Being an effective Charge Nurse:

Yes thats you!

Greg Shannon, R.N., B.S.N. Andy Fox, R.N., B.S., B.S.N.

Goals of this program include:

To increase awareness of what good charge nurse skills are. To assist you in the development of these skills. To provide you with guidelines for appropriate charge nurse duties.

Charge Nurse Program: Areas to be covered.

Delegation Critical thinking Communication Time management

Traits/characteristics of a successful charge nurse

Charge nurses are highly regarded by their peers. Being in charge is no easy task as you are expected to juggle many things while taking care of patients.

The charge nurse role is multi-faceted. Charge nurses need to be clinical experts, diplomats accustomed to addressing pt and family concerns, and well-versed in policies and procedures. They also need to be able to anticipate and prevent problems from happening on the unit (Federwisch, 2008, p. 14).

Charge Nurse Resources:

Who do I turn to when I need help?? Seek out nurses with experience. Supervisors & administrators. Other departments. Computers/formscheck the internet and hospital policies.

Part one: Delegation.

What I need to know about delegation.. How will delegation play into my role as a Registered Nurse.

Objectives with Part I (delegation)..

Define the term delegation Define the term unlicensed assistive personnel Describe the five rights of delegation Recognize barriers to successful delegation Recognize positives to successful delegation Understand the legal implications of delegation.

Delegation.definitions.

According to the Ohio Board of Nursing (OBN). means the transfer of responsibility for the performance of a selected nursing task from a licensed nurse authorized to perform the tasks to an individual who does not otherwise have the authority to perform the task. Ohio Administrative code 4723; chapter 4723-13 Delegation of Nursing Tasks.

Delegation.definitions.

According to the American Nurses Association (ANA), the term unlicensed assistive personnel (UAP) refers to an unlicensed individual who is trained to function in an assistive role to the licensed nurse in the provision of patient/client activities as delegated by the nurse (ANA, 1992, p. 1).

In order to delegate we need skills in.

Critical thinking Decision-making Communication Conflict-resolution Assertiveness And a thorough knowledge of nursing process

Trust.we must trust each other We want to empower others so tasks are carried out safely and correctly.

Barriers to delegation.

Nurses are uncomfortable with asking for help. UAPs may be new or sporadically assigned to their working area. Nurses have only been trained in the primary care nursing model.

Advantages
Using UAPs and the process of delegation, allows institutions to function with lower personnel cost margins.

OBN rules on delegation

Only licensed nurses can delegate to an UAP. The person who is delegated the task cant hand off the delegated task to another. All provisions of delegation must be met.

Appropriate resources and support need to be available. Nurse must identify the individual patient whom the nursing task is going to be performed on.

OBN rules on delegation

Nurse must posses knowledge and skill r/t the delegated task. Nurse must assure that the UAP has training, ability, and skill r/t the delegated task.

Must specify a timeframe to complete task and evaluation of conditions. Results are predictable and can be performed safely. Task requires no judgment based on nursing knowledge and expertise for the UAP.

Remember the 5 rights of delegation and examine all situations carefully.

The right task The right circumstance The right person The right direction and communication. The right supervision and evaluation.

How do I delegate??

Direct delegation versus indirect delegation. Direct delegation is usually verbal direction by the RN delegator regarding an activity or task in a specific nursing care situation. Indirect delegation is done using an approved listing of activities or tasks that have been established in the policies and procedures of the health care institution or facility.

How do I delegate??

Nurses must learn how, what, when, to whom, and how much to delegate. Use the nursing process as a tool when delegating a task (assessment, planning, implementation, and evaluation). Assessment is step one. First, make sure patient safety and quality of care are not jeopardized by delegating the work.

Step oneassessment, continued.

Second, make sure that each act of delegation is situational and depends on the work to be assigned, the people who will do the work, and the needs of the situation itself. And remember to delegate without guilt.

Step two..Planning.

Consider which work group members have the knowledge, skills, and experience to complete specific tasks. Nurse needs to have knowledge about the tasks, and must be able to explain what needs to be done in terms that are understandable to the UAP.

Learn to negotiate with peersI need you to check on Mrs. Jones, get a set of vital signs and Ill be checking the blood transfusion on Mr. Cup. Let me know the resultsIll be in room 3126.

Step two..Planning.

Decide the best way to delegate activities so UAP are motivated to complete the work in a quality manner.

Deadlines for completing the work need to be reasonable.

Step three.Implementation.

communication is the main factor required in the implementation phase of delegation. Communication must be clear, and comprehensive.

Delegation involves supporting staff.

