Preparing a unit budget
Changing staffing plans based on service needs
“It is a nurse’s professional responsibility to maintain quality control.”
“All instances of clinical incompetence are to be reported.”
“It is not considered being disloyal when one nurse reports another for poor care.”
“Patient care is the number one concern. Meeting standards is mandatory and necessary.”
a. Fidelity and justice.
b. Veracity and fidelity.
c. Autonomy and beneficence.
d. Paternalism and respect for others.
Autonomy refers to the freedom to make a choice (e.g., refuse a procedure), and beneficence to doing good (performing a procedure that will benefit the patient).
c. Undue authorization of treatment.
d. Protection against slander.
Privacy refers to the right to protection against unreasonable and unwarranted interference with the patient’s solitude, which extends, in the medical context, to protection against public disclosure of private facts about the patient to the public.
a. Practicing within legal guidelines established under state law and nurse practice acts.
b. Ensuring that nursing staff under their supervision are currently licensed to practice.
c. Referring all errors in nursing judgment to state discipline boards.
d. Ensuring that physicians are properly licensed to provide care on patient care units.
Nurses are responsible for knowing and practicing under state law and nurse practice acts. Managers are responsible for monitoring staff practice and ensuring that staff hold current, valid licensure.
a. Be able to effectively communicate with patients.
b. Build relationships with physicians.
c. Be able to adapt to daily changes in staffing.
d. Adapt in communicating information to her supervisor.
A particular challenge in team nursing is that staff mixes and staff may change daily because of individual schedules and shortages.
a. Appropriate and indicates that he has assumed accountability for the actions of his staff.
b. Indicative that he does not clearly understand the concept of accountability.
c. Indicative of strong support for his staff and their autonomy.
d. Important in clarifying the difference between his accountability and that of the community in patient care.
Accountability refers to the achievement of desired outcomes. If community agencies are noticing that limited or no change in patient behavior has occurred despite teaching on the unit, then the staff has not achieved accountability, and he is not holding his unit responsible for the outcomes. Martin is also demonstrating lack of accountability.
a. Poor morale on the unit.
b. Corruption of community relationships.
c. Corruption of patient-staff relationships.
d. Unmet patient outcomes for quality care.
Kupperschmidt (2004) points out that when accountability is not accepted, then relationships suffer, professional practice is diminished, and self-esteem suffers.
a. Flexible protocol for evaluating competency skills.
b. Standardized clinical skills checklist.
c. Newly established peer review process.
d. Formalized competency program with established standards for practice.
The competency program with established standards of practice outlines what the nurse must do to achieve desired competencies in her current position. Competency assessment and goal-setting should help the nurse identify how to excel and which competencies the nurse wants to achieve in the future.
a. “It is a nurse’s professional responsibility to maintain quality control.”
b. “All instances of clinical incompetence are to be reported.”
c. “It is not considered being disloyal when one nurse reports another for poor care.”
d. “Patient care is the number one concern. Meeting standards is mandatory and necessary.”
The nurse leader must remind employees that professional responsibility is to maintain quality care, and thus they are obligated to report instances of clinical incompetence, even when it means reporting a co-worker. Ignoring safety violations or poor practice is unprofessional and jeopardizes patient care.
a. Teaching self-catheterization to a patient with paraplegia who has limited English.
b. Basic care for a patient with a head injury who is rapidly deteriorating.
c. One-to-one observation with a suicidal patient.
d. Assessment of patients being admitted through the Emergency Department.
e. Basic hygienic care for a patient who is post MI and stable.
Functions such as assessment, diagnosis, planning, and evaluation cannot be delegated. In addition, stability, critical thinking, time, and safety are factors that are considered in assessing whether or not to delegate care to a UNP. Teaching self-catheterization to a patient with limited English requires critical thinking; basic care for a patient who is rapidly deteriorating exemplifies concern with stability; and assessment of patients through Emergency is related to the factor of time. An exception to safety and stability in which patients may be delegated to UNPs is when patients are placed on suicide precautions.
a. Decide what not to do.
b. Learn to say “No.”
c. Learn to delegate.
d. Break down your workload into large manageable tasks.
