Critical thinking – JRM Nurse Consultants

April 04 2020

Navigating Leadership Challenges and Change in Nursing

In my previous employment, I went through some challenging issues that started at the leadership level. I was a manager of case managers at the time. The role of the professional nurse when implementing a change is to identify that there is a need for a change (Rubenfeld & Scheffer, 2014). Once the need for a change is identified by the nurse, the next step is to implement a change in behaviors efficiently and with quality. When identifying the area specifically that needs the change, nurses need to be deliberate in stating the purpose of the change. When speaking to the target group about making the change, it is important to keep their attention span with non-lecturing phrases. As nurses, we are not always in our comfort zone to explain why changes need to be implemented. We should be prepared to explain why this change is needed and what improvements these changes will make (Rubenfeld & Scheffer, 2014).

Generally, people will always be resistant to change. But as professional nurses, our focus is to build trust and credibility. The goal is to acknowledge that the change is coming and that you empathize with the feelings of the upcoming change (Rubenfeld & Scheffer, 2014).

Where I used to work, they were very involved with ACHA (Agency for Healthcare Administration) because we held a state contract. Evidence-based nursing was, in a sense, required as far as patient care when our case managers were managing a case. However, on the same note, although our case managers were not performing hands-on care, they were required to know about all their diagnoses and treatments. We had social workers and nurses alike seeing the same types of members. The issue with nurses and social workers seeing the same types of patients is that the social worker is not able to use his/her critical thinking skills in their area of expertise. They were required to assist members who had complex medical issues, for instance, those on a ventilator or with more complex medical problems.

A suggestion was made when I arrived at my workplace to utilize the social workers in conjunction with the nurses to manage the social aspects of the patients; however, the decision was denied. It was noted that ACHA is not paying the company to rethink how cases were managed and by whom because it was not hands-on care; it was case management (Barr & Dowding, 2012).

There was very little nursing involved in my job role; it was primarily reports and meetings to talk about reports and how to fix these reports. It was an ideal job for someone who had an interest in the perfection of numbers and statistics. Every other day, there was a new change that was being implemented. We often questioned why there was a change, but what we were told was that the change was immediate and mandatory. For the staff case managers, these changes were difficult because the staff were in the field. They may receive an email about something that needs to be changed as soon as possible; however, they may have just returned home at 4:30 or 5 pm, looking forward to the end of their day. When the case managers checked their emails, they found deadlines on multiple items due. These changes affect the staff because they have to work after hours to get the work completed timely. This kind of change caused many good nurses and social workers to resign (Barr & Dowding, 2012).

As nurses or leaders, we tend to fall into the routine of lecturing due to the pressures that we are under. However, two of the six dimensions of dealing with complex dynamic changes are creativity and intuition. As a leader, we should not just teach our group something; we should implement a way to bring creativity into the change and use intuition to know how to speak to our group. The best way to implement a change is to get the group to commit to doing the new change and develop a SMART goal with them that will allow them to measure their own goals (Rubenfeld & Scheffer, 2014).

The leadership theory that most resembles mine is the coaching leadership style. The coaching leadership style allows me to work closely with staff at different levels and empower them to meet their goals and gain confidence in their strengths. By being confident, they can focus on themselves as they work on their weaknesses. In my previous job, the leadership style seemed like a dictatorship; however, for the discussion here, it will be stated as coercive. My manager’s favorite phrase was, “I gave a directive and everyone needs to follow it. Any questions, 1 second wait time, no, good. It’s due by the close of business.” If questioned on how to juggle that with all the meetings and other directives, the reply was always, as a manager, make it happen. My manager always reminded me that she did not take lunch or breaks, and she had “no life!” For fun, she read the ACHA contract that was 350 plus pages because reading any other book was pointless (Barr & Dowding, 2012).

References

Barr, J., & Dowding, L. (2012). What makes a leader? In Leadership in healthcare (2nd ed., pp. 13–31). [Vital Source Bookshelf]. Retrieved from https://campus.capella.edu/web/library/home

Rubenfeld, M. G., & Scheffer, B. (2014). Critical thinking and patient-centered care. In Critical thinking tactics for nurses: Achieving the IOM competencies (3rd ed., pp. 155–180). [Vital Source Bookshelf]. Retrieved from https://campus.capella.edu/web/library/home

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January 01 2017

Tuition Reimbursement by Employers

In today’s world if there is an employer that values their staff and gives them the encouragement, tuition reimbursement and educational leave to complete schoolwork, that is a great thing. It is not often that employers will allow tuition reimbursement let alone time off to do internships or flex schedules.

