CASE 1
Two new associate-degree graduates were hired for the pediatric unit. Both worked three 12-hour shifts a week, Jan in the day-to-evening shift and Ronnie at night.Whenever their shifts connected, they would compare notes on their experience. Jan felt she was learning rapidly, gaining clinical skills and beginning to feel at ease with her colleagues.
Ronnie, however, still felt unsure of herself and often isolated. "There have been times," she told Jan, "that I am the only registered nurse on the unit all night. The aides and LPNs are really experienced, but that's not enough. I wish I could work with an experienced nurse as you are doing."
"Ronnie, you are not even finished with your 3-month orientation program," said Jan. "You should never be left alone with all these sick children. Neither of us is ready for that kind of responsibility. And how will you get the experience you need with no experienced nurses to help you? You must speak to our nurse manager about this."
"I know I should, but she's so hard to reach. I've called several times, and she's never available. She leaves all the shift assignments to her assistant. I'm not sure she even reviews the schedule before it's posted."
"You will have to try harder to reach her. Maybe you could stay past the end of your shift one morning and meet with her," suggested Jan. "If something happens when you are the only nurse on the unit, you will be held responsible."
1. In your own words, summarize the problem that Jan and Ronnie are discussing.To what extent is this
problem due to a failure to lead? Who has failed to act?
2. What style of leadership was displayed by Ronnie and the nurse manager? How effective was their leadership? Did Jan's leadership differ from that of Ronnie and the nurse manager? In what way?
3. In what ways has Ronnie been an effective follower? In what ways has Ronnie not been so effective as a follower?
4. If an emergency occurred and was not handled well while Ronnie was the only nurse on the unit, who would be responsible? Explain why this person or persons would be responsible.
5. If you found yourself in Ronnie's situation, what steps would you take to resolve the problem? Show how the leader characteristics and behaviors found in this chapter support your solution to the problem.
CASE 2
Joe Garcia has been an operating room nurse for 5 years. He was often on call on Saturday and Sunday, but he enjoyed his work and knew that he was good at it.
Joe was called to come in on a busy Saturday afternoon just as his 5-year-old daughter's birthday party was about to begin. "Can you find someone else just this once?" he asked the nurse manager who called him. "I should have let you know in advance that we have an important family event today, but I just forgot. If you can't find someone else, call me back, and I'll come right in." Joe's manager was furious. "I don't have time to make a dozen calls. If you knew that you wouldn't want to come in today, you should not have accepted on-call duty. We pay you to be on-call, and I expect you to be here in 30 minutes, not one minute later, or there will be consequences."
Joe decided that he no longer wanted to work in the institution. With his 5 years of operating room experience, he quickly found another position in an organization that was more supportive of its staff.
1. What style of leadership and school of management thought seemed to be preferred by Joe Garcia's manager?
2. What style of leadership and school of management were preferred by Joe?
3. Which of the listed qualities of leaders and managers did the nurse manager display? Which behaviors? Which ones did the nurse manager not display?
4. If you were Joe, what would you have done? If you were the nurse manager, what would you have done? Why?
5. Who do you think was right, Joe or the nurse manager? Why?
CASE 3
Mr. Evans, 40 years old, was admitted to the medical-surgical unit from the emergency department with a diagnosis of acute abdomen. He had a 20-year history of Crohn's disease and had been on prednisone, 20 mg, every day for the past year. Three months ago he was started on the new biological agent, etanercept, 50 mg, subcutaneously every week. His last dose was 4 days ago. Because he was allowed nothing by mouth (NPO), total parenteral nutrition was started through a triple lumen central venous catheter line, and his steroids were changed to Solu-Medrol, 60 mg, by intravenous (IV) push every 6 hours. He was also receiving several IV antibiotics and medication for pain and nausea.
Over the next 3 days, his condition worsened. He was in severe pain and needed more analgesics. One evening at 9 p.m., it was discovered that his central venous catheter line was out. The registered nurse notified the physician, who stated that a surgeon would come in the morning to replace it. The nurse failed to ask the physician what to do about the IV steroids, antibiotics, and fluid replacement; the client was still NPO. She also failed to ask about the etanercept. At 7 a.m., the night nurse noticed that the client had had no urinary output since 11 p.m. the night before. She failed to report this information to the day shift.
The client's physician made rounds at 9 a.m. The nurse for Mr. Evans did not discuss the fact that the client had not voided since 11 p.m., did not request orders for alternative delivery of the steroids and antibiotics, and did not ask about administering the etanercept. At 5 p.m. that evening, while Mr. Evans was having a computed tomography scan, his blood pressure dropped to 70 mmHg, and because no one was in the scan room with him, he coded. He was transported to the ICU and intubated. He developed severe sepsis and acute respiratory distress syndrome.
