOMES

1. Discuss nurse’s increased roles related to diagnosis.

2. Address the importance of teaching how to make decisions about taking on increased responsibilities.

3. Identify strategies & tools to improve novices’ abilities to make decisions related to diagnosis and care management.


How Literate Are You?How Literate Are You?

“The illiterate of the twenty-first century will not be those who cannot read and

write, but those who cannot learn, unlearn, and relearn.”

(Alvin Toffler, Author of Future Shock)


Bus is Leaving the Station & Now it’s an Airplane

Will you be on it?


Think, Pair, Share*

* Developed by Professor Frank Lyman at the University of Maryland in 1981. Read more at:

http://www.eazhull.org.uk/nlc/think,_pair,_share.htm



1. Discuss increasing responsibilities of nurses related to diagnosis.


Quotes From The Trenches


The public needs to know that nurses -- regular, ordinary bedside nurses, not just nurse practitioners or advanced practice nurses -- are constantly participating in the act of medical diagnosis, prescription, and treatment and thus make a real difference in medical outcomes. Nurses can help the public understand that nursing is a package of medical, technical, caring, nursing know-how -- that nurses save lives, prevent suffering, and save money. If nurses wear not only their hearts, but also their brains on their sleeves. Perhaps the public…. will finally understand what nurses know and do.”

(Gordon, 2006)


How are you all dealing with staff “change fatigue?” Our staff is constantly bombarded with new JCAHO and other requirements. They’re already overwhelmed with work. How do you get new information to them in a timely way at a time when they can handle it? How do you get them to come to educational programs? (Listserv Posting, 2007)


I was just asked to "investigate" the possibility of starting a RN PICC team. This team would consist of RNs on various units throughout the medical center. Our intensive care nursery just did this, but now the VP wants it to go house-wide. Any ideas, comments, and how to's would be much appreciated as this is not a specialty of mine! (Listserv Posting, 2006)


I wouldn’t call this a PICC team and would run the other direction as fast as I could. For the past 15 years of training hospitals to place PICCs, I have seen many, many facilities try this approach and fail over and over again. First, PICC insertion is a complex process that demands an advanced body of knowledge about vascular anatomy, central venous catheter technology, and nursing care and complication management.

(Listserv Posting, 2006)


In regards to LPNs and narcotics, IVs, etc... as you know, states have varying regulations regarding the LPN roles in medication administration. Besides checking your nurse practice act for your state, you may want to log on to a great resource, at the National Council of State Boards of Nursing website (www.ncsbn.org) click on to the Business Book NCSBN Annual Meeting 2005, Section II, attachment C, Practical Nurse Scope of Practice White Paper. Good luck! (Listserv Posting, 2006)


WORRIED WELL & WALKING WOUNDED

Many patients today are the “worried well” (people who don’t need a doctor, but think they might) and “walking wounded” (people who are living with---or recovering from-- complex injuries or chronic illnesses at home). Knowledgeable staff with highly skilled thinking, communication, and coaching abilities are cost-effective coaches who help people manage their health at home , reducing costs & improving quality of life.

(Alfaro-LeFevre, 2006, p. 15)


CRISIS IN CRITICAL THINKING

Only 35% of new RN graduates, regardless of educational preparation and credentials, meet entry expectation for clinical judgment. Although well-versed in content, the majority are unable, or have considerable difficulty translating knowledge and theory into practice. (DelBueno, 2005, p 279)


INCREASED RESPONSIBILITIES

APNs – RNs – LPNs (LVNs) – Techs Pharmacy – Radiology – PT – Dietary Risk Managers – QI – Infection Control Leaders – Managers – Educators Triage – Diagnostic Orders


WHAT DO LAWS SAY?

Unless you’re an Advanced Practice Nurse state laws prohibit you from making medical diagnoses independently. (Buppert, 2008)

You are, however, accountable for giving high priority to assessing for---and reporting--- signs and symptoms that may indicate the need for attention from a professional more qualified than you are. (Alfaro-LeFevre, In Press)



1. Not expected to make definitive dx2. Are expected to recognize when signs

and symptoms may indicate a common problem (Diabetes, MI, CHF, Pulmonary Embolus).

