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NURS 347 Exam #3 – Blueprint

Chapter 11 – Polypharmacy
Polypharmacy-definition, risks
 Concurrent use of medications
 Increased risk in functional decline among elders living with polypharamacy
 Multiple central nervous system drugs = links to greater declines in self-reported
mobility; reports of hospitalized rehabilitation patients who used hynotics/anxiolytics
having a lower functional independence measure in motor gains than nonusers
 Benzodiazepine use  functional decline
 Anticholinergic burden  worsening functional status
 Antihypertensive medications  linked to impairment in functional status
 Multiple Medications: the prescribing cascade – is it the medication of disease?
o Multiple prescribers and Iatrogenic Harm; Multiple pharmacies; Older age:
frailty, chronic disease, cognitive impairment, and altered pharmacokinetics;
Transitions of care; Isolation
Adverse drug reactions-definition, reporting, barriers to reporting, magnitude of problem
 Definition – Unwanted side effect of medication
 ADRs as the fifth leading cause of death annually
 Statistics on ADRs = only as accurate as one’s ability to recognize when an ADR is the
 Most reported ADRs = incidents where a medication was given and the person died
shortly after or a person is hospitalized for an ADR specifically and the result was death
 # of deaths attributed to organic causes (kidney failure), which were actually caused by
organ damage due to chronic or acute medication use, is still not well quantified
 Important to be aware that current statistics on the deaths or harm due to ADRs all come
mostly, if not all, from hospital records or institutional records such as nursing homes
(where ADRs are underreported due to lack of recognition of medication side effects)
 The magnitude of ADR-related morbidity and mortality occurring in the ambulatory
population-at-large is overlooked.
 The reported statistics on ADRs thus are a potential underestimate of the true overall
harm resulting from medication use
Prescribing cascade-definition
 Definition – When medication side effects are treated with other medications
 The practice of treating medication side effects with other medications is usually not
intentional and is due to the mistaken identification of a medication side effect as organic
in origin (caused by a disease or condition)
 Example: a patient who demonstrates extreme agitation and aggression without high-dose
antipsychotic therapy and would be unable to live successfully in the community or be

part of an institutional setting appropriate for their well-being without the risky
antipsychotic use. Under such circumstances, the expected side effects of extrapyramidal
syndrome (movement disorder) and metabolic syndrome might be treated with
benztropine (a strong anticholingeric, used to address the drug-induced movement
disorder) and glyburide. Benztropine can cause serious side effects itself, such as cardiac
problems, impaired cognition, urinary retention, ocular issues, and temperature
deregulation, as can glyburide, which can cause hypoglycemia and requires constant
glucose monitoring. With the intentional use of medications to treat the side effects of
another medication, the clinician should document the rationale for doing so, including
the risks versus benefits, and the monitoring parameters along with the recommended
intervals of monitoring
 How drugs work in the body, and a person’s ability to manage medications
Iatrogenesis-definition, under what conditions might a patient experience iatrogenic harm?
 Definition – Doctor or healthcare created harm
 Decades ago this complex dynamic in the healthcare system was less prevalent b/c there
were fewer medications, interventions, and specialists
 Elders are unfamiliar with how to safely negotiate their way through today’s complicated
healthcare system
 When today’s elders were younger, the medical system left eh coordination of a person’s
health care to the physician’s office.
 A person would see one doctor for all their problems, and that doctor would spend a great
deal of time with them, knew all of their history, came to the hospital when they were
admitted, and knew their family and medications because that one doctor treated the
whole family over their lifetime and was the sole prescriber
 Average number of physicians that a patient over 65 years old today see is 7
 It would not be self-evident to an elder that bringing all of their medications to all seven
doctor visits an the hospital is a necessary precaution to foster safer medication
 For seniors living with 5 or more chronic conditions, this number goes up to 14 different
doctors at different addresses
 This group also averages over 40 office visits in one year
 Most significant threats to sound medication reconciliation is the systemic problem of
transitions of care
o 1. Leaves the patient as the healthcare provider’s only witness to all of the
medication changes. Patients are perplexed by having to navigate a healthcare
system that is very complex, difficult to understand, and hard to follow
o 2. Having to follow multiple providers’ instructions and order changes, especially
for elderly patients who are too ill to absorb so much constantly changing
information = another threat to mediation reconciliation. Serious medication-

related problems can occur as a result of lack of coordination of care, lack of

patient advocacy, and poor communication between providers
o Today, the elder is faced with multiple physicians, multiple prescribers, and the
obligation to coordinate their own care
o the more an elder is exposed toe healthcare system, the higher the risk for
iatrogenic harm
RN’s unique role related to medications
 Nurses are the only member of the healthcare team that actually witnesses the patient’s
use and outcome of medications
 Nurses have extensive knowledge of the pharmacological aspects of the medication (side
effects, intended effect, administration, and monitoring parameters)
 Nurses have been administering, monitoring, education, and documenting all components
of medication use
 This is why nurses are in a position to make significant contribution to combating the
harms of medication misadventures
 Many of the principles of medication and polypharmacy assessment are intuitive to
nurses, and the following specific assessment skills can add to nursing’s important role in
minimizing polypharmacy harm
Brown bag assessment-definition
 Lay term for when patients bring in all their current mediations that they are taking
(including OTCs, supplements, herbals) in a brown paper bag and a health professional
reviews/assesses them
 Method is far superior to relying on patient self-report, internal medical records, or
transferred medical records from other providers
 Benefit of the brown bag assessment, the clinician can see how many tablets or capsules
are present versus the last the medications were filled to prove for adherence
 Patient can be queried on how they take the medication and their knowledge of what the
medications are for while viewing the medications, which is superior to asking about
their medication use by name due to common memory and literacy challenges
Strategy taken by a physician or APN to determine if a patient’s symptoms are actually
medication side effects (?!?!?!?)
 When the intentional use of medications to treat side effects of another medication, the
clinician should document eh rationale for doing so, including the risks versus benefits,
and the monitoring parameters along the recommended intervals of monitoring
Intervention strategies to lower the risk of polypharmacy (pgs. 443-450)
 Polypharmacy is one of the few reversible and preventable causes of iatrogenic harm
 Challenge is that reversing and preventing medication-related problems requires careful
monitoring, medication use, and prescribing

 Ongoing process requires provider and patient awareness, education, and accountability;
tracking and reconciliation for the processes of medication use; follow up; information
transfer; and patient and family education and engagement
 Strategies for intervention: addressing psychological functioning, physiological
functioning, cultural factors, health literacy and linguistic factors, financial factors,
spiritual and religious functioning, physical and environmental safety, and family and
community support
 Decrease the number of unnecessary or harmful medications; Appropriate choices and
doses; Foster medication literacy; Assess to medications

Chapter 24
 Complementary and alternative medicine
 “a group of diverse medical and health care systems, practices, and products that are not
presently considered part of conventional medicine” – NCCAM
 Medical interventions not taught widely at US medical schools or generally available at
US hospitals – Eisenberg
 Many of the modalities under the CAM term is considered mainstream medicine in other
 Today, CAM may be considered a mainstream modality in the future
 CAM is used to treat illness and promote health and well-being, as well as to gain more
control over one’s health
Example of popular diets-ie vegetarian, vegan, Atkins
 Atkins – Emphasizes low carbs (40 g or less) with an increases in fat and protein
 Vegetarian – diet excludes meat, fish, fowl, or products containing these foods
 Vegan Vegetarian – diet excludes dairy, eggs, meant, fish, fowl, and other animal
 Macrobiotic – low-fat diet emphasizes whole grains and vegetables and a decreases in
fluid intake. Meat, dairy products, eggs, alcohol, sugar, sweets, coffee, and caffeinated
tea are avoided
 Ornish – high-fiber, low-fat vegetarian diet promotes weight loss by restricting the types
of food rather than calories
 Pritikin – low-fat (10% of less) diet emphasizes consumption of foods with a large
volume of fiber and water (low in calorie density). Diet includes many vegetables, fruits,
beans and unprocessed grains
 Zone – Each meal consists of 30% low fat protein, 30% fat, and 40% fiber-rich fruits and
vegetables. The goal of this diet is to control key hormone production to alter metabolism
 Lacto-ovo-vegetarian – diet is based on grains, veggies, fruit, seeds, nuts, legumes, dairy
products, and eggs. It excludes meat, fish, and fowl.