Step four.the evaluation.

the purpose of this phase of the delegation process is to verify and clarify. Tell UAP that there will be an evaluation when the delegated task is completed.

Feedback helps employees realize that their success is important, and when done positively, can increase moral.

Checking your knowledge.. about delegation.

Test your knowledge: True or False Can a Patient Care Assistant (PCA) delegate a nursing task to another PCA? When a RN delegates a nursing task to a PCA, does a time frame have to be specified?

Critical Thinking. Part II

Socrates. The only good is knowledge and the only evil is ignorance. Greek philosopher in Athens (469 BC - 399 BC). Alvin Toffler. The illiterate of the twenty-first century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn. Author of Future Shock.

Critical Thinking
If I had eight hours to chop down a tree, Id spend six hours sharpening my axe. Abraham Lincoln. 1809-1865.

Critical Thinking
Objectives: Describe how your personality and learning style affect your ability to think critically. Explain and demonstrate the characteristics of a critical thinker. Identify the difference between thinking and critical thinking.

Why focus on Critical Thinking?

We deal with information overload daily. Multiple priorities. Dealing with new challenges that require us to learn and adapt. Given more responsibilities. Asked to make more independent decisions.

Critical Thinking

Critical thinking is the key to preventing and resolving problems. Critical thinking and test-taking skills are essential to passing many tests (competencies, certifications, NCLEX).

Difference between critical-thinking and just thinking?

Purpose and control. Thinking refers to any mental activity it can be mindless, like daydreaming while brushing your teeth. Critical thinking is controlled and purposeful; it focuses on using well-reasoned strategies to get the results you need.

Critical Thinking Definitions.

A good synonym for critical thinking is reasoning. Knowing how to learn, think creatively, generate and evaluate ideas, make decisions and solve problems.

Critical Thinking is also the..

Ability to make sense of information. The process of purposeful selfregulated judgment. The cognitive engine that drives problem solving and decision making.

Different meanings.
Critical thinking refers to purposeful, informed reasoning both in and outside the clinical setting. Clinical judgment and clinical reasoning refer to using critical thinking in the clinical setting.

#1 rule for critical thinking. You must be able to answer two key questions:
1. What exactly are the results you need? 2. What are the problems, issues, or risks that must be addressed to get the results?

What characteristics do we see in someone who thinks critically?

Self aware. Self disciplined. Autonomous and responsible. Honest and upright. Curious and inquisitive. Logical and intuitive. Improvement oriented.

Genuine. Open and fair-minded. Sensitive to diversity. Creative. Reflective and selfcorrective. Patient and persistent. Flexible. Empathetic.

Factors influencing your ability to critical think:

Some personal ones: Moral development and fair-mindedness. People with a mature level of moral development - those with a clear, carefully reasoned sense of whats right, wrong, and fair are more likely to think critically. Age The older you get, the better thinker you become. Based on two things moral development usually comes with maturity and most older people have had more opportunity to practice reasoning indifferent situations.

Factors influencing your ability to critical think:

Culture upbringing. Emotional intelligence this is the ability to make emotions work in positive ways and it enhances critical thinking.

Some situational factors influencing your ability to critical think.

Anxiety, stress, and fatigue high levels of anxiety and stress have been documented to impede your ability to think. Positive reinforcement promotes critical thinking by building self-confidence and focusing on whats being done right. Awareness of risks when you know the risks you think more carefully, and make sure you make a prudent decision before acting.

10 key questions to determine your approach to critical thinking in different situations:

What major outcomes (observable results) will drive our thinking? Exactly what are the problems, issues, or risks that must be addressed to achieve the major outcomes? What are the circumstances (what is the context)? What knowledge is required?

10 key questions to determine your approach to critical thinking in different situations:

How much room is there for error? How much time do I/we have? If we have plenty of time to make a decision, we can take time to think independently, using resources such as textbooks to guide our thinking What resources can help? Textbooks, computers, or experts.

10 key questions to determine your approach to critical thinking in different situations:

Whose perspectives must be considered? Whats influencing thinking? What must we do to prevent, control, or eliminate the problems or issues identified.

Learning styles are important to know before critically thinking

Studies suggest that the brain is like a muscle the more you use it, the more capable it becomes (Alfaro-LeFevre, 2004, p. 14).

Learning Styles.

There are no right or wrong ways to learn there are only differences (Alfaro-LeFevre, 2004, p. 23).

Learning Styles.

Observers (visual learners) learns best by watching. For example, youd rather watch someone give an injection before reading the procedure.

Learning Styles.

