*Patient Care Management Topic Notes

*Source for notes: Huber, Diane. LEADERSHIP AND NURSING CARE MANAGEMENT, W.B. Saunders, Philadelphia, Pa., 1996. 

 TOPICS

1. MANAGEMENT OF CHANGE

2. COMMUNICATION: MANAGING PROFESSIONALS AND THEIR PRACTICE

MANAGEMENT OF CHANGE:

1. Introduction:

Question: Do we have too much change?

Positive change--Negative Change--Myths--Quantity and Rapidity of Change

2. Definitions:

A. Change--a change in the status quo; an alteration, haphazard or planned, to make something different. It exists on a continuum:

1) Unplanned--occurs without guidance and its outcomes are unpredictable

2) Planned--involves structuring and engineering innovations with some consideration as to the consequences of change

B. Organizational Change--Planned change seen as a deliberate effort to improve the system. Used by nursing management as a strategy to meet organizational needs and goals.

C. Change agent--a professional who relies on a systematic body of knowledge about change to guide the process:

1) articulates a clear need for change

2) gives reliable information about the change

3) leaves the details to the group to work out

4) motivates the process by rewards and benefits

5) avoids false promises

6) evaluates the impact and process of change

3. Changes in Health Care:

A. Health care delivery systems

B. Role of the R.N.

C. Reimbursement

D. Increasing use of Computerized Information Systems

4. Focus for change--Four levels:

A. Knowledge

B. Attitudes

C. Individual Behavior

D. Group or Organizational Behavior

5. Change Theory:

A. Lewin's Force Field Analysis:

1) Unfreezing--first stage of change; characterized by thawing out the system and creating the motivation or readiness for change

2) Moving--2nd. stage; the actual change occurs when those involved move to a new level of behavior and experience

3) Refreezing--final stage; new changes are integrated and stabilized; these changes need to be reinforced

B. This theory is similar to the nursing process and the problem solving process

C. Rogers--identified five factors that determine successful planned change:

1) Relative Advantage: the change is thought to be better than the status quo

2) Compatibility: the change is compatible with existing values of the individuals or group

3) Complexity: simple techniques are more readily adopted

4) Divisibility: changes tried out on a small scale(trial) have a greater chance of succeeding

5) Communicability: the easier the change is to describe, the more likely it will spread

6. Emotional Responses to Change:

A. "Any organizational change process involves continual letting go of the status quo and emotional grief reactions."

Nurses are empowered when change increases their responsibility, authority, and accountability, and gives them the mechanisms to make decisions to be able to affect client care.

B. Resistance--Is this bad?

1) Definition: Behavior intended to protect the individual or group from the effects of real or imagined change

2) Value of resistance:

a. It forces clarification of the purpose and results of change

b. Reveals inadequate problem-solving

c. If the resistance is logical or practical, it may mean the change is needless and useless

3) Occurs when:

a. the nature of the change is unclear

b. when the change ignores the established norms of the group

c. when the change causes excessive work pressure

d. when there is fear of a loss of status, power, money, etc.

e. when it is handed down arbitrarily or in an authoritarian manner

4) Four manifestations of resistance to change:

a. Acceptance on the surface

b. Active resistance through frustration and aggression

c. Organized passive resistance or resisting change collectively

d. Indifference by ignoring or attempting to divert attention elsewhere

C. Foundation for effective change:

1) Identification

2) Reassurance

3) Communication

4) Participation

5) Follow through

BURNOUT

" . . . the prime candidate for burnout is the nurse who strives for excellence in a toxic environment."

1. Definitions:

A. Physical and emotional exhaustion that involves a negative job attitude and a poor professional concept, characterized by apathy, alienation, job dissatisfaction and a depersonalization of others.

B. "Professional autism"--follows a confrontation with reality in which the human spirit is pitted against circumstances intractable to change. Mandated actions are carried out, but the emotional investment that transforms a task into an art form is missing.

2. Caused by stress and a sense of powerlessness and/or oppression within the nursing profession. Involves a multitude of interrelated job-related factors such as interpersonal stressors, role stressors, physical demands and task overload.

3. Kathryn Taroli-Jager, who wrote a Masters Thesis on managing stress in the nursing profession, described research on how to reduce or buffer burnout:

COMMUNICATION: MANAGING PROFESSIONALS AND THEIR PRACTICE

A. Introduction:

Communication is an important factor in all aspects of professional practice, just as it is in the smooth working of daily life. Good communication is necessary to avoid legal problems, settling conflicts, managing change, motivating workers, using power appropriately, and effectively delegating tasks.

1) Positive outcomes of effective communication:

Increased productivity, increased self-esteem, good working relationships and a comfortaable work environment.

2) Negative outcomes of poor communication:

Increased stress, lack of recognition, feelings of alienation, failure to reach common goals.

