Reflective Journal, Clinical Day #5, THE LAST ONE

I completed twelve hours at Timpanogos Hospital following the house supervisor today. It was my last clinical shift. My sixty hours are now done! My goals for today included learning about budgeting, conflict resolution, managing staffing, the leadership role of the house supervisor, and how to positively interact with employees.
It was much less busy today than it was yesterday. The tube system went down in the Emergency Department. My mentor was able to go to the engineering department and fix the problem with the computer, which saved the hospital money by him not having to call in staff from the engineering department for the repair. That is about as close to anything related to budgeting that we did all day today. Although there is no formal budget that the house supervisor follows, he is always financially conscientious. This example can help me in my practice as a nurse because reasonable frugality can save not only my employer money, but my patients' money as well.
The only situation related to conflict resolution came in the form of a fully oriented irate patient who needed a peripheral IV placed. Many years ago he had received severe burns on both arms which are now both covered in scars. His nurse was unsuccessful in placing an IV due to all of the scar tissue. My mentor was calm and focused while placing the IV, even though the patient pulled his arm away several times during the process and repeatedly complained about how painful it was. I got the distinct impression that the patient would have become more irate if my mentor had attempted any other approach. I will try to incorporate the same calm and focused attitude when dealing with patients who are irate, as I believe that this will help me to better accomplish my tasks in my own practice.
Staffing always seems to be a shift-long concern, and today was no different. We rounded on all of the units at least twice in order to collect the patient census. Two nurses were sent home on call, and one CNA called in sick. Additionally, Mountain View Hospital in Payson called and asked if Timpanogos had a pediatric nurse that could be sent to their facility. They didn't. I don't understand why they don't have a prn pool like IHC does, or why they think that nurses would appreciate being volunteered out to that facility. That is a long drive with little to no incentive for the trip. Anyway, I learned that it is important to stay informed and to know what is happening regarding census and staffing so that you can be better prepared to meet staffing needs. I will try to incorporate this in to my own practice if I ever become a manager by being observant and diligent regarding census and staffing.
The house supervisor continued to show leadership and a willingness to help. Outside of the women's center, there were ants on the carpet that were congregating in one spot. Engineering was contacted, but they already knew about the ant problem. In fact, the nursery had been previously moved to another floor, and the ants were partially to blame. My mentor found some ant spray and sprayed the insects down. Then he had housekeeping vacuum their remains. We checked the spot later in the day, and no new ants were noticed. I never would have guessed that pest control fell on the shoulders of the house supervisor, but he rose to the occasion once again. I will try to incorporate his example in to my own practice by trying to be helpful and take the initiative when the occasion calls for it.
He continued to positively interact with all of the employees. Every time we would round, he took the time to have pleasant conversations with the staff. Somehow we got on the silly subject of hospice for cats when talking to the staff on one unit (it does not really exist). The levity put the nurses at ease, and I think that it made my mentor more approachable. It is important to seem approachable, especially in times of potential crisis. Employees are likely to divulge more information to a leader who seems amicable. I will try to follow his example in my own practice by being pleasant and approachable to everyone I work with. This can contribute to positive morale in the work environment.

Overall, I think that my entire clinical experience was far too lengthy. I think that management-type learning could have been accomplished in eight to sixteen hours. There were several hours today when I was struggling to stay awake in the office as we awaited a call from anyone who needed anything. However, I did get to attend a cardiac stint placement yesterday. Although that has nothing to do with leadership, it was a valuable experience for me. I feel grateful to my mentor for agreeing to have me follow him, and I told him so. The worst part of this clinical for me was not being able to participate in patient care. That just seems unnatural to me at this point. While I do understand why it is that way, it still felt weird. I hope that this completes my clinical reflective journal!

