Wednesday July 29, 2009 6:00 AM to 12:00 PM

The time I spent with LH this morning was busy as usual. At the end of the AM routine, I returned a leadership book she loaned for my review and thanked her for all her patience and guidance. She has been very helpful through this process and tolerant of my questions and observations. She asked me if I would like to cover for her as DON when she goes on vacation next month. I told her I would. I feel that from what I have learned, I could hold the reigns for her for awhile. However, I don't think I would want the job permanently. I enjoy managing and leading, but there is so much drama involved in the DON role. It seemed she stayed quite irritated with many nurses and CNA's much of the time. I wondered if they just didn't get it, or just didn't care. She explained what I already knew...It is very difficult to fire someone. It doesn't matter if you know they just don't care, you have to be able to prove it. I gained a respect for her ability to hold it together under great stress. I didn't necessarily agree with all her tactics, but then again she probably wouldn't agree with mine. I was able to experience communication at a different level than I'm used to. I tend to be a bit of a cut-up, and although this is useful in the Staff Development role, I found less time that humor was appropriate in the DON role. I like my current job. I can keep a friendly nature with the staff while also acting as a leader and even manager, yet I don't get all that drama. I would like to someday learn how to balance them all. That would, I think make an amazing DON.

Wednesday July 22, 2009 6:00 AM - 4:00 PM

Today I spent the day learning how a low patient census can affect nurse scheduling, lead to budget constraints and overall frustration for management. When I met LB (or LH, it's actually L H-B) she explained to me how she feels frustrated when cutting back on staff becomes necessary when the census is low. However, she offered me some great tips for if I am ever in the position to make cut-back decisions. LH explained that she actually rarely has to make someone go home since she offers to everyone the chance to first take the day off.
Each Wednesday she holds a "Communication Meeting" between shift times, (from 2-2:30 or 3:00) and takes the opportunity to discuss with staff what is going on in the facility, including the residents' and employee announcements. Today, she informed the staff that it would be necessary for her to ask people to please take this opportunity to take a day off. I must admit, I was very impressed of the positive attitude the staff demonstrated and a few vocalized that they wouldn't mind taking their turn first. LH assured them that there would not be layoffs of any kind, and that she only needed to cut back on hours by one nurse staff member and one CNA staff member on each shift for now. She then explained there were several residents who were recently admitted to the hospital, but would be returning soon, and this seemed to reassure them. I would hate to handle a layoff type situation as a manager. Knowing that many of these employees barely make ends meet as it is would make this a chore no one would want.

Wednesday, July 15, 2009 6:00 AM- 4:00 PM

This was a very intense day of clinical. The Texas Department of Aging and Disability arrived on Tuesday to begin their annual facility survey. When I arrived to meet with LH she provided me with a verbal refresher on what I might expect to encounter. LH felt this would be an excellent opportunity for me to take the reins and become proactive in the survey process. I was a little nervous, but also surprisingly confident. I'm very proud of our facility and know that we all work very hard to do the best we can for the people we care for. I also realize that we are not perfect, so any advice and/or necessary changes for improvement should be appreciated not resented. With that in mind, I headed to the conference room to introduce myself and offer my assistance for any information the surveyors might need. I was taken up on that offer immediately, and spent the rest of the day digging for the requested facility documents. This proved to be quite a chore, and I think one of the most important lessons I learned on this day is the necessity of organization within the various departments. HR in particular could use an overhaul in organization! However, this became an experience that greatly enhanced both my management skills and confidence as a leader.

Mid-Term Self Evaluation

2 Course Clinical Objectives and 2 Personal Objectives so far in the course;
Course Clinical Objectives
Professional Accountability
Critical Thinking

Personal Clinical Objectives:
Budgeting Methods
Establishment of Respectful Relations

Course Objectives and relate them to your work in your specific clinical site, by providing examples;

Professional accountability is to me the most important of objectives. This is what allows other objectives such as leadership and communication to be effective. Without professional accountability these other goals will fail. Besides the obvious professional traits of being dependable and ethical, I think responsibility is a priority. I work hard not to depend upon others to teach me everything. I like to be given a direction to head in, and enjoy finding my way through personal experience. Although I don’t like to fail, I think a stumble here and there helps the learning process and it also instills a certain amount of compassion for others when they stumble. Being responsible and accountable for these “stumbles” is humbling, but it also then leads to respect. I have evaluated myself as a leader throughout this experience. I have found some ways in which I need improvement, but I also have found a certain amount of confidence in my current leadership style. I tend to struggle between when to keep a friendly tone to boost morale and appreciation with when to forget friendly and just drop the hammer when a sterner form of encouragement is necessary. I think finding the middle ground will come with experience.
Critical thinking is another important objective for me. I tend to take extra effort to research issues prior to making decisions. However, sometimes employees come to me with concerns and I find it difficult not to jump to conclusions (although I keep this to myself), particularly if it is regarding patient safety. My first concern is the patient’s well-being, but I must also (if for example there is an abuse issue) get all sides and details of the story before coming to conclusions. I have the tendency to stay calm and think things through, yet part of me is always on the patients side. This may not always be appropriate.