To manage time successfully, it is important to break down your workload into smaller, manageable tasks. Developing PERT and Gantt charts will aid in dealing with larger, complex projects. Both charts can be used to outline how an individual will approach a large project.
1. Instruct the UAP to empty the client’s chest tube.
2. Request the UAP to double check a unit of blood that is being hung
3. Change the surgical dressing on the client with a Syme amputation.
4. Ask the UAP to transfer the client from the ICU to the medical unit.
1. The drainage is the client’s chest tube system is not emptied. The drainage chamber should be marked for output, but not emptied
2. An RN must double check a unit of blood prior to infusing the blood; therefor this task cannot be delegated
3. The surgical dressing for a Syme amputation must be changed by a surgeon or the nurse; this task cannot be delegated .
4. The UAP could transfer the client from the ICU because the client is stable and is being transferred to the medical unit.
1. leaves for lunch and does not return to complete the shift.
2. fails to check the ID band when administering medications.
3. Has had three documented medication errors in the last 3 months
4. Has admitted to having an affair with another staff member.
1. Abandonment is a reportable offense to the state board of nursing in every state. Reportable offenses could result in stipulations made to the nurse’s license.
2. this is failure to follow the 5 rights of medication administration, but it is not a reportable offense.
3. Multiple medications errors are a management issue, not a reportable offense.
4. Not a reportable offense.
A. avoid applying any pressure to compromise personal values.
B. change their work assignment until the dilemma is resolved.
C. continually remind staff of consequences related to ignoring organizational goals.
D. refer indecisive staff members for additional training.
An important way in which those in health care facilities and their managers can assist nursing professionals in resolving ethical dilemmas effectively is by neither explicitly nor implicitly pressuring them to go against their own ethical values (Cooper et al., 2003).
A. a judicial risk.
B. an ostensible authority.
D. vicariously liable.
If a nurse negligently injured a client during the course of and within the scope of employment, not only would the nurse be directly liable for damages, but also the health care organization would be vicariously liable.
A. A duty of care was owed to the injured party.
B. An agreement was made to assume another party’s liability.
C. There was a breach of duty.
D. Causation was present.
E. Actual harm or damages were suffered by the plaintiff.
C. There was a breach of dute.
D. Causation was present
E. Actual harm or damages were suffered by the plaintiff.
These four elements are required to establish legal liability on the grounds of malpractice.
The National Council of State Boards of Nursing (1995) defines delegation as transferring the authority to perform a selected nursing task in a selected situation to a competent individual.
Supervision is the provision of guidance or direction, evaluation, and follow-up by the licensed nurse for accomplishment of a nursing task delegated to UAP (National Council of State Boards of Nursing, 1995).
Right supervision is the fifth right of delegation as outlined by the National Council of State Boards of Nursing (1995).
A. patient acuity.
B. staffing effectiveness.
C. nurse-to-patient ratio.
D. nursing workload.
Staffing effectiveness is the evaluation of the effect of nurse staffing on quality patient, financial, and organizational outcomes.
A. staffing ratios are recommended in perinatal and critical care areas.
B. Incorrect Response nurse managers may determine the nurse-to-patient ratio as long as the patient’s needs are being met.
C. hospitals must also provide the right number of competent staff members to meet the patients’ needs.
D. hospitals may limit the number of admissions to ensure there are an adequate number of staff members to meet patient needs.
