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© 2008 www.AlfaroTeachSmart.com 1
Helping Nurses Make Decisions About Increased Responsibilities at the Bedside
Rosalinda Alfaro - LeFevre, RN, MSN
www.AlfaroTeachSmart.com
© 2008 www.AlfaroTeachSmart.com 2
WHAT’S IN YOUR HANDOUTSWHAT’S IN YOUR HANDOUTS
Power Point
Clinical Decision Making Tool
Mapping Contributing Factors Tool
© 2008 www.AlfaroTeachSmart.com 3
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.
© 2008 www.AlfaroTeachSmart.com 4
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)
© 2008 www.AlfaroTeachSmart.com 5
Bus is Leaving the Station & Now it’s an Airplane
Will you be on it?
© 2008 www.AlfaroTeachSmart.com 6
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
© 2008 www.AlfaroTeachSmart.com 7
EXPECTED OUTCOMESEXPECTED OUTCOMES
1. Discuss increasing responsibilities of nurses related to diagnosis.
© 2008 www.AlfaroTeachSmart.com 9
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)
© 2008 www.AlfaroTeachSmart.com 10
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)
© 2008 www.AlfaroTeachSmart.com 11
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)
© 2008 www.AlfaroTeachSmart.com 12
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)
© 2008 www.AlfaroTeachSmart.com 13
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)
© 2008 www.AlfaroTeachSmart.com 14
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)
© 2008 www.AlfaroTeachSmart.com 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)
© 2008 www.AlfaroTeachSmart.com 16
INCREASED RESPONSIBILITIES
APNs – RNs – LPNs (LVNs) – Techs Pharmacy – Radiology – PT – Dietary Risk Managers – QI – Infection Control Leaders – Managers – Educators Triage – Diagnostic Orders
© 2008 www.AlfaroTeachSmart.com 17
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)
© 2008 www.AlfaroTeachSmart.com 18
INCREASED RESPONSIBILITIES
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.
© 2008 www.AlfaroTeachSmart.com 19
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
© 2008 www.AlfaroTeachSmart.com 20
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.
© 2008 www.AlfaroTeachSmart.com 21
INCREASED RESPONSIBILITIES
Health promotion: smoking cessation, obesity management
Screening: Depression, diabetes IV management Outcomes management (eg. Airway
management)
© 2008 www.AlfaroTeachSmart.com 22
DISEASE MANAGEMENT
Arthritis
Asthma
CHF
COPD
Depression
Diabetes
Hypertension
Kidney Disease
Wounds
© 2008 www.AlfaroTeachSmart.com 23
Identifying Problems, Risks,
Signs & SymptomsRequiring
Independent Management
Identifying Reportable
Problems, Risks,Signs & Symptoms
PATIENT ASSESSMENT
© 2008 www.AlfaroTeachSmart.com 24
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
© 2008 www.AlfaroTeachSmart.com 25
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:
© 2008 www.AlfaroTeachSmart.com 26
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
© 2008 www.AlfaroTeachSmart.com 27
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
© 2008 www.AlfaroTeachSmart.com 28
Interventions aimed
at the person
Interventions aimed at the disease
CARE MANAGEMENT
© 2008 www.AlfaroTeachSmart.com 29
SOLUTIONS
Mentor-Preceptor-Teacher Independent learner Needs Assessment Tool Development Informatics
© 2008 www.AlfaroTeachSmart.com 30
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
© 2008 www.AlfaroTeachSmart.com 32
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.
© 2008 www.AlfaroTeachSmart.com 33
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
© 2008 www.AlfaroTeachSmart.com 34
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
© 2008 www.AlfaroTeachSmart.com 35
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