Clinical Corner : Nursing Home

The Experience of Aging, Part IV - Depression and Stress

Carol Kleinman — Fri, 05 Dec 2008 20:13:00 GMT

Decreased mobility, functional impairment, and multiple losses frequently lead to depression. It has been well established in the literature that the suicide rate among people over 65 is higher than any other age group. For more on this serious issue, read the information provided on the National Strategy for Suicide Prevention's Web site.

Chronic and acute health conditions requiring medical attention, a gradual decline in functioning, increased dependency on others, and the need to live in a residential environment that may not be the desire of the elderly individual are extremely stress-producing. Excessive and prolonged stress lowers resistance to viruses and can lead to more acute, chronic, or even life-threatening health problems.

Stress affects the physical body by causing muscular tightness, tension, stiffness and restricted energy flow. Continued stress can lead to muscle spasms, as well as bodily contraction, restricted movement and rigidity. Other signs of stress may include headaches, backache, fatigue, insomnia, stiff neck, cold hands and/or feet, perspiration, shortness of breath, constipation, etc. Physical stress tends to produce more emotional stress, thus setting up a cycle of disease, discomfort, and anxiety which can generate feelings of confusion, frustration, isolation, and vulnerability for the elderly. Such feelings eventually lead to inertia, despondency, withdrawal, and may even lead to a failure to thrive syndrome with gradual deterioration and even death.

Role Conflict and the Nurse, Part I

Carol Kleinman — Wed, 08 Oct 2008 14:36:00 GMT

As health care organizations have become more integrated and complex, role expectations among staff have become more diversified. To reduce job dissatisfaction among nurses, managers and administrators need to develop an appreciation for the scope and types of role conflicts that nurses experience as well as the characteristics of nurses who are at increased risk.

Role conflict among staff nurses can originate from: 1) challenges to nurses' value systems in which moral and ethical beliefs are compromised, 2) patient care workloads that exceed nurses' capabilities, 3) multiplex role systems in which the nurse must manage two or more competing roles, for example, the nurse concerned with the patient's best interests but also as an employee who must follow hospital policy, and 4) interdependent relationships in which the nurse must take into consideration multiple perceptions and expectations of others, managers, physicians, case managers, patients, families, and fellow staff members.

Characteristics of nurses at increased risk for role conflict ten to be those who are younger in age, have fewer years in their present staff position, and work in more acute patient care areas. Registered nurses and even nursing assistants suffer role conflict due to differing staff perspectives and patient expectations. It is also clear that poor team or work group relationships contribute to role conflict.

Nurses are at risk for and may experience a variety of types of role conflict during the course of their professional work. While it is unrealistic to anticipate that role conflict can be completely eliminated, leadership behaviors and organizational work processes implemented by managers and administrators can help to reduce this experience.

INtrapreneurship

Carol Kleinman — Mon, 18 Aug 2008 15:47:00 GMT

The word entrepreneur creates the connotation of a business-minded individual who pioneers change, who wants to work for herself or himself, and who organizes, manages, and assumes the risks of a business enterprise.

An intrapreneur is a person within a large corporation who takes direct responsibility for turning an idea into a profitable product through risk-taking and innovation. Intrapreneurism encompasses a variety of concepts: identifying and fostering employees who have what a considered to be intrapreneurial traits, developing an intrapreneurial process for part or all of a business, and developing innovation through rewarding intrapreneurial behavior.

For the intrapreneurial employee, advice abounds. They are advised to be courageous, moderate risk takers, frugal, flexible, and creative about their pathway. Their task is to put together a team of enthusiastic volunteers, build a network of sponsors, and ask for advice before asking for resources.