Visual learner learn most efficiently if material is represented in written format. They prefer teachers who use illustrations, write on the chalk board, or provide handouts. Have better recall with info from movies, pictures, or maps. Likely to make a mental picture of images or words, so that info can be seen when taking a test or reporting to others. Like to study alone in a quiet area.

Learning Styles.

Listeners (auditory learners) learn best by hearing. For example, you learn best when you can listen without worrying about taking notes.

Learning Styles.

Auditory learners enjoy listening to speeches, like to participate in group discussions, and benefit from studying with others.

Learning Styles.

The auditory learner can increase recall by recording notes or outlines, and then listening to the audiotape. May talk out loud when reading instructions. Wants handouts, so they can absorb the presentation and not take notes.

Learning Styles.

Doers (kinesthetic learners) learn best by moving, doing, experiencing, or experimenting. Youd rather play with a syringe and inject a dummy before reading the procedure.

Learning Styles.
Kinesthetic learners: Prefers a learning environment with labs and hands on projects. Enjoys demonstrations, field trips, and the opportunity to try things for themselves. When studying, this individual will benefit from creating a model of concepts or draw key points.

Learning Styles
Kinesthetic person continued: Likes action and may appear distracted during long or detailed conversations. Can benefit from writing, as long as assignments are brief and focused.

Critical Thinking.

Test your knowledge: True or False Can cultural differences alter the way we critically think? The first step in critical thinking requires one to look inward (self reflection).

Communication.Part III
Objectives: Discuss how previous knowledge can help and hinder the understanding of new information. Describe the different types of communication styles.

Communication:

It is the sending and receipt of messages and a shared social experience between two or more people, each of whom has his or her own expectations, experiences, and intentions (Gran-Moravec, & Hughes, 2005, p. 131).

Variables that impact effective communication:

Hierarchythe effect of the perceived hierarchy of power and authority can affect communication. Trust.a critical concept. The degree of trust b/t individuals is directly related to effective communication. Self-disclosure.instances of sharing a personal experience, attitude, or feeling can result in increased dialogue.

Communication:

Disrespectful communication to another colleague is not acceptable; it does nothing to contribute to a supportive learning environment and so will not help the new employee achieve the goals of the institution.

Communication:

The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) suggests that poor communication is a top contributor to sentinel events reported to the JCAHO database in 2005 (Sportsman, & Hamilton, 2007, p. 157).

Communication:

Ambiguous or general feedback is unlikely to lead to improvement in performance and may actually discourage additional effort. Effective communication skills are essential if feedback is to be provided in a constructive way that will lead to improved performance (Lehman, & Taylor, 1991, p. 307).

Steps to effective communication:

First step begins with a self-assessment to determine current effectiveness as a communicator and manager of conflict and to realize opportunities for growth (Thornby, 2006, p. 267).

Steps to effective communication:

Step twoalign resources to assist you in the ability to communicate. Find a mentor or coach to provide feedback. Third.practice, practice and then practice more. It is important to understand that the skill of effective communication, confrontation, and managing of differences are attainable with education, practice, and commitment, but the process will take time (Thornby, 2006, p. 268).

Types of Communication:
There is verbal and non-verbal. Nonverbal, such as personal appearance, tone of voice, facial expressions, and body language, carry more weight than verbal communication. Interpersonal communication.is interaction between two or more people. It helps you share ideas, solve problems, and make decisions.

Types of Communication:

Intrapersonal communicationis the constant, conscious dialogue inside your head. (Heery, 2000, p. 66).

Communication 101
Consists of five steps:
Composing the message Encoding the message Determining channels.. Decoding the message. Obtaining feedback

Basic Communication Skills Include:

Listening. Asking open-ended questions. Asking closed questions. Clarifying. Paraphrasing. Using facilitators. Assessing non-verbals. Silence.

Skilled Communication Standard:

In 2005, the American Association of Critical-Care Nurses (AACN) published the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. They articulated 6 standards based on interwoven concepts and relationships of the quality of work environment, excellent nursing practice, and patient care outcomes (Thornby, 2006, p. 268).

Skilled Communication Standard:

The first standard, skilled communication, states, Nurses must be as proficient in communication skills as they are in clinical skills.

Critical Elements for Standard One: Skilled Communication.

Healthcare organization provides team members with educational opportunities to develop communication skills. Focus is on finding solutions. Seek to protect and advance working relationships. Invite and hear all relevant perspectives. Establish zero-tolerance policy for abusive communication.

Variables that effect Communication.

There are several intervening variables that affect success in communication. One of the most important is that of gender ( Grover, 2005, p. 180). Women and men communicate differently. Women speak to create a sense of harmony and use emotional words, and men are direct and have more demands (Grover, 2005, p. 180).

