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Nursing Professional Role Development Program- Day 2

Learning Objectives1. Share your Champion-session experience.2. Describe the O’Rourke 9-Step Decision-Making Model and

its application in professional nursing practice.3. Describe handover report as evidence of effective decision-

making.4. Recognize the elements of an effective handover and

demonstrate ability to observe and document the handover process.

5. Demonstrate skills in giving and receiving feedback.

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Application of Learned Models and Concepts

• Which models or legal documents from Day 1 did you use to demonstrate your performance as a role-based professional nurse in improving a patient outcome?

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O’Rourke 9-Step Decision-Making Model

Making decisions is a complex process…

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O’Rourke 9-Step Decision-Making Model • Knowing

• What to do• How to do it• When to do it• Who should do it

• Decision-Making process comes together to• Draw a picture of the patient• Formulate a plan of action• Serve the client’s needs for recovery and care

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Back to BasicsThe Professional RN is a pivotal decision-maker on the interdisciplinary team.• Decision-making process is complex (Leader component)• Decision-making process is rigorous and evidence-based• Prerequisite for acting with and on behalf of the patient• Decision-making process transfers knowledge

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Decision-Making Process• Used by all professional disciplines

• Nurses• Pharmacists• Physicians• Social Workers• Therapists

• Nine integrated steps• Best possible decision

• What actions to take• By Whom

• Professional role responsibility and core competency

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Data Collection

& Data Assessment

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Comprehensive Assessment

Patient Condition & DX

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Plan

3

Implementation

4

Evaluation

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Teach/Inform

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Stability of Patient

Condition

Unstable

ModeratelyUnstable

ModeratelyStable

7Dynamic Interaction of 1-6 with Stability (8) & Care Coordination (9)

7Dynamic Interaction of 1-6 with Stability (8) & Care Coordination (9)

Professional Role-Based System for

Decision-Making & Accountability

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O’Rourke 9-Step Decision-Making Model

9 Care Coordination/Action

O’Rourke 9-Step Decision-Making Model

Six Competencies

Professional Role Decision-Making Process: Role Accountability

Data Collection &

Data Assessment

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Comprehensive Assessment of

Patient Condition with

DX

2

Plan

3

Implementation

4

Evaluation

5

Teaching/Informing

6

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7th Competency – Integration of Professional Practice Steps

Data Collection & Data

Assessment

1

Comprehensive Assessment of

Patient Condition with DX

2

Plan

3

Implementation

4

Evaluation

5

Teaching

6

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In practice, the steps of the decision-making process must be linear or sequential.A. TrueB. False

11True

False

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Using scientific knowledge and critical thinking, the RN converts data into a diagnosis during the comprehensive assessment step.

A. TrueB. False

12True

False

0%0%

Test Your Knowledge

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8th CompetencyO’Rourke 9-Step Decision-Making Model

Determining stability requires:• Substantial scientific knowledge of nursing

and medical conditions• Knowledge of the patient population• Knowledge of the individual patient

Stability of the Patient’s ConditionEstimate of Risk for Morbidity & Mortality

8th CompetencyO’Rourke 9-Step Decision-Making Model

Estimate of Risk for Morbidity & Mortality

8Stability of

Patient Condition

Unstable

ModeratelyUnstable

ModeratelyStable

Stability of the Patient’s Condition

Stability of the Patient’s ConditionEstimate of Risk for Morbidity & Mortality

Determining Stability Level

A. StableB. Moderately StableC. Moderately UnstableD. Unstable

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Stable

Moderately Stable

Moderately Un

stable

Unstable

0.00% 0.00%0.00%0.00%

F. J. is a 68 year old male with DX of GI Bleed, 3 days ago. On this admission he had an endoscopy and an ulcer was found and cauterized. He was transfused 2 units of PRBCs and his H/H is 9.2/31.8. Latest VS: BP 117/84, HR 88, Temp 36.8, RR 18, PO 96% on RA. The current POC is that he will be discharged tomorrow assuming that his H/H remains stable and there are no signs and symptoms of bleeding. What is the stability level of this patient?

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Determining Stability Level

A. StableB. Moderately StableC. Moderately Unstable D. Unstable

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Stable

Moderately Stable

Moderately Unstable 

Unstable

0.00% 0.00%0.00%0.00%

During the night, the same patient F.J., who was admitted with a GIB, has an episode of melena. His vitals are taken. His BP is 109/76, HR 98, RR 20, Temp 36.8, PO 95% on Room Air. The doctor is notified and a CBC is ordered. The H/H comes back 7.4/25.8. The doctor orders 2 units of PRBCs. Before giving the blood, you check the vitals and find the BP is now 74/52, HR 121, RR 24, PO 91% on Room Air. F.J. tells you that he is feeling a little dizzy. What is the stability level of this patient?

