Ashley Wolcott 4/13/13 Seminar Saturday Seminar Case Studies Group A Learning Exercise 16.

8 I believe this is a problem that could have been prevented by spending more time with Brian the new nurse, and by employing strategies other than giving him literature to read. For a plan to reintegrate Brian into the team, I would assign him a preceptor on the floor that communicates thoroughly (pg.368). Through this preceptor Brian could spend a day or two observing the preceptor nurse. After that Brian could use the nurse to talk about situations in which he did not feel he communicated well, and ways to improve his skills. If after a month with working with the preceptor Brian is still having problems it may be necessary for the nurse manager to sit with him and give private coaching to see how he handles situations inappropriately (370-371). With one on one coaching the nurse manager could correct him in the moment and give him a better alternative way to communicate. If after a couple of meetings Brian would be re-evaluated and monitored for more complaints by patients if this continues to be a problem it may be appropriate for Brian to find a different situation to work in. Notes:

Case Study: Authority and Responsibility The person most responsible to correct this is the nurses and nursing aides, but also management. The nurses should work with the aides to have optimal patient care, however if the aides and nurses are both overwhelmed then it is managements duty to relieve work load. It may be up to management to find out why the nurses aides have suddenly not been able to complete their tasks. It could be a matter of laziness, or it could be a bigger issue. It seems that there is a bigger issue that needs to be resolved that overwhelming workload. Power in this situation seems to lie with the nurse aides. The aides know that if they do not get all of their work done, the nurses will be forced to pick up the slack. There is also an element of power with the nurse manager because she was able to motivate them for a short time, but not long term. Creating a work team may be useful, while it may promote teamwork and bonding, it may also do the opposite. It seems that there are personality issues going on between the nurse aides and the nursing staff. If a nurse and a nurse aide are put into the same team, and have personality differences that cause problems, the situation may worsen. Teams could always be done on a trial period and monitored to see if they promote cohesiveness. The biggest situational force that led to this seems to be stress of having a full unit. If the nurses are overwhelmed because they are always have five patients and the nurse aides feel overwhelmed by taking eight patients the combined stress will eventually cause negative outcomes. This can and should be addressed. Management should look at the stress of their faculty and make arrangements to relieve some of the stress. In this situation it may be necessary to hire another nurse aide or another nurse to relieve some of the stress of a full unit. It may even be possible to always have a nurse on call, and if the staff begins to get overwhelmed then the on call nurse can come in and assist with duties that are not being completed.

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Group B Learning exercise 24.2 For Mrs. Jones it will be important to point out positive things, such as her hard-working and pleasant nature, positive comments from patients, her follow through with patients. I would focus on tasks rather than her personality, such as giving examples; you showed compassion to Mr. Jones when you gave him a back rub (pg558). I would then like to bring up some things that I see that concern me such as her lack of taking initiative, or allowing nurses to take advantage of her. I would pose these as non-judgmental questions and ask how Mrs. Jones felt about the situations in which these things happened and if she had any insight in how she can improve on them. It seems that Mrs. Jones may lack some confidence to initiate care by herself. Encouraging her to take initiative in care would be useful, but still express that she can ask a nurse questions when she does not understand something or is uncertain about initiating care, but that these should be limited encounters. Negative factors in this scenario are that the LPN is having problems and will need correction. The way in which the need for correction is expressed could be a negative factor. As mentioned in the article Consequences of Positive and Negative Feedback: the impact on emotions and extra-role behaviors by Belschak, and Hartog it is important to keep a positive focus on the review to keep commitment and productivity high. By involving the worker it can also empower them to make changes. Notes:

Learning exercise 22.5 The Age Discrimination in Employment Act it states that employment of elderly people is based on their ability rather than their age (506-507). Mary is become unable to perform her duties as a nurse, and are is starting to put her patients in harm. This employee can no longer perform her assigned duties so it is managements duty to fix this situation. In this case the best thing might be to talk to the nurse about why she continues to work. Once the reason is met other arrangements may be made. If she continues to work because she needs the money you might suggest another position such as in management. It may be necessary to point out to her that she is not meeting her job requirements anymore and is putting patients at risk. If this is what she lives for, it may be possible for her to retire and continue to come on the unit to rock babies or another small task that will not endanger the unit. If Mary continues to be unable to do her job and refuses to retire or move to another unit it may be necessary to alert a higher authority, or ask another manager for advice. Ultimately if she is putting her patients in danger