1. List all the problems you can find with the nursing care in this case.
2. What were the nursing responsibilities in reporting information?
3. What do you think was the possible cause of the drop in Mr. Evans' blood pressure and his subsequent code?
4. If you worked in risk management, how would you discuss this situation with the nurse manager and the staff?
CASE 4
Andy is assigned to care for a 14-year-old girl, Amanda, admitted with a large tumor located in the left groin area. During an assessment, Amanda shares her personal feelings with Andy. She tells him that she feels "different" from her friends. She is ashamed of her physical development because all her girlfriends have "breasts" and boyfriends. She is very flat-chested and embarrassed. Andy listens attentively to Amanda and helps her focus on some of her positive attributes and talents.
A CT scan is ordered and reveals that the tumor extends to what appears to be the ovary. A gynecological surgeon is called in to evaluate the situation. An ultrasonic-guided biopsy is performed. It is discovered that the tumor is an enlarged lymph node and that the "ovary" is actually a testis. Amanda has both male and female gonads.
When this information is given to Amanda's parents, they do not want her to know. They feel that she was raised as "their daughter." They ask the surgeon to remove the male gonads and leave only the female gonads. That way, "Amanda will never need to know." The surgeon refuses to do this. Andy believes that the parents should discuss the situation with Amanda as they are denying her choices. The parents are adamant about Amanda not knowing anything. Andy returns to Amanda's room, and Amanda begins asking all types of questions regarding the tests and the treatments. In answering, Andy hesitates, and Amanda picks up on this, demanding that he tell her the truth.
1. How should Andy respond?
2. What are the ethical principles in conflict?
3. What are the long-term effects of Andy's decision?
CASE 5
Tanya Washington will finish her associate's degree nursing program in 6 weeks. Her preferred clinical area is pediatric oncology, and she hopes to become a pediatric nurse practitioner one day. Tanya has received two job offers, both from urban hospitals with large pediatric populations. Because several of her friends are already employed by these facilities, she asked them for their thoughts.
"Central Hospital is a good place to work," said one friend. "It is a dynamic, growing institution, always on the cutting edge of change. Any new idea that seems promising, Central is the first to try it. It's an exciting place to work."
"City Hospital is also a good place to work," said her other friend. "It is a strong, stable institution where traditions are valued. Any new idea must be carefully evaluated before it is adapted. It's been a pleasure to work there."
1. How would the organizational culture of each hospital affect a new graduate?
2. Which organizational culture do you think would be best for a new graduate, Central's or City's?
3. Would your answer differ if Tanya were an experienced nurse?
4. What do you need to know about Tanya before deciding which hospital would be best for her?
5. What else would you like to know about the two hospitals?
CASE 6
Tyrell Jones is a new unlicensed assistant who has been assigned to your acute rehabilitation unit. Tyrell is a hard worker; he comes in early and often stays late to finish his work. But Tyrell is gruff with the patients, especially with the male patients. If a patient is reluctant to get out of bed, Tyrell often challenges him, saying, "C'mon, man. Don't be such a wimp. Move your big butt."Today, you overheard Tyrell telling a female patient who said she did not feel well, "You're just a phony. You like being waited on, but that's not why you're here." The woman started to cry.
1. You are the newest staff nurse on this unit. How would you handle this situation? What would happen if you ignored it?
2. If you decided that you should not ignore it, with whom should you speak? Why? What would you say? Why do you think Tyrell speaks to patients this way?
CASE 7
A not-for-profit hospice center in a small community received a generous gift from the grateful family of a patient who had died recently. The family asked only that the money be "put to the best use possible."
Everyone in this small facility had an opinion about the "best" use for the money. The administrator wanted to renovate the old, run-down headquarters. The financial officer wanted to put the money in the bank "for a rainy day." The chaplain wanted to add a small chapel to the building. The nurses wanted to create a food bank to help the poorest of their clients. The social workers wanted to buy a van to transport clients to health-care providers. The staff agreed that all the ideas had merit, that all of the needs identified were important ones. Unfortunately, there was enough money to meet only one of them.
The more the staff members discussed how to use this gift, the more insistent each group became that their idea was best. At their last meeting, it was evident that some were becoming frustrated and that others were becoming angry. It was rumored that a shouting match between the administrator and the financial officer had occurred.
1. In your analysis of this situation, identify the sources of the conflict that are developing in this facility.
2. What kind of leadership actions are needed to prevent the escalation of this conflict?
3. If the conflict does escalate, how could it be resolved?
4. Which idea do you think has the most merit? Why did you select the one you did?
5. Try role-playing a negotiation among the administrator, the financial officer, the chaplain, a representative of the nursing staff, and a representative of the social work staff. Can you suggest a creative solution?