 Lacto-vegetarian – diet excludes eggs, meat, fish, and fowl, but includes dairy
Vitamin deficiency that may mimic dementia, including hallucinations, disorientation, memory
loss, tingling of extremities
 Vitamin B 12 deficiency
Complications/side effects from megadoses of vitamins—ie pyridoxine, vitamin A
 B6 (Pyridoxine) – nerve damage to limbs
 Vitamin A (retinol) – nausea, vomiting, headache, dizziness, blurred vision, possible risk
of osteoporosis
 B3 (niacin)– flushing, redness of skin, upset stomach
 C (ascorbic acid) – upset stomach, kidney stones, increased iron absorption
 D (calciferol) – nausea, vomiting, poor appetite, constipation, weight loss, confusion
 Folic acid (folate) – Hides signs of vitamin B12 deficiency
Common supplements and their contraindications: ie St. John’s wort, ginko biloba, ginseng
Name Contraindications/Side Effects
St. John’s wort (Hypericum Alcohol and other antidepressives may increase CNS side
perforatum) effects. Side effects: dizziness, restlessness, sleep disturbance,
hypertension, bloating, abdominal pain, flatulence
Ginko biloba (Gingko) Use with caution if individuals are on anticoagulant or
antiplatelet therapy or have diabetes. Contraindicated if
individuals have bleeding disorders or increased blood sugars.
Side effects: headache, dizziness, GI disturbances
Panax Ginseng (Asian May decrease effectiveness of warfarin; may interfere with
ginseng) MAO inhibitors; may have hypoglycemic effects; caffeine
Panax quinquefolius may increase herb effect; use with caution with estrogen; may
(American ginseng) increase risk of bleeding if used with antiplatelet herbs; may
prolong QT interval if used with bitter orange; may interfere
with immunosuppressant therapy. Side effects: agitation,
insomnia, tachycardia, depression, hypertension
Garlic supplements May increase bleeding; not as effective in lowering
cholesterol as other medications
Glucosamine Contraindicated if shellfish allergy is present; May interfere
with glucose regulation in diabetics
Echinacea purpurea May interfere with immunosuppressant drugs;
(Echinacea) contraindicated in diseases related to immune response,
multiple sclerosis, tuberculosis, AIDS, and autoimmune
diseases. Should not be used for more than 8-week intervals
or immune system may be depressed

Hormonal pathway that has direct effect on immunity

 The hypothalamic-pituitary-adrenal (HPA) pathway signals the endocrine system to
release hormones, particularly thyroid and adrenal, which have a direct effect on the
immune system
Guided imagery, biofeedback, tai chi—definitions
 Guided imagery: directed deliberate daydream that uses all senses to create a focused
state of relaxation and a sense of physical emotional well being; sights, sounds, smells, or
tastes can be used to create mental images to aid in relaxation and mange physical
symptoms of stress and anxiety; Self-created mental images = powerful self-help
technique that is easy to learn and can be used by all ages; has been used to decreases the
side effects of chemotherapy treatments and to relieve stress and pain
 Biofeedback: individual uses machines to receive information about bodily functions
such as skin temperature, brain waves, breathing, blood pressure, and heart rate;
information in the form of audible or visual signals; the person is trained to focus on
controlling the targeted bodily function with reinforcement coming in the form of the
audible or visual signals; individuals become more skilled at controlling the targeted
function; eventually the person can control the function without the use of the machine to
provide feedback; has been proven to control headaches, chronic pain, hot flashes, and
 Tai chi: an ancient Chinese martial art; can be a method of self-defense, it is practiced by
many as an exercise to promote mental tranquility and improve physical fitness, balance,
and relaxation; movements are circular and rhythmic, and each other postures moves
slowly into the next posture following the sequence of form; improves QOL
 German physician Dr. Samuel Hahemann’s natural law of “like cures like”
 When a person’s vital force or self-healing response is out of balance, health problems
with develop
 Goal is to stimulate the body’s own healing responses to present of treat illnesses
 Homeopathic remedies are prepared by diluting certain substances and then gradually
increasing the dilution until no actual measurement of the original substance exists
 Helps the body to begin to heal itself by using its own defense mechanisms; recognized
and regulated by the FDA
Evidence/research based study results of therapeutic touch, reiki
 Involve movement of a practitioner’s hands of the patient’s body to balance energy fields
 Therapeutic (healing) touch: involves either physically touching the body or noncontact
o When the body is not physically touched, touch refers to the “touching” or
movement of the individual’s energy field

o Purpose: to transfer life energy through the therapist’s hands to the client, who
will use the energy to rebalance and restore health
o Certification can be obtained through Healing Touch International, Inc; classes
are taught worldwide
 Reiki: form of healing through the manipulation of ki (Japanese for life energy; similar to
Chinese qi)
 Although anecdotal evidence and relatively small research studies tend to support
therapeutic touch, no large-scale controlled studies have been conducted with these
 A systematic review to determine the effects of therapeutic touch on the healing acute
wounds produced no evidence that therapeutic tough promotes the health of wounds
2 types of energy fields and definitions
 Veritable energy field – can be measured; Ex: mechanical vibration and electromagnetic
 Putative energy fields (biofields) – currently cannot be measured; Ex: vital energy (qi or
chi) or TCM; doshas in Ayurvedic medicine; ki in the Japanese Kampo system; and
prana, etheric energy, fohat, orgone, odic force, and homeopathic resonance in other
o Examples of practices using putative energy fields include Reiki, qi gong,
healing/therapeutic touch, and prayer for the health of others (intercessory prayer)
o These are the most controversial of CAM practices because the energy fields
cannot be measured, making traditional scientific research methodology difficult
 Therapists claim they work with these energy to improve health by reducing pain,
anxiety, and blood pressure; increasing wound healing; and providing as sense of well-
Nurse’s role related to CAM when assessing a patient
 When performing assessments, nurses must ask clients about use of CAM, why particular
modalities are used, the source of the therapy, and their knowledge of side effects
 Questions should be phrased in a nonjudgmental manner and should be phrased in such a
way as to cover the variety of modalities. Clients may not acknowledge they are taking
herbal medicines, but may identify that they are taking natural products
 Important when prescribed medications for blood thinning, B/P, depression, anxiety, or
 Elders may not consider vitamins or minerals as medications b/c dietary supplements but
if taken in large does, many interfere with actions of medications and produce side effects
 Good communication skills are key to thorough assessment of CAM use
 Nurse must be knowledgeable member of this integrated healthcare team to be able to
provide comprehensive, holistic care
 To facilitate cultural competency and to provide holistic care to patients, nursing and
medical schools have added content on CAM to their curricula