Gifford Pinchot's out-of print book "Intrapreneuring, Why You Don't Have to Leave the Corporation to Become an Entrepreneur" provides 10 commandments for intrapreneurs:

1. Do any job needed to make your project work regardless of your job description.

2. Share credit wisely.

3. Remember, it is easier to ask for forgiveness than permission.

4. Come to work each day willing to be fired.

5. Ask for advice before asking for resources.

6. Follow your intuition about people; build a team of the best.

7. Build a quiet coalition for your idea; early publicity triggers the corporate immune system.

8. Never bet on a race unless you are running in it.

9. Be true to your goals, but realistic about ways to achieve them.

10. Honor your sponsors.

Online forums that encourage new thinking have evolved, with Fast Company and The Intrapreneuring Cafe being among the favorites. Fast Company has the goal of chronicling the changes under way in how companies create and compete, highlighting the new practices shaping how work gets done, showcasing teams who are inventing the future and reinventing business, and equipping the people exploring this uncharted territory with the tools, techniques, models, and mind-sets they need. The Intrapreneuring Cafe, run by intrapreneur.com, discusses a variety of specific intrapreneurship issues such as what the best businesses are for intrapreneurship and government agency intrapreneuring. They also run want ads for intrapreneurs.

Another direction intrapreneurship is growing is in developing scenarios to anticipate future trends and responses. Scenarios are stories about possible futures which enable organizations to learn, adapt and develop better strategies. Scenario planning begins by identifying the focal issue or decision. There are an infinite number of stories that could be told about the future; the purpose is to tell those that matter, that lead to better decisions. While scenarios to-date have primarily been used for large scale planning efforts for such projects as education in the United States, it is very applicable to the business environment today.

Part 10: More Budget Secrets

Carol Kleinman — Thu, 31 Jul 2008 17:31:00 GMT

Budgets are done initially as computer-modeled projections based on previous performance. What that means is that the computer looks at what was spent and models a budget for the next cycle based on that amount. Thus, if you spend less, you will get less. It's pretty weird, but it reflects the belief that you do not need as much as was allocated.

In the real world, while all budget line items are examined, the greatest focus is placed on staff costs, followed by supply costs. I work very hard to keep those two in line. But for other line items, I have a policy of not only spending every penny, but of going over five to ten percent every year. That is often not enough of a variance in these areas to attract much attention and it allows me to be allocated just a little more next year. This strategy allowed me, over several years, to develop a few subaccounts with money I could use in various ways to the benefit of my staff and the unit. I call this "creative accounting..."

Believe me, I learned this strategy the hard way by being very attentive to budget limits and staying just under budget across the board...only to be allocated less the following year! In general, as managers you should spend up to...and even slightly over...the limit for line items (other than salaries and patient supplies, of course). I even suggested to my managers when I was the CNE (though I deny I ever said it!) that they do so as it helps all the nursing units. Sometimes, there will even be money left over in various subaccounts.

Whether or not you will be able to use the money left over toward something else is a question you will need to find out from your organization. Some allow the transfer of funds from one subaccount to another and this should certainly be explored as it will allow you to spend the money where it is most needed. Even if this is not possible, I would spend all I could on, for example, journal subscriptions, because it will tell your staff you are interested in their growth as professionals. Using the funds for books and creating a unit-based library of reference books is often another way to use subscription funds. There are truly many ways to develop creativity in managing the budget!

In most of my facilities I was able to move money from one account to another through an interaccount transfer and that helped me pool funds for different purposes. I also worked directly with finance to create new subaccounts and transferred money into them from other subaccounts. For example, there was no account for journals and books and I was able to create one so staff could have resource books and current journals available on the units.

Another example was the staff request for new lockers, to which I believed they were entitled to keep their things safe. However, in total the lockers would have cost much more than $1000, putting them in the category of a capital request, which I knew would never be approved. The cost was also more than I could authorize at the time as a nurse manager, as my signing authority was limited to $1000 and my director would have had to approve the purchase, which she would not have done. So I ordered them but used the subaccount of minor equipment (which was for beepers and cell phones and the like), ordering six at a time and doing that every couple of months until everyone had a new locker.

Managers (and even administrators) have spending limits on what they can purchase on their signature alone. Going above that figure requires the signature of a higher-level manager. As I have no interest in bringing some of my activities to their attention, I am always below that number. So, if my limit is $1000, I may have three or four orders for $900. I share this with the vendors and ask for bills or invoices for those numbers and they always comply...they also know the game!

Part 7: Thoughts on Budgeting

Carol Kleinman — Thu, 19 Jun 2008 15:40:00 GMT

The operations budget, while based in part on expenses, is also based on revenue projections. Clearly we would not knowingly budget to spend more than we expect to earn from a product or service and so we budget accordingly. In general, we do not expect to have a great deal of money left over from revenues received after deducting all the operating costs, i.e., the costs of providing services. What we do have left...and it is usually a very small percentage...we do not leave in operations accounts, we move into an account that contains all the positive balances from various operations.