Stability VS Acuity• Common misunderstanding of definition of these two

words• Stability – risk of patient’s illness becoming worse

and/or risk of patient’s death• Acuity – how many and what kind of resources are

required to manage that risk so that patient’s illness does not become worse and death does not occur

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Data Collection

& Data Assessment

1

Comprehensive Assessment

Patient Condition & DX

2

Plan

3

Implementation

4

Evaluation

5

Teach/Inform

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Stability of Patient

Condition

Unstable

ModeratelyUnstable

ModeratelyStable

7Dynamic Interaction of 1-6 with Stability (8) & Care Coordination (9)

7Dynamic Interaction of 1-6 with Stability (8) & Care Coordination (9)

Professional Role-Based System for

Decision-Making & Accountability

Dir

ect

Ind

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9th Competency: Care Coordination

9 Care Coordination/Action

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Documenting Nursing Stability in Care Connect

The Care Partner can assess data (i.e. vital signs), but cannot assess the stability of the patient’s condition

A. TrueB. False

20True

False

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Test Your Knowledge

Small Group Exercise: Scenario of Sentinel EventAt what step did the 9-Step Decision-Making Model fall apart? 0600: Pt spikes temp.(38.5,), with tachycardia and tachypnea. 0700: MD orders cultures and broad-spectrum antibiotic.0700: Shift change, Oncoming RN receives report and is advised of patient’s condition.1000: RN delivers the first antibiotic dose at 1000 hrs. 1005: Pt's temperature is 39.6 ;BP is falling in spite of a fluid bolus. It is necessary to transfer the patient to the ICU for a higher level of care.

On investigation, the RN discloses that the reason for the delay in dispensing the antibiotic was that the pharmacy did not deliver it until 1000.

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Professional Role Decision Making in Action

Nursing Handover

Role-Based Handover Observation Tool

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Role-Based Handover Observation Tool

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Exercise using the Handover Observation Tool

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Test your Knowledge!

Crossword Puzzle

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Break time

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Communication:Skills and Tools

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Why Would You Want To Master This Skill?

• As professionals, we're here for the patient.• We take our personal selves out of the role.• When communication can improve patient care/safety, it

must happen!• We only have autonomy as long as we monitor our own

practice.• It is our professional obligation to give each other

feedback.

Seven Difficult Conversationsin Healthcare

• Broken Rules• Lack of Support• Mistakes• Incompetence• Poor Teamwork• Disrespect• Micromanagement

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Why Not Speak Up?

• AACN states that caregiver's communication skills are as important as clinical skills

• Failure to speak up is related to lower quality of care, lower morale, higher turnover, lower productivity

• high personal cost• not my responsibility• it will lead to conflict• behavior is widely accepted

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Skill To Communicating Effectively

• Learn the tools:Quick Coherence Technique1

C.O.I.L.S.2

Crucial Conversations Model 3

• Practice the skills: you will improve with practice it takes time getting used to the feeling lifelong learning and improvement process

1UCLA Brite Training 2Institute of HeartMath. (2015). HeartMath science and research. Retrieved from http://www.heartmath.com/research/ 3Patterson, K., Grenny, J., McMillan, R., & Switzer, A. (2012). Crucial conversations: Tools for talking when stakes are high (2nd ed.). New York, NY: Mc Graw Hill.

© 2014 Copyright Institute of HeartMath© 2014 Copyright Institute of HeartMath

Quick Coherence Technique

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Quick Coherence Technique

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C.O.I.L.S.: The Feedback Model• Show your positive intentConvey• Describe concrete observationObserve• Explain the effect of the

behavior/action on you and othersImpact• Pause and listen for the responseListen• Determine solutions Solve

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C.O.I.L.S. in Action: Meet John

• John, a nurse at UCLA Health, is opposed to bedside report, insisting that report has always been done in the pod.

• John is known to be abrasive when other nurses have approached him to give report at the bedside, brushing them off and citing it takes too much time, he only has 30 minutes to report out on his patients.

• John insists that it is his professional preference give report at the pod, after all most patients are not alert so there is no value to give report at the bedside.

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Step #1: Convey Your Positive Intent1.Put yourself in a positive frame of mind.

2.Know clearly in your mind what the goal of the feedback session should be

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The goal is for John to give bedside report.

What is the positive goal that I am hoping for as a result of this feedback session?

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Step #2: Observe Current Behaviors1.Be brief and to the point.2.Focus on the behavior, not the person.3.Limit your feedback.

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Z” “I have observed that you do not give report at the bedside.”

How can you state the observation?

Step #3: Impact and Consequences1.State the impact of the behavior on you

and others.

2.Maintain an objective tone.

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“Your unwillingness to give report at the bedside is unsafe, and compromises our care. Mr. Jones is expecting us to give bedside report, and include his wife who is waiting in the room for updates on Mr. Jones’s medical and nursing plan of care.”

How can you state the impact in an objective tone?

Step #4: Listen to the Concerns1.Invite the other

person to respond—then PAUSE.

2.Listen with an open mind.

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“Look I only have 30 minute

change is over.”

