Working Your Staff Unsafely

This week has been the week of speaking with different professionals on training and how companies place employees in jobs that are not properly trained in their skill set to pay them less and get more out of them.  I used to work for a large insurance company that employed over 80,000 people.  I worked in the long-term care department which had about 400 staff from administrative assistants to presidents. I was the manager of case managers which consisted of RN’s, LPN’s and Social Workers.  They all did the same job and got paid different salaries to do it, however the job description and responsibility was the same.

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I felt that this policy of having nurses and social workers working on the same cases needed to be changed. Having all the staff doing the same exact work and paying them differently based on their degree and expecting the same level of skill, was inappropriate.   Nurses have a different skill set than social workers.  If a patient has a medical issue, the social worker that is visiting that member in the home completing an assessment may not be able to capture that the member has been retaining water in their ankles and think to ask if they are on a diuretic.  Much like the nurse that goes in the home setting and sees a patient that has issues paying their light bill won’t know where to call to find a resource for them.  The patient may be concerned because they are on oxygen at home; they wonder how they will pay their light bill and what they will do if the power is turned off. This can be a liability to any staff member but also a disservice to the patient.

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In contrast, I worked for another company that did case management. I loved that job, until federal cutbacks came along for the program during the new Obama administration.   The company employed RN’s, MSW’s, CHW’s, Nutritionists and Behavioral Health Specialists.   The cases were assigned only to nurses and there were two tiers of nurses, regular case managers and those that were more experienced received complex care patients.  The other staff MSW’s, CHW’s , Nutritionists and Behavioral Health Specialists were consulting on the files that the nurses referred to them.  They would work as a team with the nurses. This team work gave the patient a more well-rounded form of care.

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There are several leadership styles in companies, autocratic, democratic and laissez-faire.  In the large insurance company that had all the workers regardless of skill set do the same job,  the leadership was autocratic.  The department maintained total control in all decisions and no opinions or suggestions were accepted from others. There was no opportunity to make a change due to the leadership style.   In my prior job, where everyone worked on a tiered team,  there was a democracy; decisions were made after consideration of input from the staff (Mitchell, 2013).

A team of medical professionals  gather for a daily meeting to discuss the elderly patients at the “Acute Care for Elders” unit at the University of Alabama Hospital, Birmingham. (Hal Yeager for KHN)

There are some days that as a professional you want to see changes implemented or at least considered, however the leadership does not support that.  If you are the type of person that works for the better of seeing changes in a situation, get involved in the departments or committees that have a say in policy writing, this will be the only way to see changes that can be discussed for the betterment of the company.

References

Mitchell, G. (2013, April). Selecting the Best Theory to Implement Planned Change. Nursing Management, 20(1), 32-37. Retrieved from http://web.a.ebscohost.com.library.capella.edu/ehost/pdfviewer/pdfviewer?sid=4ba42c53-9a6d-4ec5-b6bb-2f078e04b7c7%40sessionmgr4001&vid=1&hid=4204

Using Evidence to Change Policies

Rules are sometimes implemented by people who may not actually be a staff nurse to observe and see what a family’s needs are.  In most hospitals these days there are more times that can be spent with families in intensive care units, however they are probably limited to 1-2 people.  As a staff nurse, changing a policy that is not implemented is not a good thing, because if something were to happen while the family is there, the nurse may be reprimanded for not following protocol.  What the staff nurse can do is collect information by asking a foreground question that is more specific (Rubenfeld & Schaeffer, 2014).

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An example of a foreground question can be which visiting hours work best for families that have patients in the hospital?   The nurse should look for the answers by recording the hours that the families are able to come in to see their loved one.  Once this is determined, then the nurse can speak with the manager and bring the evidence that was collected, specifically how many families were questioned, what hours they were visiting, what is the majority of the time that families selected.  Once the manager has had a chance to review the statistics provided, then this information can be taken to the decision makers of policies to review and come up with a better outcome. Making changes in the workplace can only take place when the staff genuinely cares about work place practices that will benefit their patient and the staff (Mitchell, 2013).