Chap 25 – Caring across the continuum-

Caring across the continuum
 Healthcare systems that collaborate, coordinate care, communicate, and anticipate
patients’’ needs are essential to ensuring quality nursing care that is safe, effective,
patient-centered, timely, efficient, and equitable.
 In addressing quality care across the continuum, it is critical to be familiar with the
different setting of care
 In understanding these settings, nurses can apply EBP models to ensure both safe
transitions across the care continuum and quality outcomes
 Nursing is about teamwork and collaboration
 Care across the continuum asks that health professionals critically look at the setting of
care and anticipate the needs of patients as these settings change
Fx/Fracture hip-hospital to acute rehab –purpose?
 Care of the older adult often beings in the emergency setting and may progress into
critical care, general units, or to rehabilitative services. Regardless of the acute care
setting, the optimal goal is to promote recovery and maintain the elder’s optimal level of
functioning through quality care and the prevention of complications.
 Rehabilitation services begin while in the acute care setting and extend throughout the
continuum based on the needs for the older adult
 Acute rehabilitation is an appropriate option for those who will benefit from an intensive
multidisciplinary approach to care delivery
 The typical rehab team consist of nurses, therapists, physicians, and other specialists who
work collaboratively with the patient to maximize independence and optimal level of
functioning. Additional services such as neurospychology, speech, and respiratory
therapy are also available for patients during their rehabilitation.
 The level of intense therapy in a rehabilitation unit is greater than those services provided
in acute or transitional care units and extended care facilities. Each patient admitted to an
acute rehab unit receives a minimum of 3 hours of combined therapies per day to fulfill
Medicare requirements for admission. Primary conditions necessitating a referral with
subsequent admission to an acute rehabilitation facility include conditions such as stroke,
head trauma, neurological disease, amputation, spinal cord injury, and orthopedic
Adult day care
 Definition: in community, nonresidential group programs designed to meet the needs of
older adults with cognitive and/or functional disabilities and provide respite to family
 Many older adults prefer to remain in their own homes as they age; however, many
persons are faced with the decreased ability to maintain their independence because of
age-related physical or cognitive impairments or chronic health conditions.

 Adult Day services might be an ideal alternative to congregate residential care such as
assisted living and nursing homes
 Adult day services create a partnership among the caregivers, families, and professionals
in managing the health and well-being of an individual to promote and support aging in
 ADS program may provide health care, meals, activities, and care in a group setting for
households where the caregiver might not be available to provide care at home during the
 ADS may be sponsored by a variety of organizations, including churches, hospitals, or
healthcare systems, which includes extended-care facilities.
 These centers provide socialization, planned outings, nutritional diet-appropriate meals,
supervised activity, medication administration, and a safe environment for older adults
 Many ADS providers over 6, 8, or 12 hour service options, which allows caregivers to
continue working or have respite periods. There persons who may benefit from these
services are those with chronic health conditions, cognitive impairments, limited mobility
or physical disabilities, and safety concerns.
Aging in place-definition
 The idea of providing stability for the older adult by working toward the common goal of
either maintaining the current residence or living in a non-healthcare environment.
 Aging in place successfully requires planning on the part of the older adult, caregivers,
and health care professionals.
 To accommodate physical, mental, and psychological changes that may accompany
aging, varying changes may be required within the residence
 This may be accomplished through the use of products, services, conveniences that
enable the older adult to remain in their current home setting without having to move as
circumstances change
Use of a detailed transfer form
 It is a requirement that nurses contribute to the safety and continuity of care for their
patients upon discharge or transfer to another care setting
 For interagency transfers, a detailed transfer form must be completed as must a verbal
report to the accepting facility, prior to discharge/transfer
 The basic information to be included includes: a detailed assessment, treatments, wounds,
current medications, allergies, level of independence, recent diagnostic testing, and
primary care practitioner notification upon discharge and admission to the receiving
Respite care-definition
 Services that provide a break for caregivers by providing care in the home or a facility.
 Caregivers need a break or respite from the daily responsibilities to relieve stress and
prevent caregiver burnout.

 Respite care provides much-needed time off for family members who care for someone
who is ill, injured, frail, debilitated, or demented.
 Can be provided in an adult day facility, in the home of the person being cared for, or in
an assisted living or long-term facility
 Respite care is not covered by Medicare or Medicaid, unless the person receiving care is
in hospice care and even so, the coverage is extremely limited
Elder Cottage Housing Opportunity [ECHO]— definition and purpose
 Utilizing Smart Home technology, elder cottage housing opportunities are free-standing,
mobile, modular-type homes that can be transformed to be temporarily placed on a
caregiver’s property to maintain safety for the older adult requiring assistance while
allowing for privacy and independence
 Similar to a hospital room or studio-type apartment, this “pod” can remotely monitor the
resident through sensors that alert caregivers to an occupant’s fall, monitor telemetry
remotely, and can utilize computer technology to remind the occupant to take
 Technology utilized is specialized based on the specific needs of the individual. Also
provides entertainment, offering a selection of music, reading materials, and movies. It
also contains a family communication center that provides telemetry, environmental
control, and dynamic interaction to off-site caregivers through smart and robotic
 Each unity comes minimally quipped with amenities to include living space, handicap
accessible bathroom, and a kitchenette.
Other names for nursing homes
 Long-term care facilities (LTCFs) – provide care primarily for older adults or any
persons who have lost some or all of their ability for self-care due to illness, disability, or
advanced dementia; to be able to operate, they have to follow guidelines and meet
patients’ needs to give proper care
 Utilized for rehabilitation, recover from surgery, extended illnesses, wound care, and
 Most seniors who live in nursing homes have complex medical needs, so the best option
is this type of facility
Avoidable causes of hospitalization for LTC residents
 Potentially preventable reshopitalization can be broadly understood as a rehospitalization
for a diagnosis or related diagnosis within 30 days of a hospital discharge
 Potentially avoidable hospitalizations are defined as specific conditions that could have
been identified and treated in the setting of care, for example, in the nurse home, that
would then allow the resident to avoid the risks of hospitalization

 Avoidable causes: Congestive heart failure, chest pain, pneumonia, bronchitis, mental
status change, urinary tract infection, sepsis/cellulitis, dehydration, gastrointestinal
bleeding, diarrhea, musculoskeletal pain, psychiatric problems, adverse drug effect
Continuing Care Retirement Community-definition and purpose
 CCRCs provide a continuum of care that spans independent living to skilled nursing care
in a traditional nursing home setting, all within a single campus setting
 Levels of care provided are based on the older adults’ needs
 Depending on the facility’s business model, contractual services are provided often for an
additional fee, or may be included in an upfront lump-sum type of payment plan
 Older adults can move seamlessly among the living settings, beginning with independent
living, to assisted living and skilled or long-term care as their condition warrants
 This type of facility make transition to a higher level of care someone easier for the
resident since they remain within similar environments
 Some CCRCs provide home health services while the resident maintains their current
residence in independent or assisted living based on individual need and duration of need
for the higher level of care
 Nurses in this type of setting are valuable in assisting residents as they encounter various
levels of care
 One of the most important aspects of nursing care is that of health promotion and
wellness, to assist the older adult in maintaining their highest level of functioning for as
long as possible.

