2: Leadership and Management

Often, novice nurses think that if they do not desire to be nurse leaders or
managers, they will be exempt from having to assume nurse leadership and
management roles. The reality is that every nurse, regardless of whether
they are a novice or an expert, must be ready to always apply leadership and
management concepts. For example, there may be an emergency in the
healthcare setting, in the community, or at the patient bedside requiring a
novice, inexperienced nurse to act during a crisis.

Novice nurses need to apply leadership and management skills that are
essential to healthcare organizations at multiple levels ranging from the
bedside to the boardroom. For example, it is the nurse at the bedside who
informs healthcare administrators about gaps in healthcare and the need to
ensure patient safety and quality outcomes within a rapidly evolving
healthcare delivery setting. Critical thinking is a vital component of every
decision a nurse leader/nurse manager makes in every situation regardless
of the level of simplicity or complexity of the required decision.

All nurses, regardless of whether they want to be a nurse leader or not, have
to have leadership and management skills. It is requisite for every nurse to
apply leadership and management skills in a logical and systematic manner
within the changing healthcare system. For example, due to the rapidly
changing technology, political processes, reimbursement, and regulatory
changes within the healthcare delivery system, it is important that the
nursing profession be at the decision-making processes that impact on safe
patient outcomes. There are four major content areas that every nurse
should become familiar with as a leader or manager within the nursing
profession. These areas include:

1. Leadership and Management

2. Maintaining a Safe, Effective Work Environment

3. Legal and Ethical Issues Influencing Nursing

4. Disaster Nursing and Crisis Intervention

HESI Hint

There are several assumptions underpinning nursing leadership and

management of the 21st century:
Novice and expert nurses need to apply leadership and management
knowledge, skills, and competencies to foster and promote safe, effective
care and ensure quality outcomes.

Healthcare delivery continues to migrate from acute care healthcare settings

to outpatient and community-based settings.

The healthcare workforce members and patients we care for are becoming
increasingly diverse, adding complexity to patient care, particularly related
to communication and safe outcomes.

Every nurse is a leader, a manager, and a follower regardless of their

designated title or role.

Healthcare consumers and major stakeholders influence and shape nursing

care and how healthcare is delivered.

Safe, effective, and efficient nursing care is grounded in fundamental

concepts of communication, collaboration, and teamwork.

Change in nursing and healthcare is ever constant and inevitable.

Nursing care is essential to a highly effective healthcare delivery system.

HESI Hint

Every nurse must know about and apply leadership and management
concepts to clinical practice whether caring for individual patients,
populations, or systems.

Leadership and Management

Leadership and management are not synonymous terms. Leadership is

comprised of aligning other nurses or staff and setting a direction with
expected follow-up and outcomes. Leaders motivate, inspire, and provide
resources that motivate and enable others to meet organizational goals for
organizational success.

HESI Hint

Nurse leaders inspire and engage nurses, colleagues, and other workers.

Seventy percent of American workers have negative feelings about their job.

Nurse leaders positively influence and change the way nurses, colleagues,
and workers feel about their work.

Leaders Versus Managers

Nurses desire and prefer to be led and not managed (Roussel, Thomas, &
Harris, 2020, p. 25). Leaders inspire constituents through respecting one’s
dignity, autonomy, and self-esteem (Morriss, Ely, & Frei, 2014). Good leaders
inspire and motivate others in healthcare settings to foster and promote
worker satisfaction and take pride in meeting organizational goals and
strategic plans. Not every nurse wants or aspires to be a formal nurse leader
in a healthcare setting; however, there will be opportunities where one may
have the required leadership knowledge, skills, and competencies to lead.
For example, there will be times when we are asked to be the leader of a
committee or task force on our unit. We can always improve our leadership
and management skills by accepting these opportunities.

To become a stronger nurse leader, we must assess and identify our areas of
weakness to strengthen ourselves to grow as a leader. Nurse leaders are
made up of the sum of our personal and professional lives. For example,
being a leader means the integration of who we are professionally and
personally and how we perform as a leader. One way of knowing and
understanding one’s authentic self is reflection. Reflection is an active
strategy that helps us examine and reflect on our experiences, actions, and
reactions to strengthen our professional growth (Yoder-Wise, 2019, p. 81). For
example, if there was an unfortunate patient event on your work unit and
you had to act quickly, you would be exerting your nursing leadership skill.
Thinking-on-action provides a recount of the scenario and allows us to
evaluate and reflect on our actions related to the situation that occurred and
our nursing leadership relevant to the event. Thinking-on-action is like
debriefing and reflecting on our thoughts, actions, and behaviors in the given
situation.