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References

Mitchell, G. (2013, April). Selecting the Best Theory to Implement Planned Change. Nursing Management, 20(1), 32-37. Retrieved from http://web.a.ebscohost.com.library.capella.edu/ehost/pdfviewer/pdfviewer?sid=4ba42c53-9a6d-4ec5-b6bb-2f078e04b7c7%40sessionmgr4001&vid=1&hid=4204

Rubenfeld, M. G., & Scheffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. Retrieved from http://online.vitalsource.com/books/9781284059571

Empowering Patients with Chronic Conditions

Many patients that are diagnosed with chronic conditions have a hard time understanding how to take care of themselves at home, especially if there is a language barrier.  Community Health Workers (CHW’s) work in the community and empower people to take care of their chronic conditions.  One of the chronic conditions that drives the bills up for Medicaid is Diabetes.  Many  of the people who were being seen in the clinic were Hispanic and had trouble understanding how to take care of their Diabetes.

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Some of these clinics started to take charge and work with Medicaid to decrease the cost of hospital admissions and frequent clinic visits.  What ended up happening was that once per week, a Diabetic Educator would teach classes in Spanish about managing their Diabetes.  The educator went over checking their blood sugar with the blood glucose monitor, exercise, insulin administration, diet, skin and foot care as well as regular follow up with their primary care physician.  This population was very non-compliant and would prefer to use the emergency room instead of the doctor to manage their chronic condition.

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The CHW’s made visits to the patient’s homes and reinforced the teaching that the Diabetic Educator taught the week prior at the center.  Some patients would not be able to get out to the community center, so the teaching would be brought to them by the CHW.  When I read about comparing old thinking and new thinking, one of the things that is mentioned is the difference between a background question and a foreground question.  The foreground questions are more specific and probably a better fit for the studies that need to be done on the Hispanic population suffering from Diabetes.  With the foreground question one can ask which works best for reducing hospitalizations for Diabetic patients instead of how can we manage someone’s Diabetes which is a background question (Rubenfeld & Scheffer, 2005).

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References

Rubenfeld, M. G., & Scheffer, B. K. (2005). Critical Thinking TACTICS for Nurses:Achieving the IOM Competencies (3rd ed.). [Vital Source BookShelf]. Retrieved from http://online.vitalsource.com/books/9781284059571

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How Nursing Has Evolved Through the Years

Nursing has evolved throughout the years thank goodness to a different level of respect.  Although I do believe that some doctors and even nurses still carry the old way of practicing where the doctor is the lead and nothing else matters.  This is I believe even differs from the North to the South.  I remember graduating from nursing school and working with the doctors in labor and delivery who are now looking at me not as the kid in school, but as the professional on their team.  The doctors would say call me Mike, or John when we were not around the patients and it was a comfortable working relationship (not to the extent of the TV show dramas, that is not realistic!) making everyone’s job easier, especially for a new grad that had questions.

When I moved to Florida I noticed that the nurses and staff would say Dr. Smith or Dr. Jones and he would say whatever it is he needed and the nurse would say yes sir, is there anything else that I can do for you.  It was the politeness of the South or the servant of the South one or the other.  I thought to myself,  okay this is  certainly going to take some getting used to if I am going to live in Florida.  In no time at all, I had to conform since I wanted to be gainfully employed.

When I think of being on an interprofessional team, I think of the team that I was in up North, where it was a comfortable open ended relationship between nurses and doctors to discuss what was happening with the patient and come up with a plan.  When I think of being on the interprofessioal team in Florida when I first moved here, that to me was not a team.  It was a nurse and a doctor, with the doctor stating what needed to be done, the nurse saying yes sir and doing what she was asked.  It should be a partnership collaborating together (Sommerfeldt, 2013).

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Many years have evolved since I first moved to Florida and I have seen the change happen where nurses can have a more involved relationship with doctors as a team player and include nutritionists, therapists and discharge planners. There are still some rigid single minded doctors out there that will not work on an interprofessional team; however our job is not to change them.  We can spend a long time trying to make changes and getting our point of views heard, but if we can make an impact with what we can control in our scope of practice, this will go a long way to improving healthcare.