Chapter 26 – End-of-Life Care

Patient Self-determination Act-definition—which advance directives are recognized under this
 PSDA is a federal law, requires healthcare providers to routinely provide information
about advance directives
 Several nationally recognized advance directives to help an individual identify their
personal wishes in a legal manner and to share that information with the people around
them, including medical personnel
 Durable power or attorney, living will, appointment of healthcare representative, do not
resuscitate (DNR, and life-prolonging procedures declarations are all legally recognized
documents for indicating one’s healthcare wishes.
 Additionally, Five Wishes, allow natural death (AND), and the Physician’s Orders for
Life Sustaining Treatment (POLST) are three more recent options for stating end of life
care wishes
 Five Wishes
o A movement that encourages people to provide more specific instructions than
those offered by a living will, including one’s wishes in five categories: (1) the

person chosen to make decisions when the individual can no longer make them
for himself or herself – a durable power of attorney for health care, (2) the kind of
treatment the person wants or doesn’t want – a living will, (3) how comfortable
the person wants to be, (4) how the person wants to be treated by others, and (5)
what the person wants his or her loved ones to know.
 AND order
o Considered a more descriptive and more positive order than a DNR
o Focus is on allowing death as nature takes its course at the end of an illness
o DNR implies taking something away or not doing something for the patient and
can be viewed as a harsh and insensitive statement of medical care that promotes
a feeling of abandonment by patients and families alike
o In contrast, AND provides for comfort measures so that even with the withdrawal
of artificially supplied nutrition and hydration, the dying process would occur as
comfortably as possible
o Designed to instruct emergency personnel on what actions to take while the
patient is still at home – before emergency treatment is give
o Has segments concerning CPR, medical interventions, antibiotics, and artificially
administered nutrition
o Developed for seriously ill persons receiving treatments that were inconsistent
with their stated wishes and designed to honor the person’s end of life treatment
preferences when transferred form one care setting to another
 Advanced directives can also be crafted for specific and personal converse
 All advanced directives should include a periodic review to ensure clarity and to reflect
changing needs and concerns
 Any documents relating to health care should be discussed and shared with physicians,
family members, or decision makers and place dint eh medical records held by each of
the patient’s physicians.
Examples of life-prolonging care
 Curative/acute care – focus on cure
o Care prolonging measures so someone is diagnosed and we want to do everything
we can to cure the issue; can result in placing tubes in and on machines to prolong
their lives
o Many of these deaths will take place in an ICU setting, with tubes, vents, and
devices to do everything possible to preserve life
o It is important that judgments not be made about these choices, but to note that
other choices exist as well. Options for non-life-prolonging care at end of life are
available and focus on comfort rather than cure.
Examples of non-life-prolonging care
 Hospice care – provides care and support for people in their last phases of their disease

o Provides one option for non-life-prolonging care and has the following
 Hospice provides care and support for persons in the last phases of
incurable disease (and their families) so they may live as fully and
comfortably as possible
 Hospice recognizes dying as part of the normal process of living, and
focuses on maintaining the quality remaining life
 Hospice exists affirms life and neither hastens nor postpones death
 Hospice exists in the hope and belief that through appropriate care, and the
promotion of a caring community sensitive to their needs, individuals and
their families may be free to attain a degree of mental and spiritual
preparation for death that is satisfactory to them.
 Hospice care originated in order to provide comfort and dignity at end of
 Eligibility for hospice serves is based on a life expectancy of 6 months or
less, if an illness runs its normal course
 Services are available as long as a patient is considered to be terminally ill,
even though it may be longer than 6 months
 Hospice utilizes a team approach to address the physical, emotional,
social, and spiritual needs of the patient and family
 Palliative care – evolved out of hospice care
o It assists increasing numbers of people who experience chronic, debilitating, and
life-limiting illnesses, and can be practiced in a variety of settings, including
hospitals, outpatient settings, community home health programs, and hospices.
o Palliative care refers to the comprehensive management of the physical,
psychological, social, spiritual, and existential needs of patients
o Especially suited to the care of people with incurable, progressive illnesses
o Goal is to achieve the best QOL for patients and their families
o Control of pain, other symptoms, and of psychological, social, and spiritual
problems is paramount
o Palliative care has been found to not only promote improved QOL, but to prolong
life itself.
 The choice of end-of-life care
o Can be very difficult for a patient and family to choose one of these options of
o Practical suggestion that may help the patient and/or family in weighing the
choices is to encourage a frank discussion with eth physicians, which would
include several important questions: What is the expected outcome if I do
treatment option #1? What is the expected outcome if I do treatment option #2?
What is the expected outcome if I do neither of these, and choose comfort care?
o Weighting the answers to each of these questions may help the individual make
an informed choice, based on the differences between the expected outcomes and
the individual’s own philosophy about how to experience his or her end of life.

 Delirium is an acute, fluctuating cognitive disturbance, characterized by changes in
mental status over a short period of time
 Occurs in the last hours to days of life in a large percentage of dying patients
 Delirium is especially devastating to family and friends because it can stand in the way of
meaningful conversations and goodbyes
 Most common physical causes may include dyspnea, pain, constipation, or urinary
retention, all of which can be treated
 Other causes may include medication reactions, dehydration, hypoxia, anemia, infection,
and metabolic and multisystem failure (renal failure, liver failure, hypercalcemia,
hyponatremia, or hypoglycemia)
 Delirium at EOL is often referred to as terminal restlessness, occurring in approximately
25-85% of terminally ill patients at time of death
Examples of medical interventions that should be carefully considered before use with a
terminally ill patient. ?!?!!
 Feeding tube; PEG (percutaneous endoscopic gastrostomy)
 Advance directives – DNR, living will, durable power of attorney, appointment of
healthcare representative, life-prolonging procedures, five wishes, POLST
 Focus on Symptoms: physical nonpain and pain symptoms; psychosocial, emotional, and
spiritual symptoms
 Components of Peaceful Dying
o Instilling good memories; Uniting with family and medical staff; Avoiding
suffering, with relief of pain and other symptoms; Maintaining alertness, control,
privacy, dignity, and support; Becoming spiritually ready; Saying goodbye; Dying
SWAT-assessment –definition
 Social Work Assessment where this tool includes issues related to anxiety about death,
environment, safety and comfort, and anticipated grief
 Looking at caregiver as well
 Developed to help measure not only the patient’s adjustments to aspects of the dying
experience, but also those of the caregivers
 It encompasses decision making, anxiety about death, environmental preferences, safety,
comfort, finances, anticipatory grief, and others
 It is designed to show progression in the patient’s and caregiver’s adjustments over time
 Nurses are at moderate-to-high risk for development of compassion fatigue – a condition
that is commonly present when a caregiver continues to provide compassionate care to
others in stressful situations without practicing good self-care for her/himself
 Stress, trauma, anxiety, life demands, and excessive empathy (caring for patient’s needs
than their own) were key determinants of compassion fatigue risk

 Awareness is the first step in treatment of compassion fatigue since it is preventable and
treatable; authentic, sustainable self-care is possible with education, clarification of
personal boundaries, health living choices (eating, sleeping, and exercise), stress
management, and a healthy support system – living life in balance
EPEC Project Module—definition/description
 The Education in Palliative and End-of-Life Care (EPEC) Project, supported by the
American Medical Association and the Robert Wood Johnson Foundation, as well as
End-of-Life Nursing Education Consortium (ELNEC, view the communication of bad
news as an essential skill for physician’s It is an essential skill for nurses and other
interdisciplinary team members who interact with the patients and families.
 EPEC Project Module presents a six-step approach to communicating bad news
o 1. Get started – Plant what to say, confirm medical facts, create a conducive
environment, determine who else the patient would like present, and allocate
adequate time
o 2. Find out what the patient knows – Assess his or her ability to comprehend bad
o 3. Find out how much the patient wants to know – Recognize and support patient
preference to decline information and to designate someone else to communicate
on his or her behalf; accommodate cultural, religious, and socioeconomic
o 4. Share information – Say it, then stop. Pause frequently, check for
understanding, and use silence and body language; avoid vagueness, jargon, and
o 5. Respond to feelings – Expect affective, cognitive, and fight – flight responses;
be prepared for strong emotions and a broad range of reactions. Give time to
react; listen, and encourage description of feelings. Use nonverbal communication
of tough and eye contact.
o 6. Plan/follow up – provide additional tests, symptom treatment, and referrals as
needed. Discuss potential sources of support; assess the safety of the patient and
home supports before he or she leaves. Repeat the news at future visits.

