1. PROBLEM SOLVING AND DECISION MAKING/NURSING CARE DELIVERY SYSTEMS

2. PROBLEM SOLVING AND DECISION MAKING  Are not synonymous terms  Processes for engaging are similar  Both require critical thinking, which is a high level cognitive process

3. DECISION MAKING  A purposeful and goal-directed effort that uses a systematic process to choose among options  Hallmark of decision making is the identification and selection of options or alternatives

4. PROBLEM SOLVING  Includes a decision making step  Focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be”

5. CREATIVITY  Essential for generation of options or solutions  Creative individuals can conceptualize new and innovative approaches to a problem or issue by being more flexible and independent in their thinking  See Figure 6 -1 on page 100 for problem-solving decision making model

6. DECISION MAKING  Phases of decision making:  Defining objectives  Generating options  Identifying advantages and disadvantages of each option  Ranking the options  Selecting the option most likely to achieve the predefined objectives  Implementing the options  Evaluating the results  A poor decision is likely if the objectives are not clearly identified or if they are inconsistent with the values of the individual or organization

7. DECISION MODELS  Normative or prescriptive approach: used when the situation is fairly routine  Descriptive or behavioral approach is used when the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable  Satisfying: decision maker selects the solution that minimally meets the objective or standard for a decision (allows for quick decisions)  Optimizing: the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option (Takes longer to arrive at a decision)

8. DECISION MAKING STYLES  Autocratic: Leader makes decisions independent of the input or participation of others  More appropriate in crisis situations or when a rapid decision is needed  Democratic or participative approach: The leader involves the appropriate personnel in the decision making process.  Followers are more supportive when involved in the decision making process

9. GROUP DECISION MAKING  Higher quality decisions are more likely to result if groups are involved in the problem solving and decision making process  When individuals are allowed input into the process, they tend to function more productively and the quality of the decision is generally superior  Groups are more effective if:  The group is cohesive  Communication is encouraged  Members demonstrate some understanding of the group process  Need to consider group size and composition

10. ADVANTAGES OF GROUP DECISION MAKING  When individuals with different knowledge, skills and resources collaborate the likelihood of a quality outcome increases  More ideas can be generated by groups  When followers are involved in the process, they are more likely to accept the outcome because they have an increased sense of ownership or commitment  Groups will be committed to an idea if it is derived by consensus  Majority rule can be used to compromise when 100% agreement cannot be achieved

11. CHALLENGES OF GROUP DECISION MAKING  Requires more time  Unequal power among group members  Dominant personality types may influence the more passive or powerless group members to conform to their points of view  Individuals may expend time and energy defending their positions resulting in the primary objective of the group effort being lost  Groups may be more concerned with maintaining group harmony than engaging in active discussions on the issue  Group members who manifest “group think” mentality are so concerned with avoiding conflict and supporting their leader and other members that important issues or concerns or not raised.

12. GROUP DECISION MAKING TECHNIQUES  Brainstorming is effective for generating a large volume of creative options  Should list all ideas without criticism or comments  Nominal group technique  Group members write down their ideas to solve a problem  Each member shares an idea until all ideas are shared  Very time consuming  Focus groups  Can be used to identify problems or evaluate the effects of an intervention  Groups meet face to face with a facilitator  Delphi technique involves systematically collecting and summarizing opinions and judgments from respondents on a particular issue through interviews, surveys, or questionnaires  The summaries are fed back to the respondents and then they add more information. This allows respondents to reconsider their responses. The goal is to achieve 100% consensus.

13. DECISION MAKING TOOLS  Decision Grids facilitate the visualization of the options under consideration and allow comparison of options using common criteria  SWOT analysis: used in strategic planning or marketing efforts but can also be used by individuals and groups in decision making  The individual lists the Strengths, Weaknesses, Opportunities, and Threats related to the situation under consideration

14. PROBLEM SOLVING  The process is dynamic  Define the problem, issue or situation  Most common cause for failure to resolve problems is the improper identification of the problem/issue  Gather Data  Analyze Data  Develop Solutions  Select a solution  Implement the solution  Evaluate the result

15. NURSING CARE DELIVERY MODEL  The method used to provide care to patients  Nursing care is traditionally viewed as a cost rather than a revenue producing entity.  Nursing care delivery methods should be evaluated in order to find the method that saves the institution money!