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References

Sommerfeldt, S. C. (2013, February 25 2013). Articulating Nursing in an Interpersonal World. Nurse Education in Practice, (13), 519. http://dx.doi.org/http://dx.doi.org/10.1016/j.nepr.2013.02.014

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The Nurse Leader of a Healthcare Team

A nurse can play three different roles as part of an interprofessional team.  The three roles consist of a nurse, nurse leader and nurse educator.   The interprofessionalism team consists of other healthcare workers as well, not just nurses (Sommerfeldt, 2013).   However as nurses the roles can be at different levels depending on the patient’s condition.  At my previous job, I worked as a complex case manager.  The team consisted of registered nurses, social workers (masters prepared) behavioral health specialists, community health workers and nutritionists.  The nurse case manager managed the patient, however if there was an issue with the patient in the home setting that required community resources, the community health worker would be consulted to assist in those needs.  If the member had psychological issue or other financial issues that required the need of a social worker or behavioral health specialist this referral would be added as well.  There was collaboration on the plan of care and all participated because we all were looking at the patient as a whole, not just as the part that each discipline took care of.  If the member cannot pay his light bill or water bill due to financial difficulties, until we take care of those needs through resources, any teaching that the nurse would do would be in vain.  A person cannot focus on teaching for their health or anything else if their mind is on their current financial strain, not their medical condition. In this instance the nurse is playing the role of the nurse leader.

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When a patient is in the hospital a nurse can also play the role of a nurse that is doing dressing changes, medication administration and other treatments.  The nurse’s role in the interprofessional team that may consist of the doctor, physical therapist and dietician, would be more medically involved because maybe the patient is recuperating from heart surgery and requires a lot of care initially.  The patient is on a special cardiac diet, which can also be explained by the treating nurse, however in this instance, the member is starting something new, so a consult from the dietician can help the patient understand the diet and the nurse can reinforce the teaching.

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The nurse educator as part of the interdisciplinary team can be seen for example in a disease management setting.  This type of setting also has multiple specialties that can follow the patient.  In this instance the nurse educator is educating the member on how to empower themselves and learn about managing their chronic disease by learning about taking their medications, following a diet and exercise program, learning to check their blood sugar or blood pressure.  The nurse educator measures the members learning based on return demonstration through development of a plan of care.

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All three roles bring value to the scenario that they are in, because the nurse is the one that will be around the patient most of the time.  In each role the nurses is responsible for all aspects of the patient’s care. In reading through the assigned readings for this week, I am able to see that although you have one nurse, that one nurse can play one of three roles depending on what scenario the nurse is in.  Regardless of which role the nurse is playing, working on an interprofessional teams is a style of partnership that allows decision making to be collaborative (Sommerfeldt, 2013).   It takes many people to work together in getting a patient discharged to his home.

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References

Sommerfeldt, S. C. (2013, February 25 2013). Articulating Nursing in an Interpersonal World. Nurse Education in Practice, (13), 519. http://dx.doi.org/http://dx.doi.org/10.1016/j.nepr.2013.02.014

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Tuition Reimbursement by Employers

In today’s world if there is an  employer that values their staff and gives them the encouragement, tuition reimbursement and educational leave to complete schoolwork, that is a great thing.   It is not often that employers will allow tuition reimbursement let alone time off to do internships or flex schedules.

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I used to work at a large corporate insurance carrier.  They offered tuition reimbursement, however each department director had the ability to accept or decline the area of study that the student was taking.  There were nurses that had their MSN in our department and requested tuition reimbursement for their ARNP and it was denied.  We had ARNP’s at our company, but in a different department.  The rationale for the denial that one nurse received was that this was not an area of study that they wished to approve.  The director indicated that there was not an immediate need in our department for an ARNP.  The nurse was crushed as the policy on tuition reimbursement clearly states that as long as the area of study pertains to your job, it should be approved, however at your director’s discretion.  This very same nurse would take every Friday off to do her clinical practice and did not take any other vacation days or sick days to ensure that she was able to do this. I approved this for her so that she can get her school work done. My director at the time asked why I would approve such a schedule, I explained that due to her clinical practice she needed to be off to fulfill her practice. I knew when this nurse was going to graduate so I made sure that I approved her time off for the entire year.  Do you know that my Director stated that in the future these requests could not be granted.

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In the book Critical Thinking Tactics for Nurses, there is a section that speaks about comments and behaviors that promote or squelch critical thinking.  As I read through some of those that squelch, critical thinking, they resonate in my mind, “ that’s the wrong way to do that, just do it this way, don’t you know that and you should know that ”  (Rubenfeld & Schaeffer, 2014, p. 91-92).

When I hear about a place of work,  that gives their employees a reason to stay and better themselves, it is enlightening.   I have always believed that the face of a company is every single employee that answers a call, makes a visit and does anything for the company, no matter what position they hold.  Therefore, if an employer invests time and money in that employee, they will grow and continue to make themselves and their employer successful.  This in turn will create job security because people will want to do business with happy employees.