HESI Hint

Thinking-in-action allows us opportunity to guide our nursing behaviors prior

to a situation or event.

Thinking-on-action allows us opportunity to reflect and debrief after an event

to determine what else might have been done and the impact of our
leadership actions on others by the way we intervened.

Thinking-in-action allows us opportunity when we use our existing knowledge

to guide our nursing behaviors as a situation develops (Yoder-Wise, 2019, p.
81). For example, if you have been asked to chair a policy task force related
to a policy change about patient safety in your facility, you may use thinking-
in-action to prepare for how you will lead the policy task force and meet the
goals by the due date.

There are several well-known and accepted leadership styles that nurse
leaders apply (Table 2.1) such as authentic, autocratic, assertive,
transformational, or shared governance. Authentic leadership is comprised of
honest relationships (George, 2003). Authentic leadership is described as a
direct model where truth and trust are essential to being an authentic leader.
Being authentic means if we try to adopt characteristics or behave in a way
that is not comfortable for us, chances are, we will not feel or behave in
authentic ways. Being truly authentic means you have a true passion for
helping others and the important work they do (Yoder-Wise, 2019, p. 86). No
matter what leadership style we choose for formal or informal nursing
leadership roles, we can always self-assess and develop strategies to assist
us to self-reflect and identify strategies for improvement.

HESI Hint

Becoming an authentic and effective nurse leader means having self-

awareness and insight to strengths and weaknesses

Reflection and journaling are strategies to know and understand one’s

authentic self

Effective strategies for gaining personal insight are to practice reflection

daily.

Apply what you learn from daily reflection to guide and direct you.

Use evidence-based self-assessment tools, and use the outcomes to

strengthen yourself.

Reflection helps to assess and review the impact of our choices, decision,
and actions on self and others.

Essential Characteristics and Focus of Nurse Leaders

1. Encouraging, fostering, and promoting positive working relationships

between and among members of the interprofessional healthcare team

2. Create a work environment facilitating and role modeling open

communication and collaboration

3. Align leadership focus with the mission, philosophy, and strategic plan of
the healthcare organization
4. Develop strategies to align worker talents with organizational needs with
culturally diverse workers and patient populations

5. Serve as a role model to prevent and resolve conflict

6. Coach and mentor other members of the interprofessional healthcare

teams involving creative, evidence-based problem solving and negotiation

7. Implement evidence-based strategies to prevent or minimize stress,

burnout, and staff turnover

8. Prevent behaviors leading to hostile work environments and have a zero

tolerance for incivility in the workplace

APPLICATION - Leadership case: Jamie was a new graduate nurse (GN) who
just received her license. She was employed as a medical surgical nurse on a
very busy 40-bed telemetry unit. She was delighted to be on the unit, but it
seemed understaffed. However, because she was new to the facility, she did
not want to question the charge nurse or supervisor.

After 3 months working on the unit, one afternoon when she reported to
work, she was told that she would have to have an extra patient load
because they could not get an extra nurse to cover; thus she would have five
instead of four patients. Because the telemetry unit was always staffed with
a 4:1 ratio, this load was a little more than normal. During the 12-hour shift,
two of Jamie’s patients experienced chest pain, one had a full code and
subsequently died, and the other two patients were stable.

Jamie discussed the short staffing problem with the charge nurse on duty;
however, he did not think that it was an issue (Table 2.2).

Managers

Managers are individuals who work to accomplish the goals of the

organization. The nurse manager acts to achieve the goals of safe, effective
client care within the overall goals of a healthcare facility (Table 2.3). Nurse
managers provide skills such as delegation, supervision, critical thinking, and
evaluation of the overall outcomes of patients as an aggregate.