TJC noted the following (2006): The goal of the human resources function is to ensure that the hospital determines the qualifications and competencies for staff positions based on its mission; populations; and care, treatment, and services. Hospitals must also provide the right number of competent staff members to meet the patients’ needs. (p. HR-1)
A. decreases in RN workload.
B. increased nursing satisfaction.
C. decreased patient satisfaction.
D. decreased patient safety concerns.
The approach for decreasing nursing RN skill mix was implemented in a “one size fits all” approach across organizations and often lacked evaluation of the skill mix change and other changes on the quality of care and nurse job satisfaction and retention (Eck, 1999; Norrish & Rundall, 2001). This was most apparent in California where a leaner RN skill mix was tried by Kaiser Permanente Northern California in the early 1990s. Skill mix was reduced from 55% RNs to 30% RNs in 1995 (Robertson & Samuelson, 1996). The changes in skill mix led to widespread real and perceived increases in RN workload, patient safety concerns, and nurse and consumer complaints.
A. patient days.
B. patient acuity system.
C. average length of stay.
D. nursing care hours per patient day.
The amount of work performed by a unit is referred to as its workload, and workload volume is measured in terms of units of service. The workload standard commonly used is nursing care hours per patient day, although the validity of this measure is disputed.
A. identify risks.
B. improve quality.
C. prevent damage.
D. control occurrences.
E. control legal liability.
C. Prevent Damage
D. Control Occurrences
E. Control Legal Liability
Civility is authentic respect for others requiring time, presence, engagement, and intention to seek common ground
D. product line
The capital budget is the plan for the purchase of major equipment or assets.
A. availability of handguns.
B. growing acceptance of drug use by health professionals.
C. inability of facilities to screen employees properly.
D. increasing number of patients with mental illness.
Violence in hospitals is caused by a combination of internal and external factors. External conditions include the availability of handguns.
A. a greater number of patients return to the facility for care.
B. staff nurses report increased job satisfaction.
C. the patient receives exposure to a positive role model.
D. violence escalates.
The toleration of hostile or threatening behavior can result in escalation that results in physical harm (Hoag-Apel, 1999).
A. allowing the local police force to control violence within the facility.
B. delegating the control of workplace violence to individual unit managers.
C. developing comprehensive violence prevention policies and procedures.
D. empowering each nurse to assess each situation and react accordingly.
Human resource management policies addressing hiring, discipline, counseling, training, threat assessment, threat management, and reporting are essential for the prevention and/or mitigation of violence from current or former workers in health care organizations.
Autonomy refers to the client’s right of self-determination and freedom of decision making. A patient who is not fully informed is denied the freedom and access to make a decision.
A. Notifying the pharmacy and central supply that there are delays in supply delivery
B. Gathering supplies and checking for the availability of medications so they can be ordered prior to starting care
C. Informing the prior shift that this is a problem
D. Completing an occurrence report so quality assurance will investigate the problem
Changes in patient conditions and medical orders occur frequently, which require new or different equipment and medications to be added or changed. It is always best, particularly if it is known that there are discrepancies in this area, to check to see whether all needed supplies are available before initiating care.
A. breach of beneficence.
B. example of maleficence.
C. potential assault and battery charge.
D. violation of the Health Insurance Portability and Accountability Act (HIPAA).
HIPAA provisions have heightened awareness about and encouraged strategies to protect a patient’s privacy in health care transactions. This is an example of breach of confidentiality.
A. Chief executive officer
B. Institution where the LPN/LVN works
C. Risk manager
The institution where the LPN/LVN works is liable for negligence or malpractice of the LPN/LVN or RN. Only the RN can provide discharge instruction.
A. assessment of the patient.
B. evaluation of an intervention.
C. nursing judgment.
D. teaching to a delegate.
The RN is responsible for assessment, evaluation, and nursing judgment and should not delegate these professional responsibilities.
A. a competent level of care demonstrated by the nursing process
B. a process of care
D. guidelines of care
Standard of care deal with a competent level of care demonstrated by the nursing process
Accountability refers to the liability for task performance. Accountability means being answerable and liable. The assignment of responsibility and the granting of authority create accountability.
