5/8/2015. Nursing Professional Role Development Program- Day 2. Learning Objectives. Application of Learned Models and Concepts

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1 Nursing Professional Role Development Program- Day 2 Learning Objectives 1. 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 decisionmaking. 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. 2 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? 3 1

2 O Rourke 9-Step Decision-Making Model Making decisions is a complex process 4 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 5 Back to Basics The 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 6 2

3 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 7 O Rourke 9-Step Decision-Making Model Professional Role-Based System for Decision-Making & Accountability 8 Stability of Patient Condition Data Collection & Data Assessment 1 Comprehensive Assessment Patient Condition & DX 2 Plan 3 Implementation 4 Evaluation 7 Dynamic Interaction of 1-6 with Stability (8) & Care Coordination (9) 5 Teach/ Inform 6 Unstable Moderately Unstable Moderately Stable Direct Indirect Direct Indirect 9 Care Coordination/Action Direct Indirect O Rourke 9-Step Decision-Making Model Six Competencies Professional Role Decision-Making Process: Role Accountability Data Collection & Data Assessment Comprehensive Assessment of Patient Condition with DX Plan Implementation Evaluation Teaching/ Informing

4 7 th Competency Integration of Professional Practice Steps Comprehensive Assessment of Patient Condition with DX 2 Plan 3 Implementation 4 Data Collection & Data Assessment 1 Teaching 6 Evaluation 5 10 In practice, the steps of the decision-making process must be linear or sequential. A. True B. False 0% 0% True False 11 Test Your Knowledge Using scientific knowledge and critical thinking, the RN converts data into a diagnosis during the comprehensive assessment step. A. True B. False 0% 0% True False 12 4

5 8 th Competency O Rourke 9-Step Decision-Making Model Stability of the Patient s Condition Estimate of Risk for Morbidity & Mortality Determining stability requires: Substantial scientific knowledge of nursing and medical conditions Knowledge of the patient population Knowledge of the individual patient 8 th Competency O Rourke 9-Step Decision-Making Model 8 Stability of Patient Condition Unstable Moderately Unstable Moderately Stable Stability of the Patient s Condition Estimate of Risk for Morbidity & Mortality Stability of the Patient s Condition Estimate of Risk for Morbidity & Mortality Determining Stability Level 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? A. Stable B. Moderately Stable C. Moderately Unstable D. Unstable 0.00% 0.00%0.00% 0.00% Stable Moderately Stable Moderately Unstable Unstable 15 5

6 Determining Stability Level 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? A. Stable B. Moderately Stable C. Moderately Unstable D. Unstable 0.00% 0.00%0.00% 0.00% Stable Moderately Stable Moderately Unstable Unstable 16 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 17 9 th Competency: Care Coordination Professional Role-Based System for Decision-Making & Accountability 8 Stability of Patient Condition Unstable Data Collection & Data Assessment 1 Comprehensive Assessment Patient Condition & DX 2 Plan 3 Implementation 4 Evaluation 7 Dynamic Interaction of 1-6 with Stability (8) & Care Coordination (9) 5 Teach/ Inform 6 Moderately Unstable Moderately Stable Direct Indirect Direct Indirect 9 Care Coordination/Action Direct Indirect 6

7 Documenting Nursing Stability in Care Connect Test Your Knowledge The Care Partner can assess data (i.e. vital signs), but cannot assess the stability of the patient s condition A. True B. False 0% 0% True False 20 Small Group Exercise: Scenario of Sentinel Event At 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

8 Professional Role Decision Making in Action Nursing Handover 22 Role-Based Handover Observation Tool 23 Role-Based Handover Observation Tool 24 8

9 Exercise using the Handover Observation Tool 25 Test your Knowledge! Crossword Puzzle 26 Break time 27 9

10 Communication: Skills and Tools 28 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. 29 Seven Difficult Conversations in Healthcare Broken Rules Lack of Support Mistakes Incompetence Poor Teamwork Disrespect Micromanagement 30 10

11 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 31 Skill To Communicating Effectively Learn the tools: Quick Coherence Technique 1 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 1 UCLA Brite Training 2 Institute of HeartMath. (2015). HeartMath science and research. Retrieved from 3 Patterson, 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. 32 Quick Coherence Technique 2014 Copyright Institute of HeartMath 11

12 Quick Coherence Technique 12

13 C.O.I.L.S.: The Feedback Model Convey Observe Impact Listen Solve Show your positive intent Describe concrete observation Explain the effect of the behavior/action on you and others Pause and listen for the response Determine solutions 37 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. 38 Step #1: Convey Your Positive Intent 1.Put yourself in a positive frame of mind. 2.Know clearly in your mind what the goal of the feedback session should be What is the positive goal that I am hoping for as a result of this feedback session? The goal is for John to give bedside report

14 Step #2: Observe Current Behaviors 1.Be brief and to the point. 2.Focus on the behavior, not the person. 3.Limit your feedback. How can you state the observation? Z I have observed that you do not give report at the bedside. 40 Step #3: Impact and Consequences 1.State the impact of the behavior on you and others. 2.Maintain an objective tone. How can you state the impact in an objective tone? 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. 41 Step #4: Listen to the Concerns 1.Invite the other person to respond then PAUSE. 2.Listen with an open mind. 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

15 Step #5: Determine Solutions 1. 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. 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. 43 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. 44 Crucial Conversations Technique Move to Action Get Unstuck Explore Others Paths Make it Safe(r) Techniques for Crucial Conversations Start with Master my stories Learn to Look State My Path 45 15

16 Crucial Conversation: Step 1 1. Get Unstuck Which issues do you need to address and with whom to get unstuck? Identify: Content issues Pattern issues Relationship issues I need to address pattern issues with John in order to get unstuck. 46 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 47 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

17 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? 49 Crucial Conversation: Step 5 5. Learn to Look Silence Violence Is John withholding his opinion or forcing his perspective? Am I listening to John or focused on the stories I m creating? 50 Crucial Conversation: Step 6 6. 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 intent Don 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

18 Crucial Conversation: Step 7 AMPP 7. Explore Others Paths Ask 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. 52 Crucial Conversation: Step 8 AMPP 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. 53 Crucial Conversations Technique Move to Action Get Unstuck Explore Others Paths Make it Safe(r) Techniques for Crucial Conversations Start with Master my stories Learn to Look State My Path 54 18

19 Small Group Activity: Crucial Conversation Planner Think 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 55 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. 56 Closing Reflection

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