TABLE 2.1

Common Nursing Leadership Styles, Leadership Style Characteristics, and

Competencies
Leadership Styles Leadership Style Characteristics Competencies

Transformational

• Critical to successfully meeting organizational outcomes

• Provides evidence-based innovative approaches critical to meeting

organizational outcomes and the strategic plan and mission

• Recognized by the Institute of Medicine (IOM) in reducing medical errors

and improving patient quality and safety

• Management of attention

• Management of meaning

• Management of trust

• Management of self as leader

• Serving as a coach

• Serving as a mentor

Strategic Leadership

• Provides opportunity for critical reflection

• Is focused on root cause analysis and determining causes of challenge or

failure

• Based on skills of anticipation, challenge, interpretation, decision,

alignment, and learning

• Being transparent

• Seek information on changes and products from key stakeholders to new

initiatives

• Prepare for the unexpected

• Examine trends of fast-growing rivals and competitors

• Promote open-mindedness

Lateral Leadership

• Consists of broad networking with persons internal and external to the

organization
• Need to collaborate and consult with others whose key opinions are valued
and needed

• Focuses on coalition building and avoid functional silos that overlook other
valued opinions and perspectives

• Being knowledgeable and skilled in constructive persuasion and

negotiation

• Consultation with persons whose “buy in” is needed

• Be able to create and build coalitions

• Network with others whose opinions are essential for success and from
persons including other leaders and key stakeholders whose opinions are
very valued

Quantum Leadership

• Design leadership

• Change is dynamic and essential

• Adaptation involves whole systems thinking and not linear thinking about
separate components

• Considers the whole, integration, synthesis, relatedness, and team action

• Includes knowledge, persuasion, decision, implementation, and

confirmation

• Individuals include innovators, adopters, early majority adopters, late

majority adopters, and laggards

• Concepts include design thinking, thinking inside the box, disruptive

innovation, and scenario planning (Roussel, 2020, p. 83)

Innovative Leadership

• Leadership that prepares healthcare organizations and organizational

systems for change (Roussel, 2020, p. 37).

• Often referred to as “disruptive innovation”

• Commonly characterized by vertical orientation, hierarchical structures,

focus on control, and process driven actions

• Familiarity with systems and design thinking

• Able to envision with innovation and technology

• Knowledge and understanding and leading innovators, early and late

majority adopters of change within the organization, and laggards to create
change in healthcare organizational systems

Shared Governance Model

• Often a nursing leadership model used in healthcare organizations that

either have or are seeking Magnet recognition (Yoders-Wise, 2019, p. 309)

• Is an accountability-based leadership model

• Consists of structural empowerment

• Relies on evidence-based practice improvements and innovation(s)

• Emphasis is on team collaboration through creating and sustaining a

supportive work environment

• Success depends on how well and to what degree the organization

provides human and financial resources to support the work

• Nurse leaders are responsible and accountable for creating systems and
monitoring the degree to which or how well the organization provides
adequate resources to meet organizational needs

Situational Leadership Model

• Based on the work of Hersey (2006), nurse leaders and managers are
required to behave or act differently depending on the specifics of situations
or encounters (Yoders-Wise, 2019, p. 309).

• Ability to change behavior or actions for nursing leadership based on

different situations or scenarios and circumstances

• Ability to assess behavioral characteristics, competencies, and training of

the employees to factor into decision making at different points in time

• Ability of the nurse leader to critically think and determine the best
leadership approach given the circumstances and situation needs now or
point in time

Delegation

The registered nurse (RN) has authority, accountability, and responsibility for
safe delegation. Delegation for an RN is based on the state nurse practice
act, standards of professional nursing practice, policies of the healthcare
organization, and ethical-legal models of behavior.

Delegation is not a simple matter of asking someone else on the healthcare

team to help you out. Delegation involves legal components and is typically
governed by state nurse practice acts. For example, state nurse practice acts
typically identify to whom nurses may delegate tasks to perform. The nurse
leader must be certain delegation of tasks meets the state nurse practice
acts and that there is accountability and documentation that the task or work
delegated is performed in a timely, safe, and effective manner.

TABLE 2.2

Clinical Judgment Measures: Leadership

Clinical Judgment Measure Assessment Characteristics

Recognize Cues

Number of nurses available less than standard of 4:1 ratio.

Two patients had severe chest pain and needed immediate attention.

