Building Nursing Management Skills

Case Study 1

A patient on your team is experiencing difficulty breathing. There is no change in the patient’s status after you elevate the head of bed, apply oxygen, have the patient use pursed lip breathing, and obtain a breathing treatment for the patient. Auscultation of the lungs demonstrates crackles bilaterally halfway up the lungs. The respiratory rate is 40 breaths/min, with an oxygen saturation level of 90% on 4 liters oxygen per nasal cannula. The patient is restless and having difficulty speaking because of the shortness of breath. After exhausting all nursing interventions, you call the physician by telephone regarding the change in patient’s status

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A. Describe how you would communicate the following areas using the I-SBAR-R tool.

Your Answer

B. The physician orders Lasix 40 mg IVP and morphine 4 mg IVP and 1 to 2 mg IVP every 1 hour prn. You write down the telephone order and hang up. Your transcription includes the following information:

· Lasix 40 mp IVP Stat and QD

· MSO4 4.0 mg IVP Stat and 1.0-2.0 mg IVP q1hr prn

Is this the correct transcription of the order? How would you change it?

Your Answer

C. Did you take the telephone order correctly? What additional steps should be followed?

Your Answer

D. What tips for communicating with physicians on the telephone can you recall from the textbook chapter? Which of these were missing, done incorrectly, or not done during the communication with the physician? Which steps still need to be done?

Your Answer

E. Review the previous questions. How does each contribute to patient safety?

Your Answer

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Case Study 2

You are receiving shift report from the day nurse, who states the following: “Room 32 is Mr. Jones, a 48-year-old male who had a transurethral resection for prostate cancer yesterday. He is currently having continuous bladder irrigation. He is alert and oriented, his vitals are stable, and the physician came in this morning and didn’t give me any new orders. The patient’s wife spent most of the day here but left after she and Mr. Jones got into an argument about their son’s decision to go to a local college rather than taking a scholarship to a Big Ten school. It was pretty intense for a while.”

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A. Evaluate how the nurse giving you the report used the SBAR tool. How could the tool be used more effectively when giving this shift report?

Your Answer

B. What critical elements of the shift report are missing?

Your Answer

C. How would you handle this situation? What could you say to make sure you receive the information you need to care for this patient?

Your Answer

D. Practice using the SBAR tool during your next clinical experience. Describe how the tool worked for you in giving report.

Your Answer

E. During your next clinical experience, ask the nurse about their hand-off communication process. Use the criteria from the Targeted Solutions Tool to analyze the process. Questions are provided in the analysis column to guide your evaluation of the hand-off communication process.

Your Answer

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Case Study 3

It is 7:30 am. You are the day shift nurse and have received the following data from the night shift report:

132: 66 y/o congestive heart failure patient scheduled for an angiogram today at 10 am. Vitals stable. Patient requests information about the procedure before signing the consent.

133: 42 y/o post-emergency colostomy from yesterday. Vitals stable. Patient was unable to sleep during the night, feeling upset and emotional. Midnight nurse states that the patient refused to discuss feelings.

134: 67 y/o GI bleed admitted yesterday. At midnight BP 120/70 and HR 80. At 6 am, BP 80/50 and HR 102. Physician notified and ordered a complete blood count for this morning.

135: 58 y/o post–femoral popliteal bypass 2 days ago. Vitals stable since surgery. Patient complains of incisional pain. Midnight nurse states the site is clean and dry with good bilateral pedal pulses.

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A. Prioritize these four patients based on Maslow’s Hierarchy of Needs.

Your Answer

B. During your assessment, the patient in Room 133 is noted to have a blood pressure of 84/50 mm Hg, with a heart rate of 102 beats/min and respirations of 32/min. How would this change your prioritizing of the patients?

Your Answer

C. How would you reprioritize your patients based on the new data and the ABCs?

Your Answer

D. What are the basic nursing activities that regularly occur each day during a shift (e.g., assessment)?

Your Answer

E. Using the work organization sheet below, plan your day by scheduling these basic nursing activities for each of your four patients.

Your Answer

F. For which of the above patients can you delegate taking vital signs? Why would you not want to delegate vital signs on the other patients?