Reflective Journal, Clinical Day #4

I completed twelve hours of clinical time following the house supervisor at Timpanogos Hospital today. My goals for today include learning about budgeting, conflict resolution, managing staffing, the leadership role of the house supervisor, and how to positively interact with employees.
The tube system went down (again), and we went to see if it could be fixed without calling engineering. The engineering department is on-call on the weekends. If they are called in, they are automatically paid for at least two hours, even if the repair takes fifteen minutes to complete. The house supervisor could not complete the repair, and engineering was called. However, the attempt to save the hospital money was notable. This was about as close to a budgeting lesson as I could get due to the fact that the house supervisor is not actually in charge of a specific budget.
There was a situation regarding conflict resolution. A 95 year-old patient with a decreased mental status was supposed to have a diagnostic test yesterday but the machine broke down in the middle of the test. The patient was dying, and the daughter wanted to have another test done (the machine had since been fixed), a lumbar puncture, an autopsy ordered for after the patient's death, and she wanted the hospital to pay for the autopsy because there was no diagnosed cause for the patient's impending demise. She also wanted the last day of the patient's hospitalization free of charge. The house supervisor and the physician spoke to the daughter regarding the testing options. After talking to the daughter about the rigors of the tests and the potential inconclusiveness of the autopsy, she decided against all testing and opted instead for comfort measures. The chief nursing officer was notified about the situation, and she gave permission for the last day of the hospitalization to be free of charge. Talking to the daughter and attempting to understand the cause of her demands helped to diffuse a potential future lawsuit for the hospital. Paying for the final day of hospitalization is also much less expensive than paying for a lawsuit. The daughter may still choose to file a lawsuit, but now she is much less likely to do so. Remembering this situation and the way it was handled may help me in the future to please my patients and their families, and to possibly avoid litigation.
Managing staffing was a shift-long process. There were some procedures and surgeries that required on-call staff to be called in. Some staff called in sick, and there were six anticipated admissions near the end of the shift. I think that was the most admissions in a shift I have witnessed since my clinical experience at this hospital. My mentor spent a lot of time of the phone arranging staffing for various units. I have a lot of respect for the effort that it takes to keep each unit properly staffed, and I will try to incorporate the knowledge that I gained by watching my mentor in the future if I am ever in charge of staffing.
My mentor serves well in his leadership role. He sets a good example, and helps out when the occasion arises. He arranged to have me watch a cardiac catheterization, which I found fascinating. He also arranged to have me watch most of a CT-assisted abscess drainage procedure. When we arrived and he asked the physician for permission to observe, it was discovered that one team member was missing in order for the procedure to be performed. He volunteered himself to fulfill the role, which pleased the previously-cranky physician. He also assisted a code in the Emergency Department, among other duties. He performed all of his tasks effectively and he made a point to be as helpful as possible to all staff members and patients. I hope that I can gain the skills and confidence to be as effective as my mentor is in a leadership position.
My mentor always interacts with employees in a positive manner. We made rounds to each floor, and greeted each employee. He calls everyone by name, and makes an effort to have a pleasant conversation with everyone. This makes him approachable and more informed. During down time, staff will often come to see him to chat or to voice concerns. I hope that I can learn from his example and be a kind and approachable leader in the future by positively interacting with all staff members.