One patient coded and died.

Two patients remained stable.

Analyze Cues

Reported that 4:1 ratio was not being used; registered nurse (RN) overload

Assessment of the two patients with severe chest pain, was it timely?

Assessment of one patient who coded; did Jamie have time to complete all
her patient assessments in a timely manner?

Was the nurse staffing considered based on the sickness of patients?

Prioritize Cues

Determine if staffing was a problem in providing nursing care.

Determine if patient assessment data was accurate.

Did Jamie accurately determine which patient was the most serious?

Did Jamie prioritize her plan of care for the assigned patients?
Actions

Did Jamie prioritize her nursing care based on the acuity of the patients?

If her patient load was too difficult, did Jamie speak with the head nurse to
change her duties for the shift?

Evaluate Outcomes

Outcomes for shift included: one patient died, two patients were relieved of
pain and were stabilized, and two patients remained stable.

Were the patient outcomes expected as compared with the assessment of

telemetry patients?

TABLE 2.3

Skills, Characteristics of the Skill, and Characteristics of the Nurse Manager

Skills of the Nurse Manager Characteristics of the Skills Characteristics of

the Nurse Manager

Organization Plan evidence-based strategies to address the individual,

group, or organizational issue or problem Accountability

Supervision Oversee, supervise care, and assess outcomes of care provided

by other members of the healthcare team Leadership

Evaluation Provide timely qualitative and quantitative feedback to other

members of the healthcare team who are direct reports Leadership

Delegation Identify members of the healthcare team to whom one can

legally and ethically delegate components of care according to roles and
responsibilities Responsibility

Communication

Serve as a liaison between individuals and/or groups internal and external to

the organization when issues or gaps in communication or processes occur

Apply concepts and processes for written and verbal conflict management
and resolution

Authority
Critical Thinking Serve as a role model and resource for other members of
the healthcare delivery team. Seek credible evidence-based sources to guide
decisions. Leadership

Delegation is a complex critical decision that requires critical thinking by the

nurse. Delegation is an important responsibility and must be based on a firm
scientific basis (Caputti, 2020, p. 79). Delegating consists of transferring
responsibility for performing a task that you would do yourself to another
member of the healthcare team. The nurse may delegate to other nurses as
well as ancillary and unlicensed assistive personnel (UAP) under certain
conditions. The person delegated to perform the task must be competent in
performing the task, legally able to perform the task within the healthcare
system, and accountable and competent for performing and completing the
task safely, efficiently, and effectively. The nurse maintains ultimate
responsibility, accountability, and supervision when assignments or tasks are
delegated. Table 2.4 depicts key terms associated with delegation by the
nurse to another member of the healthcare team.

When the nurse delegates a task or assignment to another person on the

healthcare team, the nurse must make certain the five rights of delegation
as defined by the National Council of State Boards of Nursing (NCSBN) are
met. The act of delegation requires a great deal of critical thinking based on
foundational knowledge known as the five rights of delegation NCSBN.

Table 2.5 indicates the rights and associated questions for each of the five
rights of delegation by an RN. It is relevant and essential for nurses to be
familiar with their state nurse practice act regarding to whom and when they
can delegate to others.

TABLE 2.4

Terms and Definition of Delegation

Term Definition Delegation

Delegation Delegating consists of transferring responsibility for performing a

task yourself to another member of the healthcare team.

Responsibility The obligation to complete the task or assignment

delegated

Authority The right to act or command actions of others

Accountability Ability and willingness to assume responsibility for actions
and related consequences according to the five rights of delegation as
defined by the National Council of State Boards of Nursing (NCSBN)

TABLE 2.5

The Five Rights and Associated Questions for Delegation by the Registered
Nurse

Right Associated Questions

1. Right Task

Is this a task that can be delegated by the registered nurse?

2. Right Circumstance

Considering the setting and available resources, should this delegation take
place?

3. Right Person

Is the task being delegated by the right person?

4. Right Direction/Communication

Is the nurse providing a clear, concise description of the task, including limits
and expectations?

5. Right Supervision

Once the task has been delegated, is appropriate supervision maintained?

Individual accountability is a major component of delegation for nurse

leaders. Individual accountability refers to the individual nurse’s ability to
explain their actions and the results of those actions as measured against
standards (Yoders-Wise, 2019, p. 309).