Variables that effect Communication.

Body language also affects communication. Another variable that affects communication is generation. Baby Boomers, Generation X, and Generation Y each espouse differing values and life experiences and, therefore, differing communication styles (Grover, 2005, p. 180).

Communication styles: 5 of them

Collaboration Avoiding Dominating Obliging And compromising.

Despite all attempts at effective communication, misunderstandings and conflicts can and do develop. What to do in these situations??? Urys (1991) model states to first go to the balcony. Take time out!!! Questions to ask yourself: Whats going on here; are others hearing me; am I hearing others; what behaviors can be observed; (Grover, 2005, p.181).

Conflict Resolution

Conflict Resolution

Rewind the tape and examine all solutions. Emphasis is on satisfying interests and not positions. Negotiation requires a climate of caring and a commitment to understand the other. Acknowledge each others feeling. Problem solving occurs as each side negotiates the question of what if (Grover, 2005, p. 181).

Time Management. Part IV.

In the Western world, time has been constructed around devices of measurement, such as clocks, calendars and schedules (Waterworth, 2003, p. 432).

Time Management

Time management skills are often learned by trial and error.

What is ones perception of time?

Abundant supply Gets away from you Care free

Objectives

Describe the definition of time. State how time management has changed historically within the nursing profession.

Time Management
Time is a duration in which things happen in the past, present, and future; a system of measuring passing of hours (Gran-Moravec, & Hughes, 2005, p. 131). Time is a resource and all individuals have access to this same resource (Minar-Baugh, 1998, p. 79).

Historical account of how nurses spent their time:

1940s 1950s: Staffing determined by average occupancy divided by # of beds. Highly inaccurate because results assumed that there were a fairly static number of patients, with static care needs (Gram-Moravec, & Hughes, 2005, p. 126). 1960s: Care needs and occupancy rates varied significantly from patient-to-patient and day-to-day. This led to nurses being utilized in various areas (float nursing developed).

Historical account of how nurses spent their time:

1970s: Patient classification systems (PCSs) came into play (acuity systems) which led to better utilization of staff ratios without compromising patient care. Issues with PCSs: Do not account for the admissions, discharges and changing patient acuities after assignments have been made out.

Why must we learn to use our time better?

Organization have downsized to achieve more efficient performance and reduce costs. Depressed economy does not allow for the mistakes of overstaffing. Organizational structures have flattenedmeaning there are less managers to manage more employees. This flattened structure can result in gaps in horizontal communication.

Why must we learn to use our time better?

Nursing shortage is expected to increase in the next twenty years..peaking in 2025. Rise in health care costs. Some states have regulated staffing guidelines.

How are nurses spending their time?

Increased time spent on documentation and reporting required of nurses. Increased litigation and technology have significantly increased the amount of record keeping and report writing necessary, and 66% of nurses thought that using electronic documentation had increased the time spent on documentation (Duffield, Gardner, & Catling-Paull, 2008, p. 3270). Making sure that all boxes are checked on that form..

How are nurses spending their time?

Increased patient acuity and complexity means spending more time at the bedside. The skill mix of the nursing staff is changing (more NAs and less RNs). Completing non-nursing activitiesfiling, ordering, stocking, phone calls not related to patient careetc. Many hospitals have laid off non-essential staff (clerical) as a way to control costs.

Analyzing time-wasting behaviors:

The first step is to look at your present use of time and be honest with yourself. Ask yourself.what am I doing that is most productive, and what is nonproductive? Maintain a time log. Keep track of this for a few shifts and analyze how your time was spent (emails; phone calls; speaking with family members; interaction with employees; etc.).

Analyzing time-wasting behaviors: Keeping a time log makes an abstract idea of time use become a concrete reality (Pagana, 1994, p. 381). Discover time wasters and try to correct them. Examplean unnecessary meeting, or frequency of meetings. Examine your environment for distractors and eliminate them.

Improving time management skills:

First step: Establish daily goals on how to use time. This written record can then be used to foster long range goals. Planning for the use of time. Take 5-10 minutes at the beginning of each shift, and plan out your day. Planning lists help organize the day because you cant do what you dont remember. Guarding prime time.

Improving time management skills:

Learn to be a better delegator without guilt. Tweak your worksheet. Using a worksheet can be valuable as you can cross off completed tasks. Custom taylor itpatients with infections, who is going to surgery, and color code tasks to be completed. Devise coping mechanisms to help eliminate distractions.