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References

Rubenfeld, M. G., & Schaeffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. http://dx.doi.org/

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The Future of Nursing Your Workplace

I was recently speaking to a nurse about her current work place and some of the changes that she sees coming.  She was concerned for the safety of her patients with many changes that will take place putting more work on the nurses and not for any greater pay or benefit.  I explained to this nurse about a previous place that I was employed at and how I had to break away  because I was not using my full potential as a nurse.

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In my previous work environment, my position was a manager of long-term care case managers. The Institute of Medicine(IOM) report was not shaping our scope of practice at my previous location. The organization was very top-heavy and there did not seem to be enough people to do the jobs that directly affects the population that we serviced, which was the Medicaid and Medicare population.  The training that was provided to the staff was more on how to complete reports and paperwork that was required by the state of Florida in order to be in compliance with AHCA.

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The issue with this was that the members were not being followed up with properly.  Nurses and social workers were going through the motions of case managing their files, with basic monthly telephonic questions asking a member living in the home how things were going, have they received their supplies was there anything new that they should be aware of.  A monthly contact should involve so much more, but yet it didn’t because the case managers did not have enough time to fulfill the job in eight hours and they would work for 12-15 hours daily some of them, to get documentation done in order to avoid a reprimand by upper management.

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In the IOM report there are six aims that healthcare providers should follow and one of them is patient centered healthcare (Rubenfeld & Schaeffer, 2014, p. 82). The goal of the health plan was to have patient centered care and have policies in place for it.  The case managers did everything in their power to obtain services for the members and get them started as soon as possible and formulate a care plan with goals.  The challenge that they were running in to was that the case managers were out in the field 4-5 days per week, they didn’t have time to complete the documentation of their assessments while they were in the member’s home, therefore creating more after hours documentation for the case managers, dissatisfaction with the job and more report concerns rather than focusing the time speaking with the member to really understand what the member’s needs are.

The nurses and social workers were not able to apply quality improvement plans because there was little collaboration as an interdisciplinary team. Nurses and social workers both did the same assessments and did not have the ability to collaborate on a case as if they were both co-managing the case.

The nurse I was speaking to was amazed that this happened in the work place that I used to work in. I explained to this nurse that the IOM report would not shape my career as a doctorate of nurse practice (DNP)  at my former job because the region that I was in did not support critical thinking or any type of evidenced based nursing.  The rigid structure would remain and no changes unless implemented or suggested by upper management would be considered in our department.

Now as a DNP on the outside of this organization, the ultimate goal is to consult with nurses, doctors. therapists, nutritionists  and specialist to get the right  people involved in carin for a patient whether at home or in a facility.  It is good to have a future goal with a plan in place to reach that goal.

Two Businesswomen Meeting Around Table In Modern Office
References

Rubenfeld, M. G., & Schaeffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. http://dx.doi.org/

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Nurses in the School System

Last year I explored the need for a nurse in the school, because my little boy who was born premature was entering kindergarten.  I believe that today the question of whether there is a nurse on staff at schools has become a frequent question.  I am just learning that many schools do not have nurses on staff (Florida Association of School Nurses website, n.d.).  In doing some research about Florida nurses after exploring this for my own child, it drew my attention to find out for myself  what options are available to families in school systems.  In one article by the Orlando Sentinel, it notes that not all Orange County public schools have a nurse, in fact their ratio out of 182 schools in Orange County, showed only 34 had nurses. One Orange County school mentioned that they have an RN and she helps a lot because it frees up the teacher to focus on their classroom instead of the child that is sick. The article went on to say that some tasks are delegated by the RN to non-clinical personnel, for instance an assistant principal or secretary when the nurse is not in the school (Roth, 2011).

In my opinion, although parents of children administer injections like epinephrine for allergic reactions or insulin, they are the parents that have been taught to watch for certain symptoms in their child that they see day in and day out.  They have a working knowledge of the situation should it arise. The school personnel, may be taught when to administer a medication like epinephrine or insulin, but if they have never used it, or administered it, how can they safely administer it? Will they know symptoms to look for if there is a reaction?

In the state of Delaware every school is required to have a registered nurse.  Some schools that have them receive the funding through the school system grants, or in the community (Roth, 2011).  I most recently went to a school that is private with an estimated tuition rate of $14,000 per year and service preschoolers through high school. The school has a large arts program and population of about 2000 kids, each child receives an IPad upon admission to use for homework.  They stated that they did not have a school nurse, if a child warranted medical treatment of medications or breathing treatments, this would not be the school for the child.  I found it rather sad to see that value was placed more on the material things of an IPad (which I know can help advance a student) but really the computers work just fine and having a registered nurse to help in times of kids needing treatment, or a school teacher needing treatment far outweighs the IPad.