HESI Hint

The Code of Ethics for Nurses with Interpretive Statements is composed of

nine provisions.

The Code of Ethics for Nurses with Interpretive Statements describes the
ethical obligations of all nurses (Yoders-Wise, 2019, p. 309).
Nurses cannot delegate nursing activities or tasks related to nursing
assessment and evaluation according to the fourth interpretive statement of
the Code of Ethics for Nurses with Interpretive Statements.

Supervision is a major component of the RN role. The RN plays a major and

essential role in supervising other members of the healthcare team. For
example, the RN must monitor the performance of the task or assignment
and monitor the level of adherence and degree to which the standards of
professional practice, policies, and evidence-based procedures are met
(Yoders-Wise, 2019, p. 306). The level of supervision must be well-linked to
the task or assignment. To determine the level of supervision required, the
RN must consider certain questions and observe certain behaviors for cues
indicating the delegate’s level of comfort performing the delegated task or
activity. A trusting relationship with strong communication with the person to
whom the task of activity is delegated is essential. The RN must be able to
assess and determine if the UAP being asked to complete a delegated task
feels comfortable or if the UAP needs support, guidance, or direct supervision
when completing the task. Box 2.1 indicates examples of types of questions
the RN should ask when delegating a task or assignment.

HESI Hint

Organizational accountability is an essential component of delegation

(Yoders-Wise, 2019, p. 309).

The shared governance model is a relationship-based model of nursing

leadership that fosters inter- and interprofessional communication,
collaboration, and accountability.

The shared governance model fosters and promotes a positive culture in the
work environment and is person-centric, promoting worker satisfaction and
joy in the work environment.

The shared governance model creates requisite work environment

characteristics essential for successful and effective delegation.

Supervision Skills

There are three basic aspects of supervision when the RN is delegating tasks
or assignments to another healthcare team member. For example, the RN
may be delegating according to the state Nurse Practice Act to a licensed
practical nurse (LPN), a GN, novice, inexperienced nurse, student nurse, or
UAP. Regardless of who is completing the delegated task or assignment, the
RN is ultimately responsible for supervision and outcome. Supervisory skills
of the RN must include clear direction and guidance, evaluation/monitoring,
and follow-up with the person to whom the delegation has been made.
Table 2.6 highlights specific parameters and characteristics to be considered
with the three basic aspects of supervision.

HESI Hint

The registered nurse (RN) must give clear explicit directions and guidance
when communicating or delegating a task or activity to other healthcare
personnel.

For example, the RN must adhere to the three components of supervision

including licensed practical nurses (LPNs), graduate nurses (GNs), student
nurses (SNs), and unlicensed assistive personnel (UAP)

BOX 2.1 Types of Supervisory Questions the Registered Nurse Should Ask
When Delegating a Task

1. Has the task/activity been completed?

2. What patient changes or outcomes did you observe after completing the
task/activity?

3. How did the patient respond before, during, and after you completed the
task/activity?

TABLE 2.6

Specific Parameters to Be Considered With the Three Basic Aspects of

Supervision

Specific Parameters Characteristics to Be Considered With the Three

Basic Aspects of Supervision

A. Direction/Guidance

1. Clear, concise, specific direction and communication

2. Clearly articulated specific outcomes

3. Time frame

4. Limitations

5. Verification/validation of the task or assignment

B. Evaluation/Monitoring
1. Frequent check-in

2. Open, clear, and mutually agreed upon communication lines and

processes

3. Achievement

C. Follow-up

1. Was the task completed in a timely manner?

2. Is the patient stable as a result?

Delegation is a high-level skill that requires a high degree of critical thinking

and decision making. Delegation is based on several key components and
considerations that include assessment, planning, assignment, supervision,
and follow-up evaluation (Caputi, 2020, p. 77). Critical thinking in delegation
requires the nurse to think about what may/can happen when you delegate a
task to another person. Think also about what might go wrong or happen in
the context when you delegate a task to another person or persons.
Table 2.7 provides an overview of key components and considerations to
consider relative to delegation in nursing.