Tips when making out your nursing assignment

Look at the acuity level of each patient. Know the geography of the nursing unit. Know the skill levels of other staff members. Keep patients in close proximity to where the assigned nurse is working. Try not to split a nurse (traveling from one wing to the other wing). Set time aside, towards the end of the shift, to make out the next assignment sheet.

Tips when making out your nursing assignment

Make a plan for admissionswhich nurse is to get the first admission, the second admission, so forth. Plan interaction time with others to get information on admissions, discharges, & transfers. Try and divide up all of the discharges b/t all RNs. Check with the Social Worker or Resource Utilization Review Nurse, about planned discharges.

Remember that float nurses can be pulled to different units every 4 hours, so give the admission to the float staff as a last resort. Attend the bed meeting. Not only will your unit information be valuable to the Administrative Coordinator (AC), but you will also find out whats going on in other nursing units that could affect your day. Assign another nurse to cover you while at breaks and lunch. Use the walkie/talkie to effectively communicate with the A/C.

Tips when making out your nursing assignment

Tips when making out your nursing assignment

Openly communicate with physicians so you know their plan for discharging patients (special needsLovenox injections at home). Become familiar with hospital policies. Learn how to complete a search on the monitor. Remember to utilize your resources. This is often overlooked when making important decisions. And the most important.be flexible in making decisions as unplanned events (patient elopement, codes, RRTs, falls, complaints) will always happen.

Commonly used policies that you need to know

1. Admission, Discharge, and Transfer. 3364.100.01.01 2. Discharge by Death. 3364.110.01.03 3. Review of Nursing Staffing Data. 3364.110.08.01

Commonly used policies that you need to know

4. Administrative Coordinator (AC) Communication. 3364.110.06.01 5. Inability to Report to Work as Scheduled. 3364.110.11.04

Click on the following policies and review them..

Inability to Report to Work Administrative Coordinator (AC) Communication Review of Nursing Staffing Data Discharge by Death Admission, Discharge and Transfer

Addendum to staff nurse job description. Charge nurse duties responsibilities.

Addendum to staff nurse job description. Charge nurse duties responsibilities .

References:

Adams, D. (1995). Teaching the process of delegation. Seminars for Nurse Managers, 4(3), 171-174. Alfaro-LeFevre, R. (2004). Critical thinking and clinical judgment: A practical approach (3 ed.). St. Louis, Mo: Elsevier Science. Arnold, E., & Pulich, M. (2004). Improving productivity through more effective time management. The Health Care Manager, 23(1), 65-70. Duffield, C., Gardner, G., & Catling-Paull, C. (2008). Nursing work and the use of nursing time. Journal of Clinical Nursing, 17, 3269-3274. Federwisch, A. (2008). Whos in charge? Retrieved on November 12, 2009, from ca@nurseweek.com/editor/epi. Gran-Moravec, M. B., & Hughes, C. M. (2005). Nursing time allocation and other considerations for staffing. Nursing and Health Sciences, 7, 126-133.

References:

Grover, S. M. (2005). Shaping effective communication skills and therapeutic relationships at work. AAOHN Journal, 53(4), 177-182. Heery, K. (2000). Straight talk about the patient: Use these techniques to improve the way you communicate with your patients. Nursing2000, 30(6), 66-68. Kopishke, L. R. (2002). Unlicensed assistive personnel: A dilemma for nurses. Journal of Legal Nurse consulting, 13(1), 3-7. Lehman, C. M., & Stephen, T. G. (1991). Participative appraisal of student performance effective communication skills = long-run success. Journal of business and Technical communication, 5(3), 307-320. Minar-Baugh, V. (1998). Survival strategies: Improving time management skills. Journal of Ostomy/Wound Management, 44(5), 78-83.

References:

Ohio Board of Nursing Website (2009). Retrieved on December 12, 2009, from http://codes.ohio.gov/oac/4723-13 Pagana, K. D. (1994). Teaching students time management strategies. Journal of Nursing Education, 33(8), 381-383. Platt, J. F., & Foster, D. (2008). Revitalizing that charge nurse role through a bespoke development program. Journal of Nursing Management, 16, 853-857. Sherman, R. O. (2005). Dont forget our charge nurses. Nursing economics, 23(3), 125-143. Sportsman, S., & Hamilton, P. (2007). Conflict management styles in the health professions. Journal of Professional Nursing, 23(3), 157-166. Thornby, D. (2006). Beginning the journey to skilled communication. AACN Advanced Critical Care, 17(3), 266271. Waterworth, S. (2003). Time management strategies in nursing practice. Journal of Advanced Nursing, 43(5), 32-440.

Thank you.

Greg Shannon, RN, BSN, Staff Development.