CASE 8
A large health-care corporation recently purchased a small, 50-bed rural nursing home. A new director of nursing was brought in to replace the former one, who had retired after 30 years. The new director addressed the staff members at the reception held to welcome him. "My philosophy is that you cannot manage anything that you haven't measured. Everyone tells me that you have all been doing an excellent job here.With my measurement approach, we will be able to analyze everything you do and become more efficient than ever." The nursing staff members soon found out what the new director meant by his measurement approach. Every bath, episode of incontinence care, feeding of a resident, or trip off the unit had to be counted, and the amount of time each activity required had to be recorded. Nurse managers were required to review these data with staff members every week, questioning any time that was not accounted for.Time spent talking with families or consulting with other staff members was considered time wasted unless the staff member could justify the "interruption" in his or her work. No one complained openly about the change, but absenteeism rates increased rapidly. Personal day and vacation time requests soared.
Staff members nearing retirement crowded the tiny personnel office, overwhelming the single staff member with their requests to "tell me how soon I can retire with full benefits." The director of nursing found that shortage of staff was becoming a serious problem and that no new applications were coming in, despite the fact that this rural area offered few good job opportunities.
1. What evidence of resistance to change can you find in this case study?
2. What kind of resistance to change did the staff members exhibit?
3. If you were a staff nurse at this facility, how do you think you would have reacted to this change in administration?
4. Why did staff members resist this change?
5. What could the director of nursing do to increase acceptance of this change? What could the nurse managers and staff nurses do?
CASE 9
Julio works at a large teaching hospital in a major metropolitan area. This institution services the entire geographical region, including indigent clients, and, because of its reputation, administers care to international clients and individuals who reside in other states. Like all health-care institutions, this one has been attempting to cut costs by using more UAP. Nurses are often floated to other units. Lately, the number of indigent and foreign clients on Julio's unit has increased. The acuity of these clients has been quite high, requiring a great deal of time from the nursing staff.
Julio arrived at work at 6:30 a.m., his usual time. He looked at the census board and discovered that the unit was filled, and Bed Control was calling all night to have clients discharged or transferred to make room for several clients who had been in the emergency department since the previous evening. He also discovered that the other RN assigned to his team called in sick. His team consists of himself, two UAP, and an LPN who is shared by two teams. He has eight clients on his team: two need to be readied for surgery, including preoperative and postoperative teaching, one of whom is a 35-year-old woman scheduled for a modified radical mastectomy for the treatment of breast cancer; three are second-day postoperative clients, two of whom require extensive dressing changes, are receiving IV antibiotics, and need to be ambulated; one postoperative client who is required to remain on total bedrest, has a nasogastric tube to suction as well as a chest tube, is on total parenteral nutrition and lipids, needs a central venous catheter line dressing change, has an IV, is taking multiple IV medications, and has a Foley catheter; one client who is ready for discharge and needs discharge instruction; and one client who needs to be transferred to a subacute unit, and a report must be given to the RN of that unit. Once the latter client is transferred and the other one is discharged, the emergency department will be sending two clients to the unit for admission.
1. How should Julio organize his day? Set up an hourly schedule.
2. What type of client management approach should Julio consider in assigning staff appropriately?
3. If you were Julio, which clients and/or tasks would you assign to your staff? List all of them, and explain your rationale.
4. Using the Delegation Decision-Making Grid, make staff and client assignments.
CASE 10
The director of CQI has called a meeting of all the staff members on your floor. Based on last quarter's statistics, the length of stay of patients with uncontrolled diabetes is 2.6 days longer than that of patients for the first half of the year. She has requested that the staff identify members who wish to be CQI team members looking at this problem. You, the staff nurse, have volunteered to be a member of the team. The team will consist of the diabetes educator, a patient-focused care assistant, a pharmacist, and you.
1. Why were these people selected for the team?
2. What data need to be collected to evaluate this situation?
3. What are the potential outcomes for patients with uncontrolled diabetes?
4. Develop a flowchart of a typical hospital stay for a patient with uncontrolled diabetes.
CASE 11
Antonio was recently hired as a team leader for a busy cardiac step-down unit.Nursing responsibilities of the team leader, in addition to patient care, include meeting daily with team members, reviewing all admissions and discharges for acuity and length of stay, and documenting all patients who exceed length of stay and the reasons. At the end of each month, the team leaders are required to meet with unit managers to review the patient care load and team member performance. This is the last week of the month, and Antonio has a meeting with the unit manager at the end of the week. He is 2 weeks behind on staff evaluations and documentation of patients who exceeded length of stay. He is becoming very stressed over his team leader responsibilities.