HESI Hint

Delegating to the right person requires the nurse is aware of the

qualifications and job description of the person delegated to perform the
task. For example, the nurse must be certain the person to whom they are
delegating the task has the requisite documented education, training,
knowledge, skills, experience, and competencies to complete the delegated
task. Unlicensed assistive personnel (UAP) generally are not allowed or
permitted by the state nurse practice act to perform sterile procedures or
invasive procedures.

HESI Hint

Some tasks may not be delegated to unlicensed assistive personnel (UAP).

For example, delegated activities fall within the implementation phase of the
nursing process and may not be delegated to UAP. The implementation
phase of the nursing process consists of assessment, analysis, diagnosis,
planning, and evaluation. Any activity or task requiring nursing judgment
cannot be delegated to a UAP.

HESI Hint
The nurse has the legal authority to delegate certain tasks or activities to a
designated (delegate), competent individual, but the nurse is responsible for
making certain the person to whom a task of activity is delegated is
competent and duly supervised.

The nurse is ultimately responsible for the outcome of the activities

delegated to others.

The nurse who delegates to the delegated must assess and evaluate the
outcome(s) of the task(s) that have been delegated.

Collaboration: Interprofessional Healthcare Teams

Healthcare delivered in 21st century healthcare organizations involves a

team of healthcare providers from diverse professions. This diverse team of
healthcare professionals is referred to as interprofessional healthcare teams.
The focus of interprofessional healthcare teams is to bring together a team
that produces optimal patient outcomes. The key to having successful
interprofessional healthcare teams is to understand the various roles of the
interprofessional healthcare professionals.

TABLE 2.7

Key Components of Delegation in Nursing

Key Components of Delegation Rationale

• Delegation is a skill performed by registered nurses to other members of

the healthcare team.

• Nurses are unable to perform each and every task involved in patient care
by themselves.

• Delegation must be done according to the purview of the state nurse

practice act.

• Delegation to others is a legal issue determined by the state nurse practice

act. For example, the state nurse practice act determines who can delegate
and to whom the person can delegate.

• Job descriptions are another important component of safe and legal

delegation when delegating nursing tasks to other members of the
healthcare team.
• Job descriptions indicate what each person’s role and position
responsibilities are and what specific tasks these persons are legally allowed
to perform.

• The person delegated to perform the task must have documented

knowledge, skills, and competencies and be legally able to perform the task
they are being delegated.

• The nurse is legally responsible and accountable to make certain the task
delegated is carried out in a timely, efficient, safe, and effective manner.

• Effective and clear communication is essential for safe delegation.

• The nurse delegating a task must provide clear, concise, timely, and
reliable communication to be certain the delegated task is timely, efficient,
safe, and in an effective manner.

• The ultimate responsibility in delegation lies with the nurse.

• There is a considerable amount of trust involved in delegation, but the

nurse must have a body of knowledge and be a critical thinker to safely
delegate to other members of the healthcare team.

• A nurse has the legal authority to delegate responsibility to complete

certain designated tasks or activities to a designated, competent individual.

• The nurse who delegates responsibility to a designated, competent

individual is accountable for ensuring that the person to whom the task or
activity is delegated is competent, has the right skills and knowledge, and is
properly and duly supervised.

Interprofessional healthcare teams must develop trust with one another and
demonstrate mutual respect to achieve optimal patient outcomes and team
satisfaction. Patients and families are also aware when interprofessional
teams are or are not working well together in a cohesive, collaborative
manner. The need for knowledge and understanding of interprofessional
practice and relationships of interprofessional teams was so important that
there were core competencies developed in 2016 by the Interprofessional
Educational Collaborative (Yoders-Wise, 2020, p. 350). It is essential for every
member of the interprofessional healthcare team to respect the unique roles
of each team member and communicate effectively and efficiently to provide
safe, quality patient care that enhances patient outcomes.

HESI Hint
Interprofessional teams are composed of multiple healthcare professionals
working together collaboratively to achieve high-quality, safe, patient
outcomes based on the collective synergy and talents of each healthcare
professional on the team.

Communication

Nursing leadership and management skills require nurse leaders to be

assertive.

Assertive communication means there are clearly defined and articulated

goals and expectations shared with the other person(s) with whom the nurse
leader is communicating. Assertive communication includes congruence
between verbal and nonverbal communication and messages or information
the nurse leader shares. Assertive communication is foundational and
essential for managing and leading as a nurse leader or manager.