Your Answer

G. What other activities from the work organization sheet can be delegated to unlicensed assistive personnel? Why?

Chapter 12: Effective Communication and Team Building

Case Study 1

Eric is the nursing supervisor in charge of the hospital operations during the 3 to 11 pm shift. Joyce is the charge nurse in the emergency department, and Diane is the charge nurse in the intensive care unit. The three meet one evening to discuss problems with moving patients out of the ED and into beds in the ICU. As they discuss the issues, Eric sits behind his desk, folds his hands, crosses his legs, and begins glancing at a paper on his desk. Joyce sits across from Eric, with her legs and arms crossed. She looks directly at Eric. Diane pulls a chair from the wall, placing it near the corner of the desk, forming a triangle with the other two participants. She sits down, leans forward, and smiles.

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A. What are the nonverbal cues from each of the participants?

Your Answer

B. Identify the verbal and nonverbal facilitative and obstructive messages from each of the participants in this case.

Your Answer

C. The three nurses agree on a process to facilitate the transition from ED to ICU. Eric makes a summary report of the meeting and submits it to the director of nursing with an appointment to meet the following week. Joyce holds a meeting of the ED personnel the next day and informs them of changes made to the process. She creates a memo describing changes to the ICU transfer process and posts it in the department classroom. She requests all staff to read and initial the memo, noting that they have read and understood the changes. Diane also informs her staff by holding mandatory meetings at various times throughout the next week. She schedules in-services for all staff and requires them to relate the pertinent information back to her to determine staff understanding of their roles in the procedural change.
Which of the three displayed upward communication? Was it effectively handled? Why or why not?

Your Answer

D. Joyce and Diane both took initiative in distributing the information to the necessary people. What were the positive aspects to their methods of handling the situation? What were the negatives?

Your Answer

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Case Study 2

Cecilia is a recent nurse graduate who worked for 2 years on the medical-surgical floor as a nursing assistant before being hired as a graduate nurse. She is eager and curious, and she graduated at the top of her class. Tony, her assigned preceptor, is an experienced nurse who is focused on completing his nursing care to the best of his ability. At the beginning of the shift, Tony explains his strategy for structuring his day. He maintains his patience with Cecilia, explaining the details of providing nursing care. By the end of the week, Cecilia questions Tony on his nursing diagnostic decisions, clinical judgments, and outcome expectations. She even questions him about how he relates to physicians. Tony loses his temper, stating, “You worked here for years, you went to school, you know these things. Why do you have to constantly question every little thing? Go look it up for yourself!” Taken off guard, Cecilia responds, “As a preceptor, you have certain responsibilities for my transition to nursing practice. I certainly did not mean to undermine your knowledge by asking questions. I simply want to be an excellent nurse and think that you can help me achieve my goal.”

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A. What aspects of gender differences may have affected the communication between Tony and Cecilia?

Your Answer

B. How was Cecilia assertive in her communication?

Your Answer

C. During the first week, Cecilia mentioned that the unit director was helping Tony move into a management position in the hospital and that he would soon be taking over another unit. Tony did not know about the management position and was taken aback. How should both Tony and Cecilia handle the information obtained through the grapevine?

Your Answer

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Case Study 3

You are participating in the week-long mandatory hospital orientation program for new nurse graduates. There are six new nurses, including you, involved in the session. As you look around the room, you note that none of the faces is familiar. Some of the participants appear completely at ease, conversing about their new careers and goals, whereas others silently look over the day’s programmed events. To break the ice, the instructor asks each person to tell a little bit about themselves, where they graduated, where they will be working in the facility, and their professional goals.

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A. Which type of team was created, and why? What long-term purpose does it serve?

Your Answer

B. During orientation, unique group roles emerge. This becomes particularly apparent while working on case presentations. The following interaction occurs during a brainstorming session:

Joan: “We are told to work through the case study and describe how we would proceed with the patient’s care, right?”
Katarina: “Yeah, I came across a similar situation while working as an aide. I think we need to reassess the patient’s condition like the nurse did on my old floor.”
Tom: “Well, that sounds logical but couldn’t we also ask the patients about their history? Maybe something was missed that might be important?”
Susan: “Okay, so we have one person with experience who thinks we should reassess. We also have a suggestion to review the patient’s history for missed information. We all agree some action should be taken.”
Lakeesha: “I think we need to keep in mind that this is a potentially serious problem and we need to act quickly. I would review the history while assessing the patient.”

What roles did each of the orientees adopt in this scenario?