Chapter 28 – Using Current System Models to Guide Care

Acute care of the elderly-definition
 ACE – program develop thorough the work of Nurses Improving Care of the
Hospitalized Elderly and the Frances Payne Bolton School of Nursing at Case Western
Reserve University.
 An interdisciplinary team with special expertise in geriatric care and training in
prevention of geriatric syndromes, as well as environmental adaptations to support het
elderly, are used to prevent functional decline in the older adult in the acute care setting
Acute geriatric unit-definition

 Care of Older adults with acute medical conditions in AGUs is more efficient than care
provided in conventional hospital units and produces a functional benefit compared with
conventional hospital care, thereby increasing the probability of the patient returning
 AGU care has been found to reduce the hospital stays and hospital care costs.
Assisted living facility-definition, who regulates these facilities
Medicare—services funded
 Initially Medicare did not cover dental care, routine eye care and glasses, hearing aids,
preventive services, prescriptions, or long-term care.
 Today, in addition to covering prescriptions with Part D, Medicare does reimburse for
some screenings on a regular basis and a physical exam when the beneficiary first
becomes eligible for Medicare services after the deductible has been met
 Covers hospice care for those patients who have been certified by the physician as having
6 months or less to live, so long as the care is provided by a Medicare-certified hospice
 Covers home care provided by a Medicare-certified agency
 All services have criteria that must be met for reimbursement
 Program of All-Inclusive Care for the Elderly
 Originated in the early 1970s, when Marie Louise Ansak, a social worker, was hired to
help families in the Chinatown section of San Francisco care for their elders
 Mission of the this program was to help older adults remain in the community
 Now a Medicare and Medicaid reimbursed program, PACE has grown to 82 programs,
operating in 29 states
 PACE programs use an interdisciplinary team consisting of social workers, nurses, day
center management, dietitians, a physician, physical and occupational therapists,
recreational/activity therapists, as well as other disciplines to assess, plan, implements,
and monitor interventions
 Each discipline brings their own expertise, but they must be able to work as a team
member, focusing on the goals of the older adult
 This can be challenging for team members whose disciplines are often passionate about
their individual areas of study
 Each team members assesses the older adult on enrollment into the program and then on
a regular basis, as least annually
 Team will work with the patient to develop a plan of care that focuses on the individual’s
needs and goals.

 PACE programs operate out of a day center that includes their primary care physician
services, nursing services, nutritional and activity therapies, as well as assistance with
 PACE interdisciplinary team works with the patient to determine home care modification
needs as well as home care assistance, then arranges the care
 PACE programs provide much-needed transportation services to and from the day center,
as well as to medical appointments as needed
 Nurse’s role in this may be as a home care nurse, clinic nurse, or home care coordinator
BOOSTing definition/description
 Better Outcomes for Older Adults through Self Transitions (BOOSTing) Care Transitions
resource site provides materials to help optimize the discharge process at any institution
 This online resource was developed through support from the John A. Harford
 The program and tools are based on the principles of quality improvement, evidence-
based medicine, and personal and institutional experiences
Eden Alternative and the 3 plagues of NH
 Bill Thomas, MD introduced Eden Alternative – found his work as a medical director in a
nursing home that the residents suffered from more than just medical issues
 Defined 3 plagues of nursing home residents: Loneliness, Helplessness, Boredom
 With his wife, Judith, he created a new type of nursing home care called the Eden
 This model has been developed and implemented in nursing homes across the US and
many other countries.
 It is a framework for culture change that guides an organization to make changes
necessary to provide more person-centered care based on the 10 guiding principles of the
Eden Alternative.
o Picture on phone – page 963
ALF-description (How is this different from above?!)
 Assisted Living Facility
 ALFs provide assistance and monitoring of older residential adults for whom independent
living is no longer appropriate but who do not need 24-hour skilled nursing home care
 In the US, ALFs are regulated and licensed at the state level
 More than 2/3 of the states use the licensure term “assisted living,” and other licensure
terms include supportive living facility (SLF), residential care home, and personal care
 Assisted living services vary by facility and recipient need
 Independent apartments include handicap-accessible units with grab bars in bathrooms
and wall mounted emergency home response systems

 Personal serves may include assistance or supervision with ADLs, medication

management, coordination of healthcare-provider services, housekeeping services,
financial management, meals provided, transportation to medical appointments, and
trained medical staff.

Chapter 27 – Global Models of Heath Care

First country to establish a national healthcare system
 Germany was the first country to establish a national healthcare program.
Who are most aging Germans cared for by? Aging Japanese? Aging Canadians?
 Germans –
o First country to establish a national healthcare program
o Social insurance is mandatory transfer system whereby employees and employers
make equal contributions for long-term care, social health insurance, pension
funds, unemployment, and worker’s compensation
o German model of health care is based on the solidarity principle, which states that
members of society are responsible for providing adequately fro another’s well-
being through collective action
o Statutory Health insurance (SHI) covers about 90% of the population and
provides a wide spectrum of services ranging from preventive care to inpatient
hospital care
o Prescription medications are covered
o Insurance scheme is operated by over 150 competing sickness funds
o Individuals have a choice of sickness funds and may change if not satisfied
o SHI covers the employee, pensioner, and dependents
o Copayments are required for most services, and copayments are required for
prescription medications, 5,000 medications are essentially free after adjustments
in costs are made
o SHI is financed through compulsory contributions based on gross earnings
o The insured employee (pensioner) contributed 8.2% of the gross wage and the
employer (pension fund) contributed 7.3% of gross wages
o Remaining population, including civil servants and self-employed, are covered by
private insurance. Those with higher incomes can opt out of the SHI and choose
private insurance. Once private insurance is chosen, the SHI is no longer an
option; private insurance is regulated by the government so the insured are not
faced with large premiums as they age and experience a decreases in income
o Primary care physicians act as gatekeepers to hospital access, but German citizens
can access specialists without a primary care referral
o Some of these specialists have direct hospital access, so it is possible to
circumvent the primary care physician gatekeeping
o There is little or no waiting for physician or care access in Germany

o Population in Germany is aging

o Aware of this, German government integrated long-term-care (LTC) coverage
into the social security system
o LTCI is mandatory and provided by the same public-private mix as the health
insurance scheme
o Everyone who has a need can apply for up to 2 years of benefits under LTCI
o Applicants are assessed for need and if need is determined, they are placed in one
of three levels of care
o Beneficiaries can choose between cash payment or in-kind services
o LTCI covers about one half of the costs of institutional care
o Goal of the LTC insurance law was to provide relief from the financial burden of
long-term disability and illness
o Before LTC insurance, 80% of the elderly in nursing homes depended on public
assistance, funded by local communities
o This created a financial strain for the local communities
o More family members were fulfilling the role of informal caregivers
o Mental strain, lack of support, and financial hardships, created when the caregiver
was no longer employed outside the home, make family members reluctant to
assume caregiving responsibilities
o Can purchase private LTCI in place of the LTCI purchased with statutory health
o Private insurance is closely monitored because as citizens age, the premiums of
private insurance increase as risk increases, and LTCI premiums may become
o Many are aging Germans are still cared for by their relatives, the LTCI provides
incentives to establish additional home health care agencies, short-term
institutional care facilities, and assisted living facilities
o LTC insurance provides cash to family caregivers and makes contributions to the
pension fund if the caregiver provides more than 14 hours of caregiving a week
o Quality of nursing homes and long-term care providers has been monitored
o Independent institution is responsible for evaluating these agencies in 5 different
areas with over 50 quality indicators
o Costs of the program have remained within the budget, but adjustments may be
required in the future as the aging population increases and the younger
population decreases
 Japanese – in-home caregivers, home care users, certified users
o Universal healthcare system
o Insurance is provided through the National Health Insurance, a variety of
employer-based health insurance plans, and Health Insurance for the Elderly.
Everyone in Japan must enroll in a health insurance plan.
o Several employer-based health insurance plans, which are based upon the size of
the company.
o Premiums are fixed and shared between employers and employees.