Reflective Journal, clinical day #3

I spent yet another twelve hours following the house supervisor at Timpanogos Hospital yesterday, and it was not nearly as busy as it was Saturday. My goals for the day included learning more about how to manage a schedule, how to positively interact with employees, how to manage conflict in order to be a more effective manager and/or leader, and learning more about the roles of house supervisor, and learning more about the role of nurse practictioner (which is what my mentor is studying to become).
My mentor carried a paper copy of the schedule with him throughout the shift, and he had to call many employees off and put many on call. He regularly went in to the computer system to make staffing updates, and we rounded on the units many times to interact with employees and to get current census information. He stated that he could collect the information over the phone, but talking to them in person adds a personal touch and creates rapport. The staff seemed genuinely happy to see him whenever we rounded. We answered some calls to obtain supplies from the central distribution area because only he had keys to the room. He did state that whenever staff calls him for supplies, he is careful to ask if they have checked other places before he must run around the hospital seeking them out. Otherwise, he would be playing fetch all day because the staff at one time had gotten in to the habit for calling him for supplies that would often be available on an adjoining unit that they had not bothered to check.
There was one incident of conflict. An RN in the nursery complained that lab staff was rude to her. The order for blood typing had, according to her, been entered in to the computer system. A lab staff member claimed that it was not in the system, and the nurse stated that the staff member was rude and unhelpful on the phone. The blood typing had been completed prior to our arrival, but the nurse stated that it took a while to get it done and the difficult situation was a waste of time and resources. The nurse was advised by my mentor to fill out an incident report regarding the situation. We then went to speak to the lab staff. The one staff member who had been reportedly rude was not there, but another lab staff member stated that the order had been entered very late in the shift, and the blood typing had been done when the order was received by them. She stated that the staff member had followed procedure. It appeared to be a problem with the computer systems not properly communicating with each other. When we finished talking to the staff member in the lab, my mentor stated that it is important in conflict situations to remain calm and neutral, and to listen to both sides. He stated that he didn't doubt that the lab staff member had been rude because she has a history of behaving in that manner. Nurses have a tendency to not fill out incidence reports, but the reports provide documentation of problems to administration. The documentation may help to reinforce future complaints from nurses of rude behavior from that particular staff member.
It appears to me that the role of house supervisor is all-inclusive. We rounded the units for census data and to see if they needed assistance. We collected supplies for units. My mentor temporarily fixed a door that would not seal with a wad of paper and some tape until engineering could get to it when they were able to come in. He told me that part of his responsibility was to make sure the place didn't fall apart over the weekend. In the emergency department, some of the nurses were discussing nipples on the fountain drink machine. I asked my mentor what was meant my this, and he took me to the machine. He told me that the apparatuses should be cleaned daily, but often they are done weekly if they are lucky. He took the nipple off one of the dispensers and showed me why. The dispenser nipple was coated in black gunk. It was disgusting. He said it didn't tend to get as bad with the Sprite dispenser, but he had seen it worse that that on the Sprite dispenser before. I don't think I will be drinking fountain soda drinks again! We then proceded to clean that portion of the machine, soak them for disinfection, and replace the nipples with previously disinfected ones.
Later in his office, we had a considerable amount of down time. He is attending school to become a nurse practictioner, and I asked him questions about the roles of a nurse practitioner. He stated that the most difficult part of becoming a nurse practitioner is learning to rely on yourself and get out of the habit of calling the physician for every problem. This is because you become the prescribing provider. He stated that the adjustment from registered nurse to nurse practitioner is a hard one to make. According to the nurse practitioners he has spoken to, that adjustment can take at least a year. A nurse practitioner can choose to work under a physician or open a private practice, but he stated that it is usually wise to work under a physician until that adjustment is made. He also stated that family nurse practitioners are reimbursed by medicare at 85% of what a physician gets. So these nurses get to do the exact same work as a physician and get less money for it. Go figure.
While I considered the day to be boring for the most part, I was still grateful for the opportunity to get some more clinical hours completed. I expressed gratitude to my mentor for allowing me the experience of following him, as I do at the end of every shift. My next shifts are scheduled for February 26 and 27. Only two more shifts to go!