A. No consent is needed because of the emergency nature of the surgery.
B. Have the patient sign the consent because he understands the explanation from the surgeon.
C. Have the patient’s sister explain the procedure in Spanish, but ask the mother to sign the Spanish consent form.
D. Obtain an interpreter to explain the procedure to the patient and mother in Spanish, and ask her to sign a Spanish consent form.
According to the Office of Minority Health (2007) in the USDHHS, the National Standards on Culturally and Linguistically Appropriate Services (CLAS) state that health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Therefore, because the patient is a minor, the legal parent must understand the procedure in her native language.
A. A succinct statement of the ethical obligations and duties of every individual who enters the profession
B. The profession’s nonnegotiable ethical standard
C. An expression of nursing’s own understanding of its commitment to society
D. All of the above
The Code of Ethics is a succinct statement of ethical obligations and duties, the nonnegotiable ethical standard and nursing’s understanding of its commitment to society
B. current federal defense attorney.
C. state nurse practice act.
D. policy and procedure manual of the unit.
Nurse practice acts exist for each state and govern the legal practice of nursing, including standard of care, delegation, and supervision.
A. A broad direction for the practice of nursing
B. A legal document
C. Authoritative statements about nursing practice
D. All of the above
A. Right task
B. Right circumstance
C. Right person
D. Right direction/communication
E. Right supervision/evaluation
The right direction/communication of delegated elements of care will be a clear, concise description of the task, including its objective, limits, and expectations. The nurse allows for clarification without the fear of repercussions.
A. Encrypted e-mail communications
B. Fax transmission sent to incorrect physician office
C. Prescription given to patient with wrong label attached
D. Case management coordinator obtaining information about a patient’s diagnosis
E. Discharge summary given to patient’s spouse
C. Prescription given to patient with wrong label attached
Fax transmissions sent to the incorrect physician’s office or prescriptions given to a patient with the wrong label attached are examples of privacy or security breaches under HIPAA. Electronic transmissions should be end-user encrypted for data security.
A. Client’s wife
B. Nurse manager
D. Staff RN
D. Staff RN
It is possible that the nurse and nurse manager could be held negligent. The nurse could be held negligent for not moving the patient closer to the nurse’s station, calling the physician or nurse practitioner for medications or change in medications, or obtaining an order for a vest restraint. The nurse manager may be held negligent because of 24-hour accountability for the care of patients on his or her unit and possible lack of supervision.
a. Weekend requirements
b. Maximum work stretch for each employee
c. Trends in acuity on the unit
d. Hours of operation of the unit
Acuity levels are determined through classification systems, which determine the nursing resources required.
a. Organizational staffing policies.
b. Professional Nursing Association standards.
c. Consumer feedback and expectations.
d. State regulations and standards.
State licensing standards outline what a nurse can do. Internal policies determine what a nurse may do in a particular setting as well as the amount of flexibility that is allowed to manage times of high and low volumes, as well as changes in acuity. Organizational policies can put the nurse manager in a situation where patient safety cannot be maintained or financial obligations met.
a. Provides more expensive care than other types of insurance plans.
b. Has a centralized administration that directs and compensates physician services.
c. Pays physicians on a fee-for-service basis.
d. Does not pay as much for acute care as other practice plans.
Managed care involves prospective pay for care received over a specified length of time or a prepaid payment period rather than a retrospective system that pays physicians for services actually rendered through fee-for-service. Health maintenance organizations are a form of managed care that is administered centrally.
a. Vacation time, holiday time, and sick time.
b. Paid hours minus meeting time.
c. Paid hours minus worked hours.
d. Work time, educational time, and holiday time.
Nonproductive hours are hours of benefit time and include vacation, holiday, and personal or sick time.
a. Requiring second opinions.
b. Providing fewer services to fewer clients.
c. Using fewer services per client.
d. Using high-technology treatments.