16. CASE METHOD (TOTAL PATIENT CARE)  Premise is that one nurse provides total care to one patient during the entire work period  Traditionally used in critical care settings or hospice  Method is very costly; in times of shortage, not enough nurses to use this method

17. FUNCTIONAL NURSING  Each licensed and unlicensed staff member performs specific tasks for a large group of patients  For example, RN performs all admissions, assessments, and IV meds. LPN may provide treatments, medications. One assistant performs all hygiene and another assistant takes vital signs; Charge nurse coordinates care and assignments  Advantages is that each person becomes efficient with task and a lot of work done in a short period of time  Disadvantage is fragmented care, patient’s response to care is difficult to assess, family and patient dissatisfaction

18. TEAM NURSING  A team leader is responsible for coordinating a group of licensed and unlicensed personnel to provide patient care to a small group of patients. The staff nurses report to the team leader and the team leader reports to the charge nurse  Advantages: Improved patient satisfaction, organizational decision making at lower levels, and cost effectiveness  Disadvantages: team leader with poor leadership skills (can result in a miniature version of functional method)

19. PRIMARY NURSING  RN functions autonomously as the patient’s primary nurse throughout the hospital stay  Primary nurse is responsible for meeting outcome criteria and communicating with other health care providers about the patient  When the primary nurse is not working, an associate nurse implements the the plan. Associate nurse notifies primary nurse of change in patient status (primary nurse has 24 hour accountability)  Advantages: encourages RN autonomy and professionalism, increased patient satisfaction, leads to an all RN staff  Disadvantages: Need prepared RNs, All RN staff, shorter hospital stays limit time to implement primary nursing

20. PRIMARY NURSING HYBRID: PARTNERSHIP MODEL  RN is paired with a technical assistant. Partner works with RN consistently. Delegation of activities is based on scope of practice of assistant (LPN or UAP)  Used in rehab settings

21. PRIMARY NURSING HYBRID: PATIENT FOCUSED CARE  Features decentralized, streamlined, and localized care  A multidisciplinary team formulates the plan of care after the nurse and MD assess the patient  Services (pharmacy, lab, etc) are located geographically to patient care areas  The nurse manager has to assume leadership of all departments (not just nursing)

22. NURSING CASE MANAGEMENT  Process of coordinating health care by planning, facilitating, and evaluating interventions across levels of care to achieve measurable cost and quality outcomes  Elements include:  Case Manager  Clinical Pathways

23. CASE MANAGER  Can be a nurse, social worker or other discipline  Case managers may be in acute, long-term or outpatient settings  May be several case managers to coordinate care for all patients or a case manager may be assigned to a specific high risk population (i.e, CHF patients)

24. CLINICAL PATHWAYS  The tool Case Managers use to achieve patient outcomes  Also called critical path, multidisciplinary care pathway, etc  Describe the clinical standards, necessary interventions, and expected outcomes for the patient at each stage throughout the treatment process or hospital stay.

25. CLINICAL PATHWAYS  Outline the critical or key events expected to happen each day of a patient’s hospital stay  When a patient’s progress deviates from the normal path, a variance is indicated  A variance is anything that occurs to alter the patient’s progress through the normal critical path.  Variances can be positive or negative

26. DISEASE MANAGEMENT  Model of care that coordinates health care interventions and communication for individuals with chronic illnesses.  Focus is on the concept of wellness: living well with a chronic disease

27. DIFFERENTIATED NURSING PRACTICE  Models of clinical nursing practice that are defined or differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision making.

28. SYNERGY MODEL  Identifies patient characteristics as the “drivers” of necessary competencies for nurses  When there is a match between competencies of the nurse and the characteristics of the patient, the best patient outcomes and safe passage through the hospital stay will be achieved

29. MAGNET RECOGNITION  Characteristics:  High level of nursing satisfaction characterized by high nurse retention, nurse autonomy, effective communication between nurses and physicians, organizational support for nursing, and nursing leadership that was strong, supportive, and visible.  Self-nominating, self-appraisal process. Usually takes 2 or more years to complete  Awarded by American Nurses Credentialing Center (ANCC)

30. FIVE MAGNET MODEL COMPONENTS  Transformational Leadership  Structural Empowerment  Exemplary Professional Practice  New Knowledge, Innovation, and Improvements  Empirical Quality Results

31. MAGNET MODEL Reference: http://www.nursecredentialing.org/Magnet/NewMagnetMod el.aspx

32. REFERENCES  American Nurses Credentialing Center. (n.d.). Magnet Recognition Program Model. Retrieved from http://www.nursecredentialing.org/Magnet/ProgramOverview/New- Magnet-Model.aspx http://www.nursecredentialing.org/Magnet/ProgramOverview/New- Magnet-Model.aspx  Yoder-Wise. P.S. (2011). Leading and Managing in Nursing (5 th Edition). St. Louis: Elsevier.