3) Barriers to effective communication include:

Stereotyping, belittling, blaming, rejecting another's ideas, offering inappropriate reassurance or advice, distraction, failure to listen before speaking, failure to clarify, minimizing another's importance, differing cultural and value systems or removing another's decision making power.

Why do communication problems occur frequently in nursing?

Related to being highly visible and on the front lines, being the focus for displaced criticism, working with people who have health problems, and working in high-stress environments.

B. Organizational Communication:

1. NETWORKS:

a. Centralized or hierarchical--more efficient in certain circumstances such as completing repetitive, unskilled tasks, but restsrict communicatio the most; less job sataisfaction of members at the periphery

b. Decentralized or democratic--freer flow of communication, better for morale, but less efficient in completing tasks and may form a more centralized structure when this need arises.

Complex and knowledge-based work by professional workers tends to pull the organization toward decentralization.

What are the barriers to effective communication in organizations?

In general, politics and necessity of communication with multiple people.

Barriers in the hierarchical network may be associated with decreased opportunity for individuals to interact with their peers or people on other levels in the hierarchy.

Barriers in the democratic network may be associated with communication inaccuracy and development of sub-hierarchies.

2. TYPES OF COMMUNICATION WITHIN ORGANIZATIONS:

a. Formal and informal

b. Vertical and horizontal

c. Personal and impersonal

d. Instrumental and expressive

Where does "the grapevine" fit in?

It emerges as a response to important situations, ambiguity, and other conditions that cause anxiety. It is extremely influential, shapes people's attitudes, and has the capacity to carry helpful or harmful information to the members of the organization--it is 75% accurate!

Are superior-subordinate communication problems more common than peer-to-peer difficulties?

Equally common--may be result in vertical relatinships due to intimidation, lack of trust, lack of feedback, or inability to express needs. In horizontal communications may be the result of inability to give and receive constructive criticism, difficulty with need expression, turf issues, and lack of trust.

3. CHARACTERISTICS OF EFFECTIVE COMMUNICATION WITHIN ORGANIZATIONS:

a. Planning for positive response to message: Timing, Choice of Channel, Choice of Words

b. Getting feedback to see if a message was understood

4. SIX AREAS OF ORGANIZATIONAL COMMUNICATION THAT CAN BE ASSESSED FOR COMMUNICATION PROBLEMS:

a. Accessibility of information

b. Communication channels

c. Clarity of messages

d. Span of control

e. Flow control and communication load

f. Individual communicators

5. COMMUNICATION RELATING TO LEADERSHIP AND MANAGEMENT BEHAVIORS:

"Communicating, along with diagnosing and adapting, is one of the three basic competencies of influencing and leadership."

a. Communicate a "vision" (a compelling image of a desired state of affairs)

b. Build trust

c. Model positive communication and mentor others

d. Accomplish goals--"empower and motivate"

e. Create and foster job satisfaction

f. Deal with multicultural issues and give individual recognition

g. Solicit feedback from peers, employer or subordinates as to communication effectiveness

6. INFORMATICS:

"Nurses generate over 50% of patient care information. . .data collection and information management consume over 30% of a nurse's time. . ."

Definition: Nursing informatics is a combination of computer science, information science and nursing science, designed to assist in the management and processing of nursing data, information, and knowledge to support the practice of nursing and the delivery of nursing care(Journal of Nursing Scholarship, 1989).

"Within the next decade or so, the network will become the major conduit through which we conduct our careers as well as our lives."

Electronic-Telecommunications Technology:

a. Computers for management of patient records, inputting orders, retrieving data, ordering supplies, communicating with other departments or doctors' offices, documentation of patient care, or generating specific forms

b. Networks of computers that link health care agencies and state or federal agencies

c. Telemedicine and distance education

d. The Internet-- increasingly important and available for: (if following topic is underlined, click on it for site)

How to validate, sort through and use this vast amount of information will become increasingly important!

7. SPECIFIC COMMUNICATION ISSUES:

a. "Self-talk"--Why important? What is "horizontal violence?"

b. Assertiveness vs. Passivity vs. Aggressiveness--Define advantages of Assertiveness Techniques

c. When giving Shift Report--guiding principle: the patient has the right to privacy and the only information that should be discussed is that which is needed to safely and effectively carry out nursing care; avoid non-essential chit-chat!

d. When dealing with Physicians: Be prepared, be professional, be specific and ask for what you want; give a timely reporting of patient change in condition

e. When dealing with angry patients: Brief but frequent contacts--establish trust; simple, direct language and LISTEN to what they are saying; open, non-judgmental attitude; avoid power struggles; let patients make choices wherever possible

f. As a new graduate:Specific issues such as taking on unsafe assignments, "floating", and when to ask for help

g. Examples from clinicals--