1. Why do you think Antonio is feeling stressed?
2. Make a to-do list for Antonio.
3. Develop a time log for Antonio to use to analyze his activities.
4. How can Antonio organize and streamline his work?
CASE 12
You have been hired as a new RN on a busy pediatric unit in a large metropolitan hospital. The hospital provides services for a culturally diverse population, including African-American, Asian, and Hispanic people. Family members often attempt alternative healing practices specific to their culture and bring special foods from home to entice a sick child to eat. One of the more experienced nurses said to you, "We need to discourage these people from fooling with all this hocus pocus.We are trying to get their sick kid well in the time allowed under their managed care plans, and all this medicine-man stuff is only keeping the kid sick longer. Besides, all this stuff stinks up the rooms and brings in bugs."You have observed how important these healing rituals and foods are to the patients and families and believe that both the families and the children have benefited from this nontraditional approach to healing.
1. What are your feelings about nontraditional healing methods?
2. How should you respond to the experienced nurse?
3. How can you be a patient advocate without alienating your coworkers?
4. What could you do to assist your coworkers in becoming more culturally sensitive to their patients and families?
5. How can health-care facilities incorporate both Western and nontraditional medicine? Should they do this? Why or why not?
CASE 13
Shawna, a new staff member, has been working from 7 a.m. to 3 p.m. on an infectious disease floor since obtaining her RN license 4 months ago. Most of the staff members with whom she works with have been there since the unit opened 5 years ago. On a typical day, the staffing consists of a nurse manager, two RNs, an LPN, and one technician for approximately 40 patients. Most patients are HIV-positive with multisystem failure. Many are severely debilitated and need help with their activities of daily living. Although the staff members encourage family members and loved ones to help, most of them are unavailable because they work during the day. Several days a week, the nursing students from Shawna's community college program are assigned to the floor.
Tina, the nurse manager, does not participate in any direct patient care, saying that she is "too busy at the desk." Laverne, the other RN, says the unit depresses her and that she has requested a transfer to pediatrics. Lynn, the LPN, wants to "give meds" because she is "sick of the patients' constant whining," and Sheila, the technician, is "just plain exhausted." Lately, Shawna has noticed that the other staff members seem to avoid the nursing students and reply to their questions with annoyed, short answers. Shawna is feeling alone and overwhelmed and goes home at night worrying about the patients, who need more care and attention. She is afraid to ask Tina for more help because she does not want to be considered incompetent or a complainer. When she confided in Lynn about her concerns, Lynn replied, "Get real-no one here cares about the patients or us. All they care about is the bottom line! Why did a smart girl like you choose nursing in the first place?"
1. What is happening on this unit in leadership terms?
2. Identify the major problems and the factors that contributed to these problems.
3. What factors might have contributed to the behaviors exhibited by Tina, Lynn, and Sheila?
4. How would you feel if you were Shawna?
5. Is there anything Shawna can do for herself, for the patients, and for the staff members?
6. What do you think Tina, the nurse manager, should do?
7. How is the nurse manager reacting to the changes in her staff members?
8. What is the responsibility of administration?
9. How are the patients affected by the behaviors exhibited by all staff members?
CASE 14
Paul Delane is interviewing for his first nursing position after obtaining his RN license. He has been interviewed by the nurse recruiter and is now being interviewed by the nurse manager on the pediatric floor. After a few minutes of social conversation, the nurse manager begins to ask some specific nursing-oriented questions: How would you respond if a mother of a seriously ill child asks you if her child will die? What attempts do you make to understand different cultural beliefs and their importance in health care when planning nursing care? How does your philosophy of nursing affect your ability to deliver care to children whose mothers are HIV-positive?
Paul is very flustered by these questions and responds with "it depends on the situation," "it depends on the culture," and "I don't ever discriminate."
1. What responses would have been more appropriate in this interview?
2. How could Paul have used these questions to demonstrate his strengths, experiences, and skills?
CASE 15
Alina went to nursing school on an Air Force scholarship. She has been directed to lead the planning for establishing a comprehensive primary care and health promotion program clinic on board NASA's newest international space station. The crew is to remain on board the station for 6 months at a time. The crew will consist of military men and women from three countries.
1. What medical and nursing equipment should Alina plan to have in this center?
1. 2.What would the physical environment on board need to have to satisfy Florence Nightingale and
2. Lillian Wald?
3. How do you believe Virginia Henderson would describe the role of the nurse in this environment?
4. Develop a possible nursing research topic for study in this situation.