In a capitated environment, a single fee is paid for all services provided. To be financially viable under this reimbursement model, organizations would be interested in decreasing the volume of services used and increasing the volume of patients. High-technology treatments and second opinions may increase the number of services used.
a. “Several staff members have commented that you don’t do your fair share of the work.”
b. “If you don’t do your share of the work, I will have to inform the nurse manager.”
c. “I need to talk to you about unit expectations regarding delegating and completing tasks.”
d. “You have been very inconsiderate of others by not completing your share of the work.”
a. staff member providing care.
b. the nurse manager for the unit.
c. admitting provider.
d. institution where care is provided.
a. The nurse in charge of the unit
b. If there is an assigned resource nurse to serve as mentor for the temporary nurse
c. If there are standing orders for interventions for hypotension
d. If the temporary nurse has had an orientation to the unit
Patient safety is always the first concern, and attention must first center on ensuring the patient’s welfare. To prevent such an occurrence in the future, the nurse manager should next determine who is in charge of the unit. Questions to ask the charge nurse include asking about the temporary nurse’s qualifications and experiences caring for critical postoperative patients, if a resource nurse was assigned to the temporary nurse so that the temporary nurse had a mentor and could ask questions if needed. Finally, the nurse manager should ask about the orientation to the unit and whether the temporary nurse was informed about the types of intravenous pumps used in this facility, how to set the appropriate drip rate, and the necessary monitoring of patients who are receiving vasopressor agents.
a. Patient was noted to have a low arterial blood pressure (76/40) and the vasopressor medication was discontinued.
b. Patient’s vasopressor medication was infusing at a higher rate than ordered and the medication was discontinued when the patient’s blood pressure dropped to 76/40.
c. Nurse MJ started the vasopressor medication; the patient subsequently was noted to have a blood pressure reading of 76/40, the medication was discontinued, and the physician notified.
d. Patient receiving vasopressor medication intravenously; blood pressure fell to 76/40 and intravenous infusion discontinued; physician notified and the patient given 500 mL of IV fluid over 15 minutes.
The most complete incident report note is Option D because it states what was happening, why an intervention was needed, and the follow-up care for the patient. Option A is also correct but is less desirable as there is no mention of what follow-up measures were done to ensure the patient’s welfare. Options B and C are incorrect; there should never be a mention or indication, however slight, of liability in the incident report, as it could later be used in a court of law to show liability against the healthcare providers and the institution.
a. Respect for others
Justice concerns treating people equally and fairly. Both patients awaiting admission to the ICU are equally in need of the medical and nursing care available in this unit. The next best choice is respect for others, transcending culture differences, gender issues, racial concerns, and, in this instance, age differences. Though one of the patients is much younger and seemingly more affluent in the local society, both are deserving of the highest quality care. Beneficence could also be said to be applied in this instance; doing good by assuring that both patients are admitted to the unit. Fidelity is the least applicable principle in this instance as it pertains to keeping one promises and commitments and, given the facts of the scenario, there is no indication of any promise being made to either of the patients to be admitted.
a. Increase the number of total nursing hours on the unit.
b. Institute a safety restraint policy.
c. Purchase side rails that are easy to raise and lower.
d. Place patients at risk for falls close to the nursing station.
Research supports the idea that patient falls increase when there is insufficient staffing on a unit. While putting patients who are at risk for falls close to the nursing station is often appropriate, it is not the most effective strategy. Restraints are a poor nursing strategy for preventing falls, and although side rails may be helpful, they do not stop patients from falling when getting out of bed or in other situations.
a. Multiple factors, such as patient acuity and nurse experience, influence the time required to adequately care for the patient. This requires nursing judgment to determine the standard.
b. Having nurses who provide direct care involved in developing a staffing plan will prevent cost from being the major influence on determining the number of staff required on a unit.
c. Mandated staffing ratios may prevent an adequate staffing pattern in some circumstances, when unusual resources are required for a particular patient.
d. Decisions by staffing committees made up of registered nurses are more likely to be accepted by the nursing staff.
a. Let her know how much her work is appreciated in a time when there is a shortage of staff.
b. Ask her to share her work schedule, since other staff may complain about a lack of opportunity to work overtime.
c. Review the research regarding the relationship between patient errors and fatigued nurses.
d. Put her on “warning” for putting patients’ safety at risk.