Ashley Wolcott 4/13/13 Seminar she cannot be allowed to continue in the same capacity she is working now. The best solution in this situation would be to offer her a position in which does not directly relate to patient care. Notes: Group C Learning exercise 19.6 Legally the person who thinks they may have HIV does not have to get tested. I would encourage the man to get tested. I would explain the benefits of him getting tested for his health and for others. I would not tell my sister directly that this man had exposure to HIV. When it came to my sister, I would talk with her about the importance of having safe sex, and the possibility that with any partner the risk of getting a sexual disease is possible. I would also talk to my sister about having multiple sex partners and the importance of both her and her partner getting tested for STIs regardless of what either of them think as far as being clean. I would also encourage her to question any sexual partner that will not get tested or refuses to share the results with her. Legally I cannot tell my sister that her new partner is suspected of HIV, because that is breaching the clients confidentiality. Ethically I feel the need to tell my sister because I would want to protect her, but legally I cannot directly tell her that this man might have HIV. I can advise her as mentioned above. I feel that I would have the same reaction to a non-family member who told me this, but I would feel more passionate about making my sister get tested and insisting that her partner does as well, than I would for a stranger. Notes:

Case Study: Organizational Power My interpretation of this policy is that it is to keep patients and family away from behind the desk without the nurses permission. The policy is there to protect the privacy of patients. This policy takes into account that the patient or family can comprehend what information they would possibly be viewing. I think that conditions to change the interpretation of policies. In this case a baby would not be able to comprehend anything that the nurse was charting, because a baby cannot read. The baby in my opinion was fine being behind the counter because the purpose of the policy was to protect privacy. A baby in no way breaches the privacy of other patients as they cannot read, or comprehend what they might be looking at. In this situation the charge nurse could have taken into consideration the use of the policy, and allowed the baby to stay. The nurse could have explained the policy to the charge nurse and showed her that a baby in no way violates patient privacy. Or the nurse could have asked the charge nurse for help feeding the baby in the room so that the nurse could chart at the desk and hopefully get out on time, and the patients needs would still be met. Notes:

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Group D Display 5.4 Case 1 For Mr. Jones I would not give any more morphine because the order parameters have not been met. Instead there are a couple of things I would try. The first thing I would try would be to promote nonpharmacological techniques such as an ice pack, playing music, repositioning, etc. The other option I see is to call the doctor and see if the doctor will change the order. The doctor could increase the dose of morphine (although this is a high dose), or he could add another medication that could help increase pain relief. Through all of this I would keep in communication with the patient letting him know that something is being done to try to diminish his pain. Notes:

Case 2 The first thing I would do for Mrs. White would be to check her chart, all blood glucose checks should be in the chart with the results. If the results are not there or I am questioning the LPN/LVN I would do a blood glucose check myself. This way I have a number and I know that it was taken. If the number is far outside the range of what the LPN/LVN told me, I would confront the LPN/LVN and ask her if she had actually taken the blood sugar and then report to my findings to her. If the number is far outside what the LPN/LVN reported I think I would also bring it to the attention of the charge nurse because the LPN/LVN is putting the patient at risk by reporting a false number. Notes:

Learning exercise 16.9 I would evaluate the accuracy of the nurses comments by thinking about what my nursing education taught me about the situation before asking her a question. I think that by relaying what I already know about the situation and what I think we should do, but then asking her for clarification would help to explain to her my knowledge level. I might be contributing to this problem by asking her questions, or not explaining my thinking clearly. So by displaying my train of thought and where I am getting caught up on what to do maybe she will see that I do have education I am just clarifying and asking someone with more experience. I personally would probably get very frustrated with the nurse if even after explaining my thinking she continued to belittle me. To cope with the situation I would talk to the nurse

Ashley Wolcott 4/13/13 Seminar and express that I feel belittled when she says things like that and I would ask her to stop. If she continues to do so, I would talk to the charge nurse about it. To improve relationship with this nurse I would do the things mentioned above, treat her with respect and emphasize that I respect her years of knowledge and practical application which is why I am asking for her help. Notes:

Group E Case Study: Staffing and Nursing Care Nurses have different roles on different units depending on the care that a typical patient needs on a specific unit, and also based on how that particular unit decides to coordinate tasks. Nurse managers decided how many nurses and other staff should be on the unit to give care. In my experience nurse managers usually take into account hospital policy but also ask the staff on the unit how they are feeling. I have seen an example where ample nurses where present per hospital policy but several critical patients where on the floor so rather than have a nurse take four patients as per hospital protocol the nurse manager called in a float nurse. This ensured that the nurses where able to care for less patients but to give better care to the patients they were working with. Unions are also a big part of how the nurse manger decides how assignments will be made. Unions dictate certain regulations that the nurse manager may have to follow if the organization is part of a union. Notes:

Case Study: Head Nurse Power The power of favoritism and intimidation are being used in this situation. Many of the nurses are afraid to talk with the nurse manager or voice concern because the nurse manger is intimidating, and she shows favoritism so the nurses not in her favor get less choice in hours. Consequence for this type of leader are division among staff which the case study points out, there is no sense of teamwork, and problems between staff members escalate because they cannot solve problems and there are hard feelings between those in favor and those out of favor. I also believe there would be retaliation; when people do not like someone else they are usually looking for ways to make that person look bad, or to get back at the one who they feel has done them an injustice. In this situation it would be wise for the nurses to go above the authority of the nurse manager to human resources to file complaints or to bring it up with a director of nursing, or another likewise authority. Notes:

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Group F Learning exercise 4.3 As a nurse in this situation I would report this case to the child protective services and alert them to the concerns I had and also alert them to the concerns of the father. The risks of this decision are that there was nothing going on and you may have wrongly accused the childs mother. Word may also get back to the supervisor that someone made a call to child protective services and you may be reprimanded or questioned about this by the supervisor after she advised you not to push the matter further. Values play a role in this decision based on your individual value of a human life. If you feel no obligation to care for this child beyond your care then there would be no ethical obligation to further investigate the situation. However if your values dictate otherwise then you must press the matter further. Knowing the outcome of the situation does not change how I would have handled the case. The other alternative would be to hold the child hostage in the hospital until the father could get there and things could be sorted out and that is not a feasible possibility. This would make me question the response from the supervisor. The supervisor should have been more receptive to my concern and taken it more seriously. The supervisor should have at the least supported my suspicions and helped to take the right actions to alert agencies about possible neglect and abuse. Notes:

Learning exercise 4.9 My duty in this case is to follow the law and be a patient advocate. I cannot leave out important information such as this from the chart or withhold information from the physician. At the same time I have to advocate the patients situation and wishes to go home. Mr. Cole has the right to leave AMA; he also has the right to talk with his doctor about decisions made for care. He does not however have the right to dictate what I, as a nurse, chart and what are my legal obligations. I do not believe that it is ever justified to withhold information from a physician. The physician must be informed of the patients condition in order to best treat the patient. I would chart this incident and report it to the doctor. I would also express the request of my patient to live the rest of his life at home. I would continue to explain that if the patient leaves AMA his insurance will not pay for his hospitalization and he will not be able to receive home care. Hopefully the doctor will be able to discuss options with the patient and will be compassionate toward this patient and allow him to live out the remainder of his life at home. Notes:

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Group G Learning exercise 5.5 At this point I would return to the patients room and ask her if she knew the consent form was also a release for the doctor to take out her ovaries if necessary. If the patient states that she did not know this I would call the doctor back and inform him of my discussion with the patient, and demand that he come up and explain the procedure to her again. I chose this course of action because legally the patient has a right to know what will happen in the surgery and for possible complications before signing the informed consent and it does not appear that was accomplished; she has the right to be fully informed. The issue involved is that she did sign the informed consent for this procedure. The other issue seems to be that the doctor does not want to take the time to explain things again with the patient. Notes:

Learning exercise 4.6 I feel that the supervisor handled the situation appropriately considering the severity of the actions at hand. If I had been the manager I would have looked into any ways to prevent reporting her to the license board. I have heard through friends who are nurses that many facilities have avenues for discipline in situations like this where the nurse completes a rehab program, and then is allowed back at the hospital on a trial period in which they are closely monitored and tested for drugs and alcohol regularly. Legally I am not certain about what is necessary. If the law requires that this nurse be reported to the licensing board then, yes I would report her. Ethically I want this woman to be able to care for her family, but legally she is putting patients in danger. In my opinion the manager has the highest obligation to the patients at the institution. In this situation it seems that Beverly had other issues going on in her life that were causing her to drink. I think I would have referred her to a psychologist for a screening and for emotional help. Overall however I do not think this situation could have been prevented. I do not think this outcome reflects the quality of problem solving, as I stated above it sounds that emotionally and psychologically Beverly was already going through a rough patch and was in a dark place. Notes:

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