Helping Nurses Make Decisions About Increased Responsibilities at

WHAT’S IN YOUR HANDOUTS Power Point Clinical Decision Making Tool Mapping Contributing Factors Tool

EXPECTED 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. Alfaro. Teach. Smart. com 3

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. Alfaro. Teach. Smart. com 4

Bus is Leaving the Station & Now it’s an Airplane Will you be on

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. Alfaro. Teach. Smart. com 6

EXPECTED OUTCOMES 1. Discuss increasing responsibilities of nurses related to diagnosis. © 2008 www.

Quotes From The Trenches © 2008 www. Alfaro. Teach. Smart. com 8

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 knowhow -- that nurses save lives, prevent suffering, and save money. If nurses wear not only their hearts, but also their brains on © 2008 www. Alfaro. Teach. Smart. com their sleeves. Perhaps the public…. will 9

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 © 2008 www. Alfaro. Teach. Smart. com 10

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! © 2008 www. Alfaro. Teach. Smart. com 11

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. © 2008 www. Alfaro. Teach. Smart. com 12

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 © 2008 www. Alfaro. Teach. Smart. com 13

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 © 2008 www. Alfaro. Teach. Smart. com 14

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. (Del. Bueno, 2005, p 279) © 2008 www. Alfaro. Teach. Smart. com 15

INCREASED RESPONSIBILITIES § APNs – RNs – LPNs (LVNs) – Techs § Pharmacy – Radiology – PT – Dietary § Risk Managers – QI – Infection Control § Leaders – Managers – Educators § Triage – Diagnostic Orders © 2008 www. Alfaro. Teach. Smart. com 16

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 © 2008 www. Alfaro. Teach. Smart. com 17

INCREASED RESPONSIBILITIES 1. Not expected to make definitive dx 2. 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 a lot of responsibility goes with this. © 2008 www. Alfaro. Teach. Smart. com 18

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 © 2008 www. Alfaro. Teach. Smart. com 19

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. Alfaro. Teach. Smart. com 20

INCREASED RESPONSIBILITIES § Health promotion: smoking cessation, obesity management § Screening: Depression, diabetes § IV management § Outcomes management (eg. Airway management) © 2008 www. Alfaro. Teach. Smart. com 21

DISEASE MANAGEMENT Arthritis Asthma CHF COPD Depression Diabetes Hypertensio n Kidney Disease Wounds ©

PATIENT ASSESSMENT Identifying Reportable Problems, Risks, Signs & Symptoms Identifying Problems, Risks, Signs &

OLD 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. Alfaro. Teach. Smart. com 24

CLINICAL WORKSHEET Name_______ Medical Room_____ Dx___________ Age____ Religion___ Dr. ____________ Culture_____ Allergies_________ Diet____ Activity________ Neuro: Resp: Oxygen: Medications/IV’s: Cardiac: Circ: Potential Complications: Skin: © 2008 www. Alfaro. Teach. Smart. com 25 GI: Nursing DX/problems:

Digoxin 0. 25 mg po OD CIPRO 500 mg po BID KCl Elixir 20

QUICK PRIORITY ASSESSMENT (QPA) Start with patient “snap shot”: § Allergies – Medical Problems § Age - Height – Weight – Hydration § Risk for Infection – Injury § Breathing – Comfort – Communication § Other Relevant Specialty Data © 2008 www. Alfaro. Teach. Smart. com 27

CARE MANAGEMENT Interventions aimed at the disease Interventions aimed at the person © 2008

SOLUTIONS q Mentor-Preceptor-Teacher q Independent learner q Needs Assessment q Tool Development q 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 © 2008 www. Alfaro. Teach. Smart. com 30

Summary © 2008 www. Alfaro. Teach. Smart. com 31

EXPECTED 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. Alfaro. Teach. Smart. com 32

Bibliography Alfaro-Le. Fevre, R. (In Press). Applying nursing process: A tool for critical thinking (7 th ed. ). Philadelphia: Lippincott- Williams & Wilkins Alfaro-Le. Fevre, R. (2008). Giving and Taking Constructive Criticism in: Critical Thinking and Clinical Judgment: A practical approach to Outcome-focused thinking, 4 thed. ). Philadelphia: Elsevier-Saunders Alfaro-Le. Fevre, 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 33 © 2008 www. Alfaro. Teach. Smart. com nursing. The Journal for Nurse Practitioners,

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/Magazine. Article s/article. cfm? AID=5948 Rich, P. Giving and receiving feedback. Retrieved 2/20/2008 from http: //www. selfhelpmagazine. com/articles/growth/feedb ack. 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. Alfaro. Teach. Smart. com 34