o 20% copayment is required for hospital costs and 30% copayment is required for
outpatient costs.
o National Health Insurance covers workers in agriculture, forestry, or fisheries; the
self-employed; and those not employed, including students and retirees.
o Copayments are required for both inpatient and outpatient services and for
o As with the employer-based insurance plans, premiums are fixed and divided
between employees. IF there is no employer, the government pays for that portion
of the plan
o Premiums are automatically deducted from pensions for those who are retired
o 2000-2008 – those over 65 years of age or 40-64 years of age with certain
disabilities were covered by Health Insurance for the Elderly. In 2008, the
government implemented a new insurance program for those 75 years of age and
older, known as insurance for the Old-Old or Late Elders’ Health Insurance.
o Half of the cost of the plan is covered by the general budgets of the three levels of
government and the other half comes from premiums and subsidies from other
insurance plans
o Each insurance scheme contributes a fixed amount per enrollee to a central fund
o Japan has one of the largest elderly populations in the world
o Since WWII, policies related to the elderly in Japan have undergone changes
o Pension Reform Act covered about 20% of the labor workforce; payments into the
program were contributed by both the employee and the employer.
o National Pension Law provided coverage for the entire population and benefits
for the elderly were expanded to include free medical care; pension benefits were
also significantly increased
o Policies in place encourages an overuse of acute care hospitals, and Japan
experienced a large increase in health care expenses
o Health Care for the Aged Law terminated free medical care to the elderly; with
this initiative, the elderly have to pay a small deductible for outpatient and
hospital care
o Coinsurance and copayments were required
o The act also discouraged the use of acute hospitals for long-term care
o Law called for an increase use of intermediate nursing care, rehabilitation, and
other lower-cost strategies to support discharge elderly patients
o Gold Plan was a 10-year-plan that targeted health promotion and welfare for the
elderly trying to control future cost escalation.
 Promoted three services: home help, short-stay institutions, and day
 Also included education regarding normal aging to prevent misuse of
health resources by persons acting as they though elderly persons should
act – for instance, many elderly were bedridden because they believed
elderly people were suppose to be bedridden

 Modified to place even more emphasis on community-based-care, such as

respite care for caregivers, daycare centers, short-stay nursing homes, and
in-home care
o LTCI program’s purpose was to “support the independence and QOL fro frail and
impaired elderly persons by providing them with adequate health and welfare
 All those age 65 or older were entitled to receive long-term care according
to their eligibility levels
 Six levels of care were determined by physical and mental status;
availability of family support was not considered when determining the
level of care required
 To fund the program, everyone contributes to a designated fund based on
 5-year review of LTCI revealed that both the number of certified users and
home care users increased; institutional users increased
 Several reasons were posited fro the increase in the use as well as the cost
of program
 Elders no longer had to meet a means test to be eligible for services, so
elders who were not eligible in the past were able to secure services
 Under the 2000 LTCI plan, it was less expensive for seniors to pay the
copayment for a nursing home with food and around-the-clock care than
to pay for rent and utilities for most apartments or copayment for
community-based settings, such as a group home
 Institutional costs the LTCI program more than three times the cost of
community-based settings
 Municipalities had little control over the type and quality of services
 Originally, public health nurses were scheduled to act as care mangers and
create care plans based on a senior’s certified need, but the shortage of
public health nurses led to other health professionals with at least 5 years’
experience being bale to assume this role
 Lower-income seniors are exempt from this increase
 The goal of this increase is to lessen the gap in cost between institutional
and community-based care
o Hallmark of Japan’s long-term care insurance is that it does not offer monetary
benefits; instead, it provides services to help relieve the stress on caregivers
o These include community-based services such as help at home, adult day care,
respite care, assistive devices, and visiting nurses
o Long-term care approach has fostered a changed in attitudes in Japan
o Traditional Japanese values would neither allow a stranger into the home to
proved care nor consider sending the elder out of the home for care
o Emphasis on in-home caregivers for the Japanese elderly, combined with a
growing elderly population, elder abuse has received additional attention

o Japan Federation of Bar Associations submitted a report to the Health, Labor, and
Welfare Ministry that included recommendations to assist both the victims and
o Elderly were reluctant to report abuse because they felt responsible when their
children were the perpetrators because they raised them
o Japan enacted the elder abuse prevention and caregiver support law
 Canadians –
o Known as Medicare, provides universal coverage at no cost at eh point-of-care
access for physician and hospital services
o Each of the 10 provinces is responsible for establishing, maintaining, and
evaluating the provision of healthcare services within the province; their programs
must follow national guidelines of universality, portability, ability to access, and
public administration
o The services must be based on need, rather than ability to pay; sharing of best
practices; accountability; and flexibility among provinces
o Even though each province has a slightly different coverage plan, a resident could
receive covered care in another province if it was necessary
o Funded primarily through tax monies. The federal government provides some
money to the provinces; most of the costs are covered by the provinces
themselves, which in turn levy taxes to pay for health care. Most physicians are in
private practice, and they charge on a fee-for-service basis, though they cannot
charge more than the negotiated fee. Hospitals are primarily private, not-for-profit
institutions. Most provinces and territories cover the cost of regular vision and
dental care for children, seniors, and social assistance recipients. Most public drug
plans cover seniors as well as those in low-income groups.
o One criticism has been the long waiting periods. Self-reported median wait time
for specialist physician visits for a new condition was 4.3 weeks. Timely access to
care is an area of priority for the National Health Service, and wait times have
decreased in targeted areas. The wait list is triaged by medically trained
professionals who follow best medical practices, which helps ensures that more-ill
patients can be moved to the top of the list.
o Canadian Health Act does not guarantee coverage for care provided out of
hospital or by providers other than physicians. Long-term care services and end-
of-life care are considered “extended health services.” Coverage for those services
varies among provinces. Even when health services in residential care facilities
are covered, housing and meal costs are generally out-of-pocket unless the client
meets a means tests. Individuals with financial resources are able to purchase
long-term care services from private providers to offset the cost of care
Responsible entities for provision of healthcare services in Canada
 Improvement of waiting periods ? LOOK ABOVE ^ at Canada
Medicare Part A—eligibility criteria and coverage

 Helps to cover inpatient hospital care, inpatient care in a skilled nursing facility (for
transitional, but not custodial, care), hospice care, and some home healthcare services.
 Financed by payroll taxes paid by the employer and employee
 Available without charge for those who are eligible to receive Social Security or Railroad
Retirement benefits
 If an individual is 65 years of age and has not worked 10 years (40 quarters) in a job that
has paid Medicare taxes, he or she can receive Medicare Part A by paying a premium
 Reimbursement purposes under Part A, Medicare establishes benefit periods, which
consists of 90 days of inpatient hospital care
 When a patient is admitted to a hospital inpatient care, the benefit period begins
 If an individual requires additional skilled care in the transition from at least a 3-day
inpatient hospital stay to home, Medicare Part A will cover the first 20 days of each
benefit period in a skilled nursing facility for no out-of-pocket expense. However, after
100 days in a skilled nursing facility, the individual is responsible for all costs in the
benefit period
LTC insurance Benefit trigger-definition
 Long-Term Care Insurance; Expensive which creates a barrier to LTCI
 LTCI is designed to cover those expenses of long-term care that are not covered by
traditional health insurance or Medicare
 Only 10-15% of the elderly is covered by private LTCI
 Wide spectrum of benefits: home care, assisted living, adult daycare centers, respite
services, and nursing home care
 Services not included are care provided by family member who is snot an employee of a
contracted service, care or services for which there would be no charge if insurance were
not present, care for alcoholism and drug addiction, services usually covered by
Medicare, and services or care for self-inflicted injury
 Benefit trigger
o Eligibility for long-term care under a policy begins with a benefit trigger, which
consists of those criteria that are usually defined in terms of activities of daily
living or cognitive impairments
o Benefits can be paid on either a daily basis or a monthly basis
o If daily benefits are chosen, costs that costs that exceed the daily amount would
be paid out of pocket
o If a month benefit were chosen, then the expenses up to the monthly limit would
be covered, regardless of when they were incurred during the month
o Benefit periods refers to how long an individual wants the benefits to continue
after they being, usually a period of 5 years
o If the total amount of coverage is not used during the benefit period, then the
benefit period may be extended until the enter benefit amount is used
o Long-term care insurance policies also have a waiting period called an
elimination period, usually 30, 60, or 90 days