HESI Hint

Communicating assertively means nurses care about the person and the
person’s feelings with whom they are communicating.

Communicating aggressively means nurses do not think or care about the

person and the person’s feelings with whom they are communicating.

Communication is the beginning of understanding. Therefore the nurse

needs to be sure that all team members understand the outcomes necessary
for quality healthcare. To provide a platform for effective communication, the
nurse should understand that there are leadership skills necessary to be an
effective change agent. Change theory is a commonly use theory used by
nurses to lead change. Lewin’s change theory includes three stages of
change: unfreezing, moving, and refreezing. Examples of the application of
these three stages can be found in Table 2.8.

Critical thinking strategies that promote decision making by nurse leaders

and managers must focus on:

A. Application of the Clinical Judgment Model to problem solve and establish

priorities

B. Apply the Clinical Judgment Model to:

1. Determine assessment of the need or problem.

2. Analyze the data and establish the highest priority.

3. Plan to determine the established goals and outcomes that must be met.

4. Determine resources needed to meet goals and outcomes.

5. Implement the evidence-based best practice to meet the goals and

outcomes.

6. Evaluate the goals and outcomes to determine if effective or not.

7. Modify the process or goals and outcomes if goals and outcomes are not
met.

Maintaining A Safe, Effective Work Environment

A. Nurse managers are responsible for addressing

1. Workplace violence

TABLE 2.8

Three Stages of Lewin’s Change Theory

Stages of Lewin’s Change Theory Characteristics of the Stage Example of

Application of the Stage

Unfreezing Initiation of a change

• A new policy must be initiated in the healthcare setting due to changes in

reimbursement by the Centers for Medicare and Medicaid (CMS).

• Example: CMS will no longer reimburse healthcare facilities if a patient

develops a catheter-associated urinary tract infection (CAUTI) from having an
indwelling foley catheter.

Moving Motivations toward the change

• The unit manager must coordinate the education of staff and share the
needed change and new policy and why the change is necessary and
required.

• Example: The unit manager works with staff development nurse educators
to schedule in-services and staff development sessions to educate nurses on
the new evidence-based practice policy.

Refreezing Implementation of the change

• The new policy is implemented and is spread throughout the healthcare
facility and is monitored for sustainability and adherence.

• Example: Retrospective chart audits are conducted for the next 6 months
to assess incidence and prevalence of CAUTIs on the unit.

2. Nursing staff substance abuse.

3. Incivility and bullying

a. Incivility and bullying include actions taken and not taken.

b. Example: Refusing to share pertinent information with another nurse

regarding a client’s stats, thus jeopardizing the client’s safety.

c. Example: Deliberately withholding information pertinent to the client’s

well-being and safety, such as not telling a nurse that the healthcare
personnel (HCP) requested that a client’s medication should be held.

4. Inappropriate use of social media

5. Inappropriate nurse-client relationships

B. Nurse leaders and staff members must provide systems to educate staff
for heightened awareness of common behaviors associated with the
aforementioned items, as well as providing mechanisms for reporting.

1. In dire cases, nurse managers must implement remediation and training to

protect clients from these egregious behaviors that infringe on patients’
safety.

2. The Joint Commission, the American Nurses Association, and other entities
are addressing the dangerous impact of incivility and bullying on patients.

Legal and Ethical Issues Influencing Nursing

Intentional Torts

A. Assault and battery

1. Assault: Mental or physical threat (e.g., forcing [without touching] a client

to take a medication or treatment).

2. Battery: Actual and intentional touching of one another, with or without

the intent to do harm (e.g., hitting or striking a client). If a mentally
competent adult is forced to have a treatment he or she has refused, battery
occurs.

B. Invasion of privacy: Encroachment or trespassing on another’s body or

personality.

1. False imprisonment: Confinement without authorization

2. Exposure of a person:

a. Body: After death, a client has the right to be unobserved, excluded from
unwarranted operations, and protected from unauthorized touching of the
body.

b. Personality: Exposure or discussion of a client’s case or revealing personal

information or identity.

3. Defamation: Divulgence of privileged information or communication

(e.g., through charts