Reflective Journal, clinical day #2

Today I spent twelve hours following the house supervisor at Timpanogos Hospital. It was a busy day. My objectives for today included learning more about how to manage a schedule, how to positively interact with employees, and how to manage conflict in order to be an effective manager and/or leader. Some employees had to be called off on certain units due to low census. Later in the shift, a few employees had to be called back in due to admissions. I was given the task of calling one employee and telling her that she was being called off of the upcoming night shift. I completed the task without difficulty or hesitation. My mentor told me that sometimes employees try to argue him into not calling them off, but if census is low and staffing is excessive for patient acuity levels, staff is called off regardless of their argument.
My mentor interacted with all employees in a respectful and positive manner. He took the time to talk to each of the nurses not only about the patients, but also about their personal lives. He called them by name, and shared humorous stories on more than one occasion. He appeared to put the staff at ease, and let them know that he was there to help. We were called to get supplies on more than one occasion, and the staff verbalized their gratitude.
There was one nurse who had gone above and beyond her job description. She made necessary calls and arranged to have the next shift as well as her own appropriately staffed for her unit. My mentor presented her with a gift card for her extra efforts to express appreciation. The hospital has several gift cards to different businesses set aside for that purpose, and the boost to this nurse's morale was obvious upon her receipt of the card.
The NICU currently is equipped with six beds. There were eleven babies total in the NICU, so they had to open one of the adult ICU units that had been closed specifically for those other babies. Each of the babies in the makeshift NICU had its own large room, and the nurses loved the setup. A new NICU is being built to accommodate the anticipated increase in patients due to a new neonatologist the hospital has recruited who is in high demand.
Last night, there was a mixup regarding the physicians and a patient. One physician attempted to admit a patient, but was unable to because someone mistakenly thought he did not have admitting priviledges. A hospitalist was involved, and yet another physician was angry about the situation because he was called at two o'clock in the morning regarding the patient's necessity for admission and the patient was not his. I think, and my mentor agreed, that the situation could have been easily resolved without unnecessarily upsetting a physician. My mentor and I had the pleasure of listening to the uninvolved physician rant about the other physician in the emergency department. Apparently the original physician was to blame for the entire fiasco. My mentor encouraged him to file a formal complaint in order to better resolve the situation. Neither my mentor nor myself understood why three physicians instead of one became involved in the attempted admission of the patient last night. The botched admission process caused major delays in that patient's care, and could have been avoided.
The operating room staff were placed on standby for a possible surgery that never happened. They were already present from a previous emergency procedure, and my mentor was reluctant to let them go until we knew whether the other possible surgery would happen that afternoon because they were technically not on call at that time. We took a few trips between the ER and the OR in an attempt to expedite the process. The second surgery did not happen.
In the midst of all of this, a fountain soda machine in one floor's nourishment room began gushing fluid spontaneously from the top of the machine and under the sink where tubing was located. It was a huge, wet, sticky mess. I watched my mentor and another male staff member shut the machine down. I am glad they knew what to do, because I was never taught how to handle that in nursing school!
Today I met my goals. I observed my mentor frequently consulting the schedule and making changes according to the units' needs. I watched him calmly and positively interact with hospital staff, and calmly handle the conflict regarding the physicians. I am happy to have one more clinical shift complete, and I am pleased that I have only three more shifts left. My mentor works every other weekend. I will follow him tomorrow, and again in two weeks on Saturday February 26 and Sunday February 27.

Lesson 6: The Nurse Leader's Role in Managing Change

What is your attitude toward change?

My attitude toward change depends upon the situation. During an orientation meeting for my first job as an LPN, the word "change" was repeated frequently. Phrases such as, "change is good," "change is inevitable," and, "change is constant," were a large part of the meeting. I felt as though I were being primed for brain washing because it was repeated so much. Within the coming months, I discovered why the word "change" stressed so much during this meeting. I found that over time, my responsibilities were gradually being reduced, and I began to feel like a nurse assistant instead of an LPN. One RN even asked me why I was there due to the new limitations of my position. All of the LPN positions at this hospital were eliminated within two years. I was fortunate enough to have left that particular position for another one before I was a victim of that particular institutional change. Because of the negative experiences at that institution, I now have little desire to work there as registered nurse.
I realize that change is constant and inevitable. Sometimes an individual has control of the change, and sometimes not. When implementing a change that may affect others, I think it is important to involve them as much as possible in order to eliminate some of the confusion and anxiety that can result from change. Keeping them involved may possibly reduce some of the resistance that can come with change, depending upon the circumstances.

Lesson 5: Organizational Structure, Power and the Role of the Nurse Leader

I am scheduled to do two clinical day shifts at Timpanogos Hospital this Saturday and Sunday. My mentor was great to follow last time, and I look forward to having two less shifts to complete by next week.

For the purpose of the assignment, I will focus on my second job for the discussion of patient care models. I work for a home health agency, and the case management care model is utilized. The model works well because of increased work efficiency. The case manager coordinates the care of the patient and is directly involved in the care as well. A disadvantage of the model is the need for prior experience to effectively act in that role due to its extensive requirements.

Reward power is gained by the ability to grant rewards to others. Coercive power is based on fear and punishment. Legitimate power is the power inherent in one's position. Expert power is gained through knowledge or skill. Referent power is gained through association with others. Charismatic power results from a dynamic and powerful persona. Information power is gained when someone has information that another needs. Feminist or self-power is obtained through maturity, ego integration, confidence, and security in relationships. Strategies to increase my personal power base include being polite and kind to everyone I work with in order to build positive work relationships, learning all that I can to increase my knowledge base, and maintaining positive relationships in my personal life. Power can be used for good and less nobel purposes. Advocating for a patient to further facilitate their care is an example of a positive use of power. Attempting to dominate someone simply for the sake of dominance would certainly not be a noble or a long-term productive use of power. I agree with the text book on page 296 when it states that, "Power, therefore, is not good or evil; how it is used and for what purpose it is used determine if it is good or evil."