My question then becomes to what extent is the Affordable Care Act going to benefit schools with the rise in costs of healthcare? Will every school have grants to hire a nurse?  Will they have these mini clinics on site?

 

 

References

Florida Association of School Nurses website. (n.d.). https://fasn.nursingnetwork.com/page/18381-school-nurses-save-money-

Roth, L. (2011, September 26). A nurse in every school? Not in Florida not even close. Orlando Sentinel. Retrieved from http://articles.orlandosentinel.com/2011-09-26/business/os-fewer-school-nurses-florida-20110925_1_school-nurses-practical-nurses-students-with-chronic-illnesses

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The Ever Changing Role of Healthcare

In the ever changing world of healthcare,  as new illnesses come along and as managed care gets more involved, nurses and doctors alike will be required to be on top of different ways that they can provide care to patients, DNP’s ( Doctorate of Nurse Practice)  will have to step in and provide expert clinical advice.  With health care costs on the rise, there are new and improved ways to provide care to patients both in and out of the hospitals.  Much of it involves empowering patients and their families to learn more about healthcare.  This will put more responsibility on the nurse to manage the care.  Many people use the emergency room as their primary care doctor.  This is the information that nurses can take to empower patients to have a primary care doctor or go to a less urgent facility like a walk in clinic if it is after hours to allow them to determine severity of their condition.

With the Affordable Care Act, it would be helpful for the DNP to be in an interdisciplinary team, because the nurse cannot possibly function in all the capacities and take care of multiple patients.  Nurses these days coordinate care for patients at home and even in the hospital, so that the different disciplines that need to see the patient, can help them recuperate from their illness or adjust to a new way of life due to a life changing illness.  The eight essential roles for the DNP may be interwoven, however each is a specialty in of itself and that is where the interdisciplinary team can come in to play (Fain, Asselin, & McCurry, 2008).

 

References

Fain, J., Asselin, M., & McCurry, M. (2008, July). The DNP why now. Nursing Management Springhouse, 39(7), 34-37. http://dx.doi.org/10.1097/01.NUMA.0000326565.46790.c0

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Systematic Review of the Evidence

Various studies have been conducted on the stress level that parents of premature babies go through while their baby is in the Neonatal Intensive Care Unit (NICU).  A qualitative approach study was retrieved for the purpose of supporting the evidence of the subpopulation of parents of premature babies.  The method that was used was semi interview style.  Two mothers that were in preterm labor were used for the study.  The mothers were found to be feeling separation anxiety after delivering their babies prematurely.  The feelings that the mothers felt were that of a shattered dream, their ideal situation of having an uncomplicated birth and taking a newborn home right after delivery and planning that so called “normal life,” had been shattered  (Da Costa Krieger et al., 2014).

There are many studies conducted on the stress level that parents of premature babies face therefore making it a good population to continue researching and seeing what kind of impact can be made to support this group.  The evidence that was found compounded more stress on parents and this was stated in the study using Spradley’s domain analysis.  In Spradley’s domain analysis,  mothers were found to be stressed not only because of the fact that their baby was in the NICU,  but stressed because the nurses taking care of their baby made the parents feel like they were a visitor as opposed to a mother (Heerman, Wilson, & Wilhelm, 2005).

The findings obtained from this research  proved that no matter how many parents are used for the studies, the common denominator remains the same, parents of premature babies carry a lot of stress.  The stress carried at home due to family obligations with other kids, financial, different schedules, trips to the hospital, attending other kids’ schedules, brings stress to the parents who have babies in the NICU.  The NICU stress alone wondering whether the baby will survive is part of the stressors in the NICU.

References

Da Costa Krieger, D., Valeria de Oliveira, J., Bittencourt, V., Garcia Parker, A., Ambrosina de Oliveira Vargas, M., Regina de Luz, K., & Marin, S. (2014, August). Perception of Prematurity A Case Study Aimed at Approaching Mothers. Journal of Nursing, 2754-2761.

Heerman, J. A., Wilson, M. E., & Wilhelm, P. A. (2005, May/June). Mothers in the NICU: Outsider to Partner. Pediatric Nursing, 31(3), 176-200.

 

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