o Some policies also state that the beneficiary must receive paid care or pay for
services during this period. This is the time a beneficiary must pay out of pocket
before the policy begins to cover expenses; the shorter the waiting period, the
more expensive the policy premiums will be
o Policies may also include an escalator to help cover the increases in care costs
over time

Chapter 19
NMLP Learning domain-describe each section
 Nurse Manager Leadership Partnership
o Describes essential functions of nurse managers and outlines opportunities that
may be useful to achieve mastery of these functions
o The framework includes three domains: (1) the leader within: creating the leader
in yourself; (2) the art of leadership: leading the people; and (3) the science of
leadership: managing the business.
 Learning Domain Framework for NMLP
o The Science: Managing the Business – Financial Management, Human Resource
Management, Performance Improvement, Foundational Thinking Skills,
Technology, Strategic Management, Clinical Practice Knowledge
 Effective business practices for the unit
 Manager must understand how to provide high-quality care in an efficient
manner in their unit
 Most important aspects = having clear understanding of how staffing
decisions impact the financial stability and health of the organization as a
 Managers = become familiar with graphs and reports used within the
organization to monitor budgets; to facilitate this, it is helpful for the
manger to find someone in the organization to serve as a budget-specific
 Nurse manager balances the needs of the patients, unit staff, and overall
organization with the provision of safe, high-quality care
 Page 681 – table on tasks associated with the role of nurse manager
o The Leader Within: Creating the Leader in Yourself – Personal and Professional
Accountability, Career Planning, Personal Journey Discipline, Optimizing the
Leader Within = Specific tasks included in this domain
 New leader develops a personal understanding, gaining self-confidence,
and learning to trust and empower others
 Good place to start with gaining this understanding of self is to do a self-
assessment. Ex: the Center for Creative Leadership has a variety of tools
to provide a baseline self-assessment. These assessments provide focus on

areas that may need additional attention as the manger becomes

comfortable in the new role
 New managers should set goals for themselves that will lead to growth in
the role
 Relationships with employees are established and networks of peers are
built. Mangers develop an awareness of self, see how their actions impact
the unit, and learn to find the style that is comfortable for them and works
well for the unit
o The Art: Leading the People – Human Resource Leadership Skills, Relationship
Management and Influencing Behaviors, Diversity, and Shared Decision Making
 Focus is building on specific teams
 Nurse managers use effective communication, conflict resolution skills,
and motivation techniques to move the team beyond day-to-day conflicts
 Building a high-performance work team is critical to providing high-
quality patient care
 Teams are usually comprised of high, middle, and low performers
 High-performing individuals have brilliance and drive, with the ability to
propose solutions to problems
 Middle performers are supportive of the team, but often lack the
knowledge, expertise, or self-confidence to put solutions forward
 Low performers place blame on others, fear change, and spread
 Effective nurse managers will recognize the strengths, talents, and skills of
each individual on the team and strive to assist them to become even better
 High performers should be encouraged to bring concerns and solutions
forward. The manager can foster this by conducting rounds and interacting
with the high performers, soliciting their input and offering praise for
proposed solutions. To encourage middle performers to become high
performers, the manger needs to be visible to them, empowering them by
offering support and encouragement. Low performers can be encouraged
to become better performers by arranging private meetings where direct
and decisive plans for improvements, with clear consequences for
continued low improvement. Follow-up meetings should be scheduled to
monitor progress.
 Specific strategies that are useful to foster improved teamwork among all
unit staff include establishing a common goal for the team, conducting
briefings for staff, and using team huddles to ensure that the lines of
communication are open
 Effective communication = staff members need to trust the manager
 Manager seeks out staff members’ opinions = staff feel valued and
empowered and trust is established

 Conflict resolution: uncomfortable task for new managers; essential to the

functioning of the unit; conflict = manger focuses on mutual goals among
the team and encourage collaborative decision making to move the team
beyond the conflict
 Relationship management, includes fostering culture of safety within the
 Composition of teams providing care fr older adults may include
staff with wide variety of education preparation and skill
development, ranging from RNs, to CNAs, to unlicensed assistive
personnel (UAP), such as medication aides
 RN – responsible for safely delegating care to appropriate
members of the team
 NCSBN (National Council of State Boards of Nursing) and ANA
(American Nurses Association) issued a joint statement on delegation: the
process for a nurse to direct another person to person form nursing tasks
and activities
 Delegation Steps: (1) assessment of the client, the staff, and the
context of the situation; (2) communication to provide direction
and opportunity for interaction during the completion of the
delegated task; (3) surveillance and monitoring to assure
compliance with standards of practice, policies, and procedures;
(4) evaluation to consider the effectiveness of the delegation and
weather the desired client outcome was attained
 To safely delegate a task, nurse needs to be familiar with
certification, educational preparation and skill level of the staff
member to whom they are delegating a task
 Asking questions of the staff member about the task, seeking
clarification of their knowledge about the task, or requesting a
return demonstration of the task prior to delegating are all good
ways to determining if a task can be safely delegated to a specific
team member
 Nurse practice acts vary from state to state, RNs should be aware
that in most states licensed practical nurses (LPNs) do not
independently develop the plan of care, make changes in the plan
of care, or perform telephone triage, so these duties cannot be
delegated to them.
 Use of unlicensed assistive personnel (UAP) provides additional
delegation challenge for RNs in the long-term are setting
o Significant variations from state to state with regard to the
educational preparation of and roles for UAP – some states
allowed UAPs to pass medications; RN is responsible for
ensuring that UAP is competent enough to do so

 Nurse manager role – provide intentional acknowledgement of the work

and contributions of staff to the unit. Staff members need to feel valued
and respected by the manager (thank you, providing rewards to celebrate
achievements, nominating staff for awards)
Leading the People--High performance team is encouraged to do what on a unit?
 Building effective teams. Above ^ the art of leadership: leading the people
Managing the business-sharing the vision, focus on mutual goals
 Above under the science of leadership
Delegation process-describe the steps
 Above ^ under the art of leadership
 Five rights of delegation: right task, right circumstance, right person, right
direction/communication, right supervision
Demonstrating communication standards—strategies to responding to staff
 Page 685, 693-695
 Nurse leaders must set professional communication standards and then role model these
standards in their interactions with others. Examples of these standards included
responding quickly to staff questions and following up on concerns. Nonverbal messages
are also sent to staff when nurse leaders answer call lights, pick up trash, and present a
calm demeanor when dealing with others
 Robinson
 Need for straightforward and unambiguous communication is paramount
 Needs to be an opportunity to verify what was heard and ask clarifying questions
 Visibility and open communication among the leader, subordinates, and colleagues
provide this opportunity
 Collaborative problem solving
o Bringing people together to discuss concerns = sense of team camaraderie
emerged, instead of an us-versus-them mindset
o This has implications for patient safety
o Team members were open to hearing different perspectives and weighting various
o Opinions of others were highly valued and sought after as respect grew among the
team members
 Maintaining calm and supportive demeanor, even in stressful situations, was integral to
effective communication
o Included displaying a collegial tone and normal volume of voice
o Positive reinforcement, expressed as appreciation
 Establishing sense of trust and building mutual respect