3. They are the first in the chain of command and a lot of responsibility goes with this.


EXAMPLE

If the patient has signs and symptoms of an MI (chest pain--shortness of breath), you’re accountable for:

• suspecting that this could be the problem• recognizing that it’s a high priority, • doing what you can to address the

problem (e.g. raise the head of the bed) • reporting it immediately


ACTIVATING THE CHAIN OF COMMAND

• Follow policies and procedures for getting help

• Be persistent---stay with the problems until the patient gets the qualified help they need.



Health promotion: smoking cessation, obesity management

Screening: Depression, diabetes IV management Outcomes management (eg. Airway

management)


DISEASE MANAGEMENT

Arthritis

Asthma

CHF

COPD

Depression

Diabetes

Hypertension

Kidney Disease

Wounds


Identifying Problems, Risks,

Signs & SymptomsRequiring

Independent Management

Identifying Reportable

Problems, Risks,Signs & Symptoms

PATIENT ASSESSMENT


OLD vs NEW THINKINGOLD vs NEW THINKING

Old Thinking

We must be creative

Staff must remember Tools are crutches

New Thinking

We need more evidence

Staff will forget We ALL need tools


CLINICAL WORKSHEET

Name______________ Room_____

Age____ Religion___ Culture____

Diet____ Activity_______________

Neuro:

Resp: Oxygen:

Cardiac:

Circ:

Skin:

GI:

Medical Dx_____________________

Dr.____________________________

Allergies_______________________

Medications/IV’s:

Potential Complications:

Nursing DX/problems:


Digoxin 0.25 mg po OD 1000CIPRO 500 mg po BID 1000

2000KCl Elixir 20 mEq po OD 1000 Multivitamin po OD 1000Ambien 5 mg po hs 2000MOM 30 cc po hs 2000


QUICK PRIORITY ASSESSMENT (QPA)

Start with patient “snap shot”: Allergies – Meds – Medical Problems Age - Height – Weight – Hydration Risk for Infection – Injury Breathing – Comfort – Communication Other Relevant Specialty Data


Interventions aimed

at the person

Interventions aimed at the disease

CARE MANAGEMENT


SOLUTIONS

Mentor-Preceptor-Teacher Independent learner Needs Assessment Tool Development Informatics


Think, Pair, Share*

* Developed by Professor Frank Lyman at the University of Maryland in 1981. Read more at:

http://www.eazhull.org.uk/nlc/think,_pair,_share.htm


Summary



1. Discuss nurse’s increased roles related to diagnosis.

2. Address the importance of teaching how to make decisions about taking on increased responsibilities.

3. Identify strategies & tools to improve novices’ abilities to make decisions related to diagnosis and care management.


Bibliography

Alfaro-LeFevre, R. (In Press). Applying nursing process: A tool for critical thinking (7th ed.). Philadelphia: Lippincott- Williams & Wilkins

Alfaro-LeFevre, R. (2008). Giving and Taking Constructive Criticism in: Critical Thinking and Clinical Judgment: A practical approach to Outcome-focused thinking, 4thed.). Philadelphia: Elsevier-Saunders

Alfaro-LeFevre, R. (2008). Evidence-based Critical Thinking Indicators. Available at http://www.alfaroteachsmart.com/cti.htm

Buppert, C. (2008). The legal distinction between the practice of medicine and the practice of nursing. The Journal for Nurse Practitioners, 4(1), 22-24


Class, P (2006) The Walking Wounded. Nursing Spectrum (FL ED), 9(21), p. 3

Henneman, E., & Roche, J. Eight ways to nurture a new student. Retrieved June 2, 2002 from http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=5948

Rich, P. Giving and receiving feedback. Retrieved 2/20/2008 from http://www.selfhelpmagazine.com/articles/growth/feedback.html

Walters, J. The 4-1-1 On Constructive Criticism. Retrieved 2/20/2008 from: http://www.inc.com/articles/2001/08/23257.html


NP BookNP Book (2006)(2006)LippincottLippincottwww.lww.comwww.lww.com

USA: 800-638-3030 USA: 800-638-3030 CANADA: 800-223-CANADA: 800-223-

23002300


CT Book (2008)CT Book (2008)Saunders/Saunders/ElsevierElsevier

USA: 800-325-4177USA: 800-325-4177 www.us.elsevierhealth.com www.us.elsevierhealth.com

CANADA: 866-896-3331CANADA: 866-896-3331 www.elsevier.cawww.elsevier.ca

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