I used to work at a large corporate insurance carrier. They offered tuition reimbursement, however each department director had the ability to accept or decline the area of study that the student was taking. There were nurses that had their MSN in our department and requested tuition reimbursement for their ARNP and it was denied. We had ARNP’s at our company, but in a different department. The rationale for the denial that one nurse received was that this was not an area of study that they wished to approve. The director indicated that there was not an immediate need in our department for an ARNP. The nurse was crushed as the policy on tuition reimbursement clearly states that as long as the area of study pertains to your job, it should be approved, however at your director’s discretion. This very same nurse would take every Friday off to do her clinical practice and did not take any other vacation days or sick days to ensure that she was able to do this. I approved this for her so that she can get her school work done. My director at the time asked why I would approve such a schedule, I explained that due to her clinical practice she needed to be off to fulfill her practice. I knew when this nurse was going to graduate so I made sure that I approved her time off for the entire year. Do you know that my Director stated that in the future these requests could not be granted.

In the book Critical Thinking Tactics for Nurses, there is a section that speaks about comments and behaviors that promote or squelch critical thinking. As I read through some of those that squelch, critical thinking, they resonate in my mind, “ that’s the wrong way to do that, just do it this way, don’t you know that and you should know that ” (Rubenfeld & Schaeffer, 2014, p. 91-92).

When I hear about a place of work, that gives their employees a reason to stay and better themselves, it is enlightening. I have always believed that the face of a company is every single employee that answers a call, makes a visit and does anything for the company, no matter what position they hold. Therefore, if an employer invests time and money in that employee, they will grow and continue to make themselves and their employer successful. This in turn will create job security because people will want to do business with happy employees.

References

Rubenfeld, M. G., & Schaeffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. http://dx.doi.org/

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January 01 2017

The Future of Nursing Your Workplace

I was recently speaking to a nurse about her current work place and some of the changes that she sees coming. She was concerned for the safety of her patients with many changes that will take place putting more work on the nurses and not for any greater pay or benefit. I explained to this nurse about a previous place that I was employed at and how I had to break away because I was not using my full potential as a nurse.

In my previous work environment, my position was a manager of long-term care case managers. The Institute of Medicine(IOM) report was not shaping our scope of practice at my previous location. The organization was very top-heavy and there did not seem to be enough people to do the jobs that directly affects the population that we serviced, which was the Medicaid and Medicare population. The training that was provided to the staff was more on how to complete reports and paperwork that was required by the state of Florida in order to be in compliance with AHCA.

The issue with this was that the members were not being followed up with properly. Nurses and social workers were going through the motions of case managing their files, with basic monthly telephonic questions asking a member living in the home how things were going, have they received their supplies was there anything new that they should be aware of. A monthly contact should involve so much more, but yet it didn’t because the case managers did not have enough time to fulfill the job in eight hours and they would work for 12-15 hours daily some of them, to get documentation done in order to avoid a reprimand by upper management.

In the IOM report there are six aims that healthcare providers should follow and one of them is patient centered healthcare (Rubenfeld & Schaeffer, 2014, p. 82). The goal of the health plan was to have patient centered care and have policies in place for it. The case managers did everything in their power to obtain services for the members and get them started as soon as possible and formulate a care plan with goals. The challenge that they were running in to was that the case managers were out in the field 4-5 days per week, they didn’t have time to complete the documentation of their assessments while they were in the member’s home, therefore creating more after hours documentation for the case managers, dissatisfaction with the job and more report concerns rather than focusing the time speaking with the member to really understand what the member’s needs are.

The nurses and social workers were not able to apply quality improvement plans because there was little collaboration as an interdisciplinary team. Nurses and social workers both did the same assessments and did not have the ability to collaborate on a case as if they were both co-managing the case.

The nurse I was speaking to was amazed that this happened in the work place that I used to work in. I explained to this nurse that the IOM report would not shape my career as a doctorate of nurse practice (DNP) at my former job because the region that I was in did not support critical thinking or any type of evidenced based nursing. The rigid structure would remain and no changes unless implemented or suggested by upper management would be considered in our department.

Now as a DNP on the outside of this organization, the ultimate goal is to consult with nurses, doctors. therapists, nutritionists and specialist to get the right people involved in carin for a patient whether at home or in a facility. It is good to have a future goal with a plan in place to reach that goal.

Two Businesswomen Meeting Around Table In Modern Office — References

Rubenfeld, M. G., & Schaeffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. http://dx.doi.org/

Follow Rosie Moore https://www.facebook.com/rosiesnursecorner/

April 04 2015

Multiple Factors Can Interfere With Teamwork

In every organization there are communication barriers, but overcoming them is part of being professional and respectful of others’ opinion. In some organizations the leadership structure has a medical director, senior health service director, a health service director, a manager and the case manager. The case manager manages the file, develops the plan of care with the assistance of the member or the family. The nurse is responsible to ensure that the member is attending their doctor’s appointments, taking their medications and maintaining their insurance eligibility monthly. This should be done by the social worker however in some organizations, the social workers manage the same types of patients that the nurses manage.