Your Answer

C. How do the roles contribute to overall team performance?

Your Answer

D. Which role(s) do you feel comfortable assuming as a new nurse? Present a real or potential nursing situation (people involved on the team, environment) that demonstrates the environment in which you would feel comfortable contributing to a team process.

Your Answer

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Case Study 4

A continuing issue on your nursing unit is the amount of overtime by staff nurses. Management decides to form an ad hoc team charged with addressing the overtime issue. You were chosen to participate, along with the unit manager, the charge nurses from each shift, a unit secretary, an aide, and two experienced nurses (one with chronic overtime and one with little to no overtime).

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A. What is the rationale for selecting each of the various individuals to serve on the team?

Your Answer

B. What other hospital personnel could be included on the team? Defend your choices.

Your Answer

C. What is the purpose for forming this team? How could the goal be worded?

Your Answer

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Case Study 5

The nursing program at your school decided that they would like input from students regarding the current structure and type of nursing curriculum offered. The faculty decides to solicit input from the students in your class. They will only accept four proposals for change in written form.

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A. Have students form four groups in the class and allow at least 30 minutes for this exercise. Let students decide on their own how their group will proceed, the format for writing the proposals for changes, and which changes to include in their proposal. Once done, have students discuss their perceptions of the group assignment.

Your Answer

B. Have students create a presentation on their proposals for change. Each group can present their proposal to the class. Have students use the tips for effective presentation from the chapter. Students can evaluate the use of the tips after the presentation:

Your Answer

C. Review “Components of Written Communication” in the textbook. Have students evaluate their proposals against the suggestions in the text. What would students change? What would they keep the same?

Your Answer

D. Have students review the group process. How did each group follow the processes of forming, storming, norming, performing, and adjourning? What occurred in each of the stages? Were any of the stages more useful than the others?

Your Answer

E. Review the basic roles of group members in Box 12-3 in the text. Reflect on how students assumed the roles during the group process

Chapter 13: Conflict Management

Case Study 1

It is 2 months before graduation, and you have volunteered to coordinate the graduating student nurse ceremony. There are 42 students in the graduating class. As you begin planning the ceremony, you discover that two groups have emerged with two very different philosophies and values about how the ceremony should proceed. The traditionalists want the history of nursing preserved in the proceedings. The nontraditionalists want to break free of the mold and design a celebration that resembles the future of nursing. Both sides feel very strongly about their opinions. There appears to be little hope of compromise between the two points of view. The course instructor has given you 2 hours of class time to negotiate a compromise between the two factions.

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A. Of the five types of conflict (role, communication, goal, personality, and ethical), which applies to this case study?

Your Answer

B. How would you initiate a discussion to promote collaboration between the two groups?

Your Answer

C. While negotiating between the two sides, one student stands up and states, “I spent the last few years studying like crazy and my family paid for it. They want to see a traditional ceremony, not some stupid celebration without meaning. I absolutely refuse to participate unless we are allowed a traditional ceremony.”
How would you handle this situation?

Your Answer

D. Congratulations! You were able to bring both sides together in a mutual agreement regarding the ceremony. It is now a month before the event, and you are explaining how the plans are coming along to the graduating class and asking for input into the details. You look up and note an undercurrent of tension as several students roll their eyes, yawn, and whisper derogatory comments. When you ask whether anyone has suggestions or comments, you are greeted with blank stares.
How would you address this problem?

Your Answer

E. The department chair asks you, in front of some classmates, how the plans for the ceremony are proceeding. As you begin to speak, a classmate says, “She’s pretty controlling, so you know, of course, everything’s already taken care of.” How would you address this person?

Your Answer

F. You ask your classmates each week for help in planning the event. So far, only three students have volunteered to assist. As time draws nearer, you become increasingly angry and feel resentment toward your classmates. After all, you are spending a lot of valuable time planning a ceremony for the entire class.
What is the cause of your anger? How could you effectively manage the anger?

Your Answer

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Case Study 2

Sherry is a nurse in the intensive care unit. She is the only nurse assigned to two patients. Feeling discouraged, she begins preparing for report. During the hand-off report, the oncoming nurse tells Sherry that she really should confront the charge nurse about her heavy assignment to see whether she could change it. Sherry shakes her head and states, “I can handle it.” The other nurse suggests that Sherry tell the charge nurse that if she took one patient away, Sherry would take the first admission. Again, Sherry shakes her head. Another nurse overhears the conversation and assures Sherry that she could help her care for her patients. At this point, Sherry thanks the nurse and tells her how much she appreciates the teamwork on the unit. The charge nurse transfers one of Sherry’s patients to the medical-surgical unit while Sherry was at lunch. When Sherry returns from her break, she is surprised to find only one of her patients on the unit.