Beginning evidence is emerging that working more than 12 hours and rotating shifts can lead to errors that compromise patient safety.
a. A nurse 9 months post licensure working on an orthopedic unit is asked to float to a cardiac step-down unit.
b. An experienced psych nurse is asked to work on a palliative care unit.
c. A nurse who has worked in the CCU for 2 years is asked to work on a cardiac step-down unit.
d. An experienced nurse working on a medical-surgical unit is asked to work in a medical-surgical ICU.
The nurse who has worked in the CCU will have had the necessary competencies validated for this assignment.
a. First, determine if the employee issue is a will or skill issue.
b. Conduct a chart review that reflects the care issue.
c. Ask questions of the employee that can reflect the employee’s knowledge base.
It is appropriate to obtain more information and questions regarding the employee’s knowledge base of both the standards of care and the evidence. Policies and procedures help add to this information so that the leader can make the best assessment possible. The leader could also use scenarios.
a. Attempt to remove the visitor from the room.
b. Attempt to reason with the visitor and calm him or her down.
c. Assess the patient for injuries.
d. Call security for help.
The nurse should not attempt to intervene in this situation with a clearly agitated and aggressive visitor. In this situation, the safety of the nurse is the primary concern. Assistance is needed to first control the situation, remove the aggressor, and then assess the patient and provide appropriate care.
a. Avoid the issue and say nothing but remain angry about the situation.
b. Confront the charge nurse about the inequity in the assignment.
c. Approach the peer and ask to switch assignments.
d. Share concerns with the charge nurse and find a mutually acceptable compromise for the situation.
Avoiding the situation creates feelings of powerlessness and frustration that can lead to the nurse feeling that she may not want to work in this environment, or may cause lack of focus that could result in patient safety concerns. Confrontation creates a power struggle and may escalate bad feelings for both parties. It may also affect the ongoing relationship between the charge nurse and the bedside nurse. Attempting to switch assignments without the charge nurse’s involvement is unacceptable. The best solution to the problem is to initiate a dialogue with the charge nurse. This may shed light on the rationale behind the assignment and allows the charge nurse to acknowledge the nurse’s concerns and negotiate an acceptable solution. It also allows the charge nurse to work on developing a better team environment.
a. Loss of productivity and potential for high staff turnover
b. Potential for patient safety errors that may increase the cost of care
c. An increase in teamwork and communication
d. Increase in anxiety, low self-esteem, and sleep disorders among the staff
Bullying behaviors negatively impact teamwork and communication and can contribute to all of the other issues listed.
Ms. Viola is assessing the circumstances (environment) on the unit to determine if she needs to use high-level delegation strategies to provide high-quality patient care.
d. Legal authority.
Legal authority is the ability to transfer selected nursing activities in a given situation to a competent individual. Responsibility is the reliability, dependability, and obligation to accomplish work. Accountability determines if the actions taken were appropriate and provides a detailed explanation of what occurred. Supervision is the oversight of delegated work.
a. Patient’s condition.
b. Complexity of the task to be performed.
c. Medical insurance of the patient.
d. Predictability of outcomes
In the delegation process, the three major factors that need to be assessed are the patient’s condition, complexity of the task to be performed, and the predictability of outcomes. The patient’s medical insurance is not a factor in the delegation process.
a. Improve the work performance of staff.
b. Decrease the registered nurses’ accountability.
c. Achieve nursing goals.
d. Improve patient care outcomes.
Delegation is a multifaceted decision-making process implemented to improve the work performance of staff, improve nursing care, and achieve nursing goals. The registered nurses maintain accountability for delegation decisions.