o Comfortable rapport among members of the team ensures that even

uncomfortable issues can be raised with the knowledge that they will be dealt
with in a professional manner
 Developing authentic understanding of and appreciation for the unique role of each
member of the team
o Each profession experiences unique challenges and brings unique contributions to
the team process
o When everyone works in isolated silos, instead of in teams, they lose the richness
that comes with welcoming others tot eh table for discussion
o By developing an understanding of these varied contributions, each profession
will establish a sense of respect for the other
 Gil – Describes aspects of communication styles that lead to effective communication by
o These include: listening to the concerns of stakeholders, maintaining professional
integrity, adhering to ethical standards, balancing stakeholders interests, and being
aware of the emotional barriers (preconceived opinions and beliefs, prejudices,
biases, egos and politics)
 Also describes four additional key attributes of effective communication
o Assertiveness – ability to forcefully state your own position, despite opposition
from influential others
o Leaders need to exhibit strategic influence – ability to build coalitions with
influential others, gaining their support and mutually overcoming obstacles
o Spending time and energy getting to know influential is referred to as relationship
o Political awareness – leader understands who the influential people are and how
to work effectively with them
 Role of the nurse leader in the process of establishing effective communication = to
facilitate the establishment of a collegial relationship among the team members, whether
the team is comprised of all nurses or is more interdisciplinary
o When nurse leader sets clear expectations
Strategies for Retaining employees
 Employee retention has become even more crucial in the long-term care environment, as
turnover among direct care workers in the long-term care environment has been reported
to range from 40% to 100%, and the cost to replace a registered nurse can range from two
to three times the annual salary. Because of this high turnover, fewer employees are
challenged to provide high-quality care, using fewer resources. At the same time, resident
care needs have become more complex and demanding.
 Shifting demographics and workforce demands lead to the prediction that additional
nurses will be needed. Potential to empower, engage, and satisfy nurses through the
formation of staff-led EBP councils. By giving nurses a voice in the implementation of
EBP findings, there is potential to improve quality outcomes and reduce turnover.

 Staff turnover was tied to psychological and global empowerment, as well as perceived
organizational support. These are all areas over which the leaders ahs the ability to exert
influence. When an employee identifies with and feels accepted as a member of a work
group, this leads to increased job satisfaction and retention. Sponsoring celebrations and
social events are one way to accomplish this. Opportunities for ongoing education can
also foster workgroup cohesion. Leaders can foster feelings of personal accomplishment
among the staff by recognizing and rewarding employee accomplishments, which is just
one method of addressing staff turnover
 Emotional exhaustion is detrimental to job satisfaction. Finding ways to make sure that
staff takes their coffee and meal breaks can prevent emotional exhaustion and boost
feelings of satisfaction. The work environment should also assist employees to find a
better quality of work-life balance
Qualities of effective leaders
 Maintain an awareness of these qualities and strive to grow and gain knowledge in any
areas where they may identify weaknesses
 Sims proves a list of these qualities
o Knowledgeable in their area of expertise and willing to share that knowledge;
willing to collaborate with others; having self-awareness and a conviction of
beliefs; goal oriented; lifelong learners; take responsibility for their actions and
for those of their staff; trustworthy; create a health work environment where staff
are free to contribute to work; possess vision and is willing to share it with others;
foster an environment in which staff feels free to contributes; have a good
relationship with the staff; create a sense of relationship with staff; create a sense
of community; have good oral communication skills; have a positive attitude; has
the ability to make hard choices; takes advantage of teachable moments; flexible;
assists others to develop their practice; acts as a mentor; recognizes the strength of
others; recognizes their own strengths
 Sometimes organizations may embrace a specific theory and expect that all staff use this
theory as a basis for relationships and decision making
 Other times, leader may be free to select whatever theory is comfortable for them
Transformational leaders—describe them
 “You scratch my back, I’ll scratch yours”
 Leaders and followers exchange economic, political, or physical items of value, which
ties them loosely together
 Sim indicates an individual employee’s strengths are identified and a system of rewards
and punishments is established by the leader
 Ties between the leader and their employee are loose at best and relationships are
 Transactional leaders may exhibit behaviors associated with management-by-exception,
where action is taken only after problems occur or mistakes are made

 They intervene only when issues are obvious, seeking to maintain the status quo
 When transactional leadership is used, control is maintained at the top of the hierarchy
 Characteristics of Transformational Leaders: Inspire a shared vision, model the way,
challenge the process, enable others to act, encourage the heart (table 19-4)
Dealing with diversity of the generations—bobay boomers, millennials, generation X
 Page 698 – Stanley
 As the population of older adults in need of healthcare services continues to climb, the
need for an adequate supply of nurses prepared to meet their specialized needs will
increase as well. Maintaining a stable staff is important and retention of staff is essential.
The workforce is made up of nurses from several generations, each with unique views,
attributes, and concerns
 The first group is often referred to as the veterans and includes people born before 1945.
The number of nurses in this group is declining as they retire, but the influence of their
presence is still felt in the structure and policies that remain in the workplace. Those that
remain in the workforce bring a lifetime of experience. Many are in formal and informal
leadership positions. These nurses generally are loyal, often working for one organization
for their entire career. Values held by this group included maintaining the professional
image of nursing, respect for authority, dedication, and sacrifice.
 Baby boomers
o Born between 1946 and 1964
o Many are approaching retirement age.
o Nurses of this generation are usually optimistic and value personal growth and
interpersonal communication, often questioning the status quo.
o Baby boomers bring a strong work ethic to the workplace
 Generation X
o Born between 1965 and 1980
o Experienced a rapidly changing society, including two-career families, divorced
parents, and an explosion of technology
o Generation X nurses value independence, informality, technological literacy, and
having fun, with less emphasis place on work
 Generation Y/Millennials
o Born between 1981-1999
o Bring a mastery of all things technical to the workplace
o These nurses are adept at multitasking and wish to collaborate in decision making
o Group membership is highly valued, as is achievement; members of this
generation present themselves in a confident manner
 Leaders need to recognize and leverage the different values and strengths of each
 In the former chain of command, older nurses were the supervisors and the younger
nurses were the apprentices. This has been replaced by teams of all generations. Younger
nurses are more likely to make demands, speak their mind, and voice opinions

 Leaders must use caution to avoid stereotyping of individuals. Lack of reorganization of

employees may lead to further misunderstandings and tension. Generational differences
may lead to misunderstandings and conflicts surrounding communication styles, values,
problem-solving methods, and work ethics. IF left unresolved, the organization may see
absenteeism, interpersonal conflict, communication breakdown, and turnover
 To deal with these differences, several strategies should be used
o Core nursing values that transcend the generations, such as quality care, respect,
and ethical decision-making, should be emphasized
o The mission and values of the organization should be reinforced
o Each employee should be held to the same standards as described in the goals,
policies, and procedures in the organization. Opportunities should be made
available for nurse to have a voice in the organization
 Leaders need to be open, flexible, and approachable
o Leaders conduct a self-assessment of their own managerial type and generational
cohort; this can help with achieving a greater understanding of their own values,
in relation to those of the nurses in their unit
o Efforts must be made to deal with conflict and differences through dialogue and
solutions that retain respect for all employees
 Nurses from all generations should be given the opportunity to make contributions to the
organization that recognize and celebrate their unique perspectives, insights, and views.
Engaging nurses from all generations will improve retention and facilitate quality care