Statement of your personal objectives and discuss how you have or have not accomplished them, supporting them with reasons and/or examples;

Learning budgeting methods has been a goal I have wanted to accomplish for a long time. As staff nurses we often hear that we need to be thrifty with certain pharmaceutical or equipment expenses. We take for granted that Protonix is typically three times more expensive than Prilosec. Knowing how Medicare, Medicaid and private insurance pays for certain supplies or treatments has a tremendous effect on company profit. It is this profit that is necessary for raises, renovations, equipment, technology, etc. that eventually benefits the employees, the patient and the facility. I think if staff nurses were made aware of how this system functions they would work harder to ensure cost savings practices were used regularly.
Establishing respectful relations has never been very difficult for me. However, there have been times when I have had disagreements with other leaders and I have lost a certain amount of respect for them. Sometimes establishing respectful relations can be very difficult even if you are a respectful person. Communication is the key here. I have learned that showing respect to those who you may not truly agree can lead to improved relations and possibly an understanding of why this person believes or behaves the way they do. You don’t have to necessarily agree with someone to be respectful of them. I think I have accomplished a path to reaching my objective goals. I think professionalism and leading require ongoing learning and experience to excel. I think for this course, I have achieved much of what I set out for.

Statement and discussion of 1 way in which these items discussed above have enabled or fostered your growth as a professional nurse.

I have a broader understanding of management. I can see the “big picture” more clearly. The priorities and difficulties of managing have given me a direction of where I need to set personal goals and where I need to improve and learn. Since I have to choose only one way these objectives have fostered my growth as a professional nurse, I would say that I have learned to determine my weaknesses more effectively. By learning what is expected of me, I know where I need to focus for improvement.

Wednesday July 8th, 2009 6:00 AM - 3:00 PM

Today I spent the morning making AM rounds with LH. She demonstrated to me the importance of evaluating QA (quality assurance) first hand. I watched closely as she interacted with the staff and the residents. LH is a self proclaimed "perfectionist" and I don't think anyone would argue with that. It was interesting to watch her delegate so effortlessly. This has been something I have always struggled with. I am more of the, "If you want something done right..." kind-a girl. It's not that I have difficulties asking people to do things, I'm just afraid they will not do it good enough. My gosh, putting it that way really makes me sound horrible doesn't it? But, it is a realization for me that I should have more faith in others so that they might learn and grow and also receive credits for accomplishments. However, there were other leadership skills in which I felt I had more skill. All leaders have their different leadership methods and styles. I think it is important for leaders to be able to identify their weaknesses, and excellent leaders will work to improve upon those weaknesses.
LH also spent some time showing me the State of Texas's LTC guidelines and expectations. She showed me how to view the information on-line, from what sites, and how to read the information correctly. She showed me how our company keeps track of surveys and how they set goals for improvement. I spent some time reviewing HIPPA guidelines and attended a leadership meeting as well. I was informed as part of meeting my objective to become comfortable speaking in leadership meetings, that I should be prepared to present new corporate abuse and neglect policy information to all departmental heads on July 28th. I was given the information to review prior to this presentation. Nothing like having to jump right in there.

Wednesday July 1, 2009 6:00 AM -2:00 PM

I spent a lot of time on Wednesday researching the effects of Medicare and Medicaid on healthcare (in LTC facilities in particular). I can now understand why so many seniors are confused by this information. There are many supplemental programs that are included with these services which only worsens the confusion. I learned that federal Medicaid grants to states now account for the fifth largest federal budget item, after social security, defense, the federal debt and Medicare, but will soon overtake Medicare for 4th place. So many elderly depend on this form of insurance for all their medical expenses. Many cannot afford supplemental, or are just not knowledgeable regarding the information to see a need for it. Encourage any senior citizen you know to get supplemental insurance if at all possible, now! It will save them and their families from serious monetary and healthcare problems later. I read an article in my research titled, New Analysis of Bush FY 2009 Budget: Texas Medicare Cuts 4th Highest in Nation. This proposed budget and regulatory changes will cut Medicare-financed nursing home care in Texas by $104.90 million in the year ahead. Texas has slipped to 49th in the nation in terms of Medicare reimbursement rates! This information makes me very nervous. As an advocate for the elderly, how can I help to improve upon the care they need when our government cuts back on what it takes to pay for this care. Less money = less staff = less RNs (which we need desperately in LTC) = less effective treatments = more medical problems = need for more money = ongoing cycle!
I'm so frustrated!

Wednesday, June 24, 2009 6:00 AM - 3:00 PM

This week’s clinical experience initiated several objection goals for me. I spent the first two hours with the DON in her office (I'll refer to her as LB from now on). She compiled a stack of useful information for my review. This included budgeting reports, a corporate specific manual titled "A Managers Guide to Understanding Financial Reports", and literature regarding the effects of Medicare and Medicaid on LTC services and funding. She allowed be to explore the corporate budgeting software and explained to me how the information demonstrates and calculates departmental reports to manage department finances. I studied how overtime is tracked and monitored and discussed with LB how overtime effects the nursing budget. She allowed me to review the "Key Indicator Report" which is a measurement of overall performance of the facility. This information includes results from family and staff surveys, targeted budget dollars for specific outside expenses such as lab and pharmacy, as well as comparisons of actual vs. target patient care issues such as dehydration, falls, UTIs, weight loss, etc. I also attended a leadership meeting and learned how facility information is distributed throughout all departments.
This was just a dent in the information I hope to learn from this experience. I'm very impressed with how our company manages both patient and financial issues. It's much more complicated than I ever imagined, but it is reassuring to know our company keeps such a close account of what goes on in the facility.