There are other professionals on the team that help maintain the members with their eligibility for their Medicaid insurance. Part of the team is the operations team. This is where things in an organization get blurred due to communication gaps, lack of resources, support and professionalism. The team in operations are not nurses. The operations team will email the nurse and copy the manager to let them know that the member is going to lose eligibility if they do not send in their paperwork timely to the state. When the nurse receives this email, the nurse is to drop all that they are doing to attend to the member’s eligibility. This will involve contacting the state to see what is happening with their eligibility. This is something operations can handle but they state their function is just to advise the case managers of the discrepancy.

Another barrier that is seen in management of cases is the inability to show respect to other team members and allow a learning environment. One agency case manager stated that every two weeks the team of case managers reviews case files on a conference call with the medical director. These cases are reviewed in their team meetings weekly before submitting to the medical director and as a team they discuss what has been done and make suggestions. The cases are emailed to the medical director and his assistant selects the cases. Recently, a case manager stated that two cases were selected for review from her team. The case managers present them to about one hundred and eighty people or more on the call from directors to managers and case managers. As the doctor asks his questions and makes his recommendations, the case manager indicated that her director, who is her manager’s superior, made a statement on both cases stating to the team that their manager should have known this and taken a different approach before sending this to review. The case manager did not know what to say, but this was stated over and over about five or six times throughout the presentation of both cases. At the end, what was stated by that director was if your manager does not know what to do, then call her. This is a prime example of a barrier in trying to be in a learning environment that will help the case manager grow and benefit the patient. (Rubenfeld & Schaeffer, 2014)

Collaboration can only exist in a team when the leader uses critical thinking, an interdisciplinary team approach and collaborate on cases together. But in the big picture of corporate America under some managers this is not acceptable, it is more along the lines of a multidisciplinary team. In this type of team, you only have individual thinking in the group, meaning their way and no other opinions. The focus will be on tasks and check off systems regardless if it is feasible to do. (Rubenfeld & Schaeffer, 2014)

In conclusion, nurses do have the ability to be leaders, educators and changers of a system, if assertive enough to make that change, but in order to do so a good team of interprofessional people are needed. Because at the end of the day, the patient is who counts and why changes are necessary.

References

Rubenfeld, M. G., & Scheffer, B. (2014). Critical Thinking Tactics for Nursing Achieving the IOM Competencies (3rd ed.). [P2BS-11]. Retrieved from http://online.vitalsource.com/books/9781284059571

Written by Rosie Moore, RN, BSN, LNC

March 03 2015

Organizational Culture and Critical Thinking

In some managed care organizations, there are several factors that inhibit critical thinking skills to be utilized. Some of these factors are contract led and others are management style. Long term care programs are mandated by the state to follow a certain protocol on managing their cases for the members that are seen. The care part for the member is not an issue, however the reports and assessments that are required to be filled out, keep the case manager from adequately spending appropriate time with the member. If there is one item not completely filled out, the assessment will be returned by the state. The assessment is at times sent back late from the state, forcing the case manager to redo the entire assessment that can easily take two hours. This in turn causes a high turnover of staff because the demands on their time as salaried employees working 12 plus hours and 6-7 days per week are not what they want to do.

These company cultures do not lend themselves for new implementations for a better way to manage the staff and their time. The industry has seen some of the staff say that they have PTO (it should be paid time off) but at times they are still checking emails and phone messages for fear of getting behind, so one has to ask themselves are they on paid time off or pretend time off? One manager cannot implement changes in the entire company, but with their own team they can apply evidence based nursing and critical thinking skills to make a difference internally.

Some ideas that a manager can work on with their team can be, discussing best practices for different aspects of the job. It seems that all team members and managers have to address emails, projects and reports, these will always interrupt the flow of the day. The team however, can control when they see their patients, make phone calls and when notes are entered in the system. When a manager is preparing to discuss the best practices, some things to consider can be based on the issues that the staff come up with ahead of time during the week or audits on their files. This can help the morale of the staff as well as their performance, decreasing the amount of turnover. (Marchionni & Ritchie, 2007)

In conclusion, every manager has their own style of managing. The best style of management is always going to be one that empowers employees to do their job based on examples and positive reinforcement. If all the employee ever hears is what they did wrong and never a word of praise, the employee will not strive after a while to grow and better themselves.