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A. At what point did Sherry display avoidance of the conflict?

Your Answer

B. How was compromise used to suggest a resolution to the conflict?

Your Answer

C. Do you think that collaboration was used effectively in this scenario?

Your Answer

D. During the day, Sherry speaks with the charge nurse about the inappropriate assignment of patients. The charge nurse responds, “I make the assignments as I see fit. You don’t know what else is going on in the unit,” and she walks away. What type of conflict resolution has occurred? Defend your position.

Your Answer

E. During the day, Sherry speaks with the charge nurse about the inappropriate assignment of patients. The charge nurse responds, “I make the assignments as I see fit. You don’t know what else is going on in the unit,” and she walks away. How should Sherry address this problem?

Your Answer

F. Sherry becomes very angry with the charge nurse for “bowling her over” and running the care of her patients. She feels inadequate because the transfer occurred while she was taking a break, which makes her feel guilty that she did not have a chance to speak with the patient or family prior to the transfer. How should Sherry deal with her anger and guilt?

Your Answer

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Case Study 3

Tina is a new nurse who is 2 weeks into her orientation with Maurice, her assigned preceptor. One evening, a patient on Tina’s team begins to deteriorate and a code is called. During the code, Tina is given the task of writing down everything that is being done. Standing near the crash cart, Maurice rubs against her chest while reaching for a medication. When Tina turns, Maurice grabs her rear end. She respects Maurice for his knowledge and willingness to teach her during orientation, but she feels embarrassed and physically ill after the code. After work, Maurice calls Tina at home to discuss how she feels about the code. Tina asks him not to contact her after work hours. Maurice explains that as her mentor, he feels responsible for how she interpreted the experience. The next day, Tina goes to the unit director to file a complaint.

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A. Was Maurice sexually harassing Tina? Defend your position.

Your Answer

B. Was Maurice’s interpretation of his relationship with Tina as a mentor valid? Explain your view of the relationship.

Your Answer

C. Could Maurice’s actions have been misconstrued by Tina? Explain.

Your Answer

D. If Maurice had apologized for his actions immediately after the code, would this change your perception of the situation?

Your Answer

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Case Study 4

During a clinical experience in a medical-surgical course, Ray is assigned to care for a patient with end-stage renal failure who is semiconscious. He is told in report that the family members have been present at his bedside the entire hospital stay and hospice has been contacted. As part of his assignment, he must take a complete history, provide total patient care, and educate the patient and family about the medical problems and medications. During his care of the patient, family members comment that this is the most anyone has done for their father the entire time he has been in the hospital. Ray discusses the pathophysiology and medications with the patient and the family members. He explains how the hospice nurses will come to the home to provide care and comfort until the end. Confused, the family members state that they were told that their father’s condition would stabilize and possibly improve if he followed the physician’s orders. One family member tells Ray that she has never heard of hospice and certainly doesn’t want a stranger coming to the home. The family members confront Ray about the lack of communication between the doctors and nurses at this hospital. Ray leaves the room feeling angry at the doctors and other nurses for not communicating with the family, and he is discouraged that his meticulous planning of care for the patient “stirred the pot.”

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A. What was the first indication that the family was concerned about the quality of care?

Your Answer

B. How could Ray have de-escalated the conflict among the family, patient, and caregivers?

Your Answer

C. Was there an issue regarding treatment decisions that contributed to the conflict?

Your Answer

D. How could the conflict have been avoided in respect to nursing care?

Chapter 14: Delegation in the Clinical Setting

Case Study 1

Sam is a new nurse working the day shift on a busy medical-surgical unit. He asks his aide to walk the patient in Room 244 while he admits another patient. The patient in Room 244 is a postangioplasty, and it would be the first time he has ambulated since the procedure. Sam tells his aide to walk the patient only to the nurse’s station and back. He also says that if the patient’s heart rate rises more than 20 beats/min above the resting rate, the aide should stop, have the patient sit, and inform Sam immediately.

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A. Did Sam appropriately delegate in this scenario? If not, which of the rights of delegation was not followed? Why?