“Look I only have 30 minute for report, and I always give report in the pod, why are you being so pushy? I took care of Mr. Jones last night and he can wait until shift change is over.”

TIP:If the person becomes defensive, stay calm

and return back to the observed behavior

and its impact.

“John, giving report in the pod excludes the patient and family from the care plan. Bedside report helps us improve patient safety. It also helps the pt and family gain our trust as we partner to ensure the care we provide is patient-centered.

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Step #5: Determine Solutions1. Include the receiver in the

problem-solving process.2. When appropriate, ask directly

for the change you want.3. Seek agreement on specific

action(s) to be taken.

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“I hear your hesitation to give report at the bedside, but where patient safety is concerned, we have no choice. It is our professional obligation to transfer knowledge to Mr. Jones and his wife. Can we agree that it is best to give bedside report.”

Small Group Activity; Pat & Sam• Find a partner and decide on which part you will play,

Pat or Sam. • Sam will use the Quick Coherence and C.O.I.L.S

techniques when having a “Professional Conversation” with Pat.

• Then a Debrief as Group.

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Crucial Conversations TechniqueGet Un-

stuck

Start with

Master my stories

State My

PathLearn to

Look

Make it

Safe(r)

Explore Others’ Paths

Move to Action

Techniques for Crucial

Conversations

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Crucial Conversation: Step 1

1.Get Unstuck•Which issues do you need to address and with whom to get unstuck?

Identify: Content issuesPattern issues Relationship issues

• “I need to address pattern issues with John in order to get unstuck.”

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Crucial Conversation: Step 2

2. Start with Heart•What do you really want for: Yourself? Other? Relationship? Organization?

•What can you say to make what you want clear?

• Curious open mindset; point out consequences

• I want:- to include the

pt/family in handoff- -John to give

bedside handoff- Safe professional

delivery of care and excellent outcomes

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Crucial Conversation: Step 3

3. Master My Stories• What stories are you telling yourself

about the person or situation? • Ask yourself: What am I pretending

not to notice about my role in this situation?

Why would a reasonable and rational person do this? What should I do right now to move towards what I really want?

• “John is lazy and is always in a rush to get out of here. He doesn’t like to give me report.” •I’m pretending not to notice that I don’t try talking to John. I’ve never asked him why he doesn’t do bedside report. •I should start a conversation with John.

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Crucial Conversation: Step 4

4. State My Path• Start with the facts• Tell your story • End with an inviting question

• Yesterday and today you asked to do report at the nursing station.

• I’m wondering if you perceive bedside report to be of little value.

• What are your perceptions about bedside handoff?

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Crucial Conversation: Step 5

5. Learn to LookSilence Violence

• “Is John withholding his opinion or forcing his perspective?”

• “Am I listening to John or focused on the stories I’m creating?”

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Crucial Conversation: Step 66. Make it Safe

• What’s the worst possible response you could get?

• Use safety skills to make it safe Apology, create Mutual Purpose)

• Use contrasting statements if the other person misunderstands your intentDon’t and Do Statements

• I don’t want you to think that I don’t trust your assessment.”

• I think you are a very thorough and caring nurse, but I do want us to include the patient and his family in our handoff report.

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Crucial Conversation: Step 7

7. Explore Others’ PathsAsk Mirror Paraphrase Prime

• “I really want to hear your thoughts.”

• “Let me make sure I understand you correctly. You want to do bedside handoff with me but you need me to be prepared and ready to go promptly at 7am.”

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AMPP

Crucial Conversation: Step 8

8. Move to Action• How will you establish a way

to follow up after the crucial conversation?

• Who will do what by when?

• Let’s touch base next week

• “Next Tuesday I’ll be ready to go on time and you will do patient handoff at the bedside so that we can include and keep our pts and families safe.

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AMPP

Crucial Conversations TechniqueGet Un-

stuck

Start with

Master my stories

State My

PathLearn to

Look

Make it

Safe(r)

Explore Others’ Paths

Move to Action

Techniques for Crucial

Conversations

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Small Group Activity:Crucial Conversation PlannerThink of a recent incident when you wish you had the courage and skills to have a professional conversation with someone (your supervisor, a peer, or a direct report).• In your small group discuss a situation when you should

have had a crucial conversation. • Pick one story from the group• Use the Crucial Conversation Planner to present the

steps you will take and what you will say.• Each group will present their story

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Plan for Day 3

• Plan on sharing your experience in using one of the communication tools.

• Deliverables due for next class:• Complete 2 handover observations using the tool and bring them to class.

• Have a peer observe you and complete a Handover Observation on you.• Observe a handover and complete a Handover Observation on your peer.

• Discuss the Role-Based Handover Observation Tool with your Coach (CNS/Educator, AN2) or unit champion. Return observations to Unit Coach.

• Complete reading homework and submit at the start of day 3 for CEUs.

• Familiarize yourself with the Professional Role Development Guide (PRDG) before class and start your self-assessment.

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Closing Reflection

http://www.youtube.com/watch?v=76nhIfp9gr0

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