Essentially, capital budget funds come from these assets, ones that are left in the organization after all expenses are deducted. This includes not only operating expenses, but such expenses as depreciation, interest paid, taxes, etc. What is left is usually a pool of money call unrestricted net assets as we can do what we wish with them, up to a point. What is generally done is that the funds are used to replace outdated major equipment, expand existing services, and develop new product lines.

So, we expect operations to pay for themselves through the revenue we generate and we use the resources left to continue to grow our operations. We do this for various reasons. Sometimes we simply do this to remain competitive. In one place I worked, the L&D area was dismal, old and un-renovated, and no one care because most of the mothers were Medicaid recipients. Then another nearby hospital opened a state-of-the-art LDRP center and all the Medicaid moms went there. Despite the fact that the revenue was low on a per-patient basis, losing ALL of it was a blow. My hospital had to create an L&D area that was just as up-to-date in order to regain market share. Similarly, if we want to keep our primary referral sources, usually physicians and payers, we need to have the kind of environment and equipment they expect.

I wish we could allocate those funds back into operations and add to staffing ratios and so on, but you will find other compelling realities exist in the executive offices that require senior administration to make some difficult financial decisions.

Do you feel ready to do this?

Part 5: Creative Accounting

Carol Kleinman — Tue, 13 May 2008 16:23:00 GMT

I thought I would confess one of the strategies I employ in dealing with difficult-to-acquire capital items, something I call "creative accounting." As all of my experience has been in behavioral health operations, it was always been clear to me that providing the best equipment for the mentally ill has never been a priority in most hospitals.

In my last administrative position, the unit was old, the furniture was broken down (when the unit first opened the furniture had been acquired from the warehouse of discarded furniture with the belief that there was no point in providing decent furniture to patients who would not appreciate it or who would destroy it), and the floors in terrible disrepair. There were no supplies, no recreational equipment, and the whole environment was pretty sad. The nurses were still using thermometers with probes while every other unit had the ear thermometers. My nurses were still taking manual blood pressures while all the other units had electronic ones that operated automatically. All the other patient care units had a Pyxis machine for medication administration but we still had a rickety cart with wobbly wheels and drawers that wouldn't open or would fall out. The list could go on and on.

I requested capital funds year after year and was turned down. But because I spent just over the limit in every line item-other than salaries-each year I got a little more allocated for that line item in the budget. One of the line items was for repairs to materials and equipment, but this could not be used for replacement as that would be a capital expense with depreciation over several years while repairs were simply expensed out each year. So one year I "repaired" the floor. The whole floor. Three feet at a time. Continuously...until it was all new. If I had been questioned I simply would have said the floor was in such disrepair that I just kept repairing the parts that were dangerous and might trigger patient falls.

Another example I will share was cited in a book published by Sigma Theta Tau called "Ordinary People, Extraordinary Lives." It is a book about inspirational nurses whose personal stories were written by someone whose life the nurse impacted. I am honored to be one of the nurses included in this book and I will post to document sharing the story that was written about me by one of my graduates. That story, too, describes an example of creative accounting and how I used it for the benefit of the patients for whom I was responsible.

One of the most valuable things nurse managers and administrators can learn is how to find "workarounds" to solve problems that are caused by the often-rigid structures and policies within our organizations.

Both stories illustrate one of my mottos: "I would rather ask forgiveness than permission." I did what I needed to do for the patients and did so creatively. Does anyone have a similar story?

When I reflect further on "creative accounting" and tried to think of more examples, I first thought I would share my personal accounting activities in which I rely on the famous "float" so I use more of my money than the bank does, but then I realized the IRS might read the post and notice and I would have to finish my postings from a Federal prison...

Seriously, part of the strategy has to do with willingness to engage in risk-taking behavior. As you become more experienced, you begin to develop a sense, quite frankly, of what you can get away with in the system and which activities are too far below the radar to get anyone's attention.

Noncompliance

Carol Kleinman — Fri, 07 Mar 2008 20:09:00 GMT

Few situations challenge and frustrate us as the need to deal with residents who are noncompliant with treatment protocols. In a world in which health care dollars are increasingly scarce, we must carefully allocate the resources we have to those who will benefit most. These decisions become far more complicated when patients and residents refuse the care that is recommended.

The consequences of noncompliance with treatment are profound. Estimates of the total annual healthcare costs in the US resulting from patient noncompliance vary from $100 billion to $170 billion to $300 billion. These costs include relapse, readmission, repeated tests and treatments, additional medications required, recurrent infections, drug resistance, and more.

Many reasons have been proposed as explanations for this seemingly self-destructive patient behavior. Lack of understanding of drug or treatment regimen, previous experiences with treatment, fear and anxiety, side effects of medication or treatment, pain and discomfort, cost of copayments or coinsurance, presence of psychological symptoms, cultural bias, and others have been identified.

To a physician it makes perfect sense to say, “I recommend this medication regimen because, left untreated, your hypertension could increase your risk of renal failure, myocardial infarction, and cerebral hemorrhage.” However, it would make absolutely no sense at all to many residents, leaving them more confused than motivated to be compliant.

Compliance generally increases if patients are given clear and understandable information about their condition and progress in a sincere and responsive way. One of the most effective ways to enhance compliance is to simplify the instructions or treatment regimen as much as possible. Residents should always get the sense that the members of the health team care about them and their health and respect their concerns. Finding out residents’ attitudes and past experiences can deeply affect compliance and save time and problems later.

Noncompliance with treatment has been a quality issue with which I have long been interested. I was asked to consult a few years ago with a wound care clinic in a hospital that tracked its patients and found almost 30 percent in varying degrees of noncompliance. After working with them for a while, I implemented a simple depression screening evaluation with all patients and discovered that a large percent of the patient population in the clinic suffered from some degree of undiagnosed depression. Implementing treatment for the depression reduced the noncompliance rate significantly.

There are no simple answers to this problem. It is imperative to try and determine the reasons behind the behavior. Solutions, for the most part, lie in quality education and communication between the resident and his or her caregivers.

For more information, see the Massachusetts Medical Asscoation's site: http://www.massmed.org/Content/NavigationMenu2/DifficultPatients/TheNoncompliantPatient/default.htm

High Quality, Low Costs

Carol Kleinman — Wed, 28 Nov 2007 15:20:00 GMT

Long-term care organizations must continue to achieve high quality patient care and positive patient outcomes without increasing costs. One consequence of this reality is the development of care delivery models using "nursing substitutes" or unlicensed assistive personnel (UAP).

While these health care workers fill the void created by the shortage of nurses and decrease costs of providing patient care, many dilemmas are associated with their use. As nurses maintain responsibility and liability for the actions of unlicensed personnel, it is imperative they effectively delegate and supervise to ensure UAPs are providing safe and effective patient care. Nurses act in a supervisory capacity over UAPs to whom they must delegate but are rarely taught to do so in formal educational programs, requiring managers to find ways to develop staff nurses' delegation and supervision skills.

Nurses can look for guidance to the National Council of State Boards of Nursing's "Five Rights of Delegation"

Right Task - one that is delegable for a specific patient.
Right Circumstances - appropriate patient setting, available resources, and other relevant factors considered.
Right Person - right person is delegating the right task to the right person to be performed on the right person.
Right Direction/Communication - clear, concise description of the task, including its objective, limits and expectations.
Right Supervision - appropriate monitoring, evaluation, intervention, as needed, and feedback.

Steps in the delegation process may also be used to develop delegation expertise.

assessment of patient needs and UAP's knowledge and skill level
identification of tasks that may be safely assigned
prioritization of tasks and timeframe for completion
communication with UAP and encouragement to ask questions that may arise
evaluation to review progress toward goals
revision of plan as patient needs change

The use of the RN/UAP model is an undeniable reality. Nurses must develop the skills necessary to adapt to evolving professional roles and must be skilled not only as clinicians, but as leaders of the healthcare team.

References:

Sheehan, JP. UAP delegation: a step-by-step process. Nurs Manage. 2001 Apr; 32(4):22.

Kleinman, C. and Saccomano, S. Registered nurses and unlicensed assistive personnel: an uneasy alliance. J. Contin. Educ. Nurs: 37 (4):162-70