Your Answer

B. The aide misunderstands Sam’s instructions and instead ambulates the patient in Room 234, who is 3 days post-hysterectomy and has been walking in the halls for 2 days. Where did the breakdown in communication occur?

Your Answer

C. Who would be accountable for the outcomes if the patient in Room 234 had fallen and broken a hip during ambulation? Would it be Sam, who directed the aide to ambulate the patient in Room 244, or the aide, who actually ambulated the patient in Room 234?
Your Answer

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Case Study 2

Kim is a student nurse in her final medical-surgical rotation. Her patient has a new left forearm arteriovenous graft for dialysis. As part of her clinical assignment, Kim must select a task that could be delegated regarding the care of her patient. The instructor also requires Kim to include how she would communicate, supervise, and provide feedback to a nursing assistant. Kim describes how she could delegate the vitals to the nursing assistant. She states that she would ask if the assistant had ever taken vitals before, ask her to demonstrate the task, clearly state how often the vitals needed to be completed as well as parameters for the vitals, and provide feedback on the performance.

The instructor says that she is pleased with Kim’s thoroughness and allows her to delegate the vital signs to the nursing assistant, Juanita, who accepts the task. After 3 hours, Kim notes the patient’s graft arm has decreased pulses and is cool to the touch. She asks Juanita if she noted the same findings. The assistant responds, “I thought it was strange that you asked me to check her blood pressure on her left arm, but I figured you knew what you were doing and had checked it with your instructor.”

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A. What went wrong in this scenario?

Your Answer

B. How were the five rights applied to this scenario?

Your Answer

C. Who retains accountability for the outcome? Why?

Your Answer

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Case Study 3

John is a new nurse, still in orientation with a preceptor, on the intermediate care unit. These patients are currently on the unit:

230—A 48-year-old admitted yesterday evening with an acute myocardial infarction; waiting for an angiogram

231—A 72-year-old patient with chronic congestive heart failure; taking multiple medications for blood pressure

232—A 51-year-old patient who had a coronary artery bypass graft 3 days ago; waiting for discharge

233—A 54-year-old patient in the ED with a medical diagnosis of uncontrolled atrial fibrillation; waiting for admitting orders

John is caring for the patients under the supervision of Dana, his preceptor, who is also the day shift charge nurse. He has completed the first assessment and is looking at the medications for his patients. He notes multiple medications ordered for bed 231, new medications ordered for bed 230, and medication teaching needed for bed 232. As he makes the notations to himself, Dana gives him the abnormal lab values for the patients, with instructions to notify the attending physicians. She also reminds him of the admit waiting in ED. The nursing assistant points out that the patient in 232 is very impatient; he is waiting for his diet and medication instructions so that he can be discharged. At this point, John becomes frustrated trying to juggle all the demands on his time.

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A. Identify the resources available to John regarding available personnel to whom he might delegate tasks.

Your Answer

B. Of those individuals identified as resources, which tasks could be delegated to each person?

Your Answer

C. Write at least one appropriate outcome for each patient and identify the right person to assist John in achieving the outcomes. Describe how John would evaluate the outcome.

Your Answer

D. Which of the patients can John delegate assessment to a licensed practical nurse?

Your Answer

E. When in doubt about delegating to other health care professionals, where would you find information about which actions you can delegate and to whom?

Your Answer

F. Construct a case scenario that demonstrates how John would correctly implement the five rights of delegation based on one of the answers listed.

Your Answer

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Case Study 4

You are the nurse caring for a postoperative appendectomy patient who had surgery 6 hours ago. The following tasks need completing:

Assess the patient’s ability to drink clear liquids.

Determine the amount eaten.

Document the patient’s tolerance of clear liquids.

Assess the patient’s tolerance for sitting at the side of the bed.

Assess the patient’s tolerance for ambulating.

Document the patient’s tolerance for activity.

Assess the patient’s pain level.

Provide education about activity levels.

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A. Which of the tasks can be delegated, and to whom can they be delegated?

Your Answer

B. If the patient were 2 days post-operative, would this change how you delegate?

Your Answer

C. To whom could the tasks be delegated if your co-workers included the following: licensed practical nurse, medication aide and nursing assistant?

Your Answer

D. Select one of the tasks and describe how you would delegate to an appropriate person by using the 5 rights. Specify how you would meet each of the rights.

Your Answer

E. Select one of the tasks and develop an outcome. How would you evaluate the ability of the patient to achieve the outcome if the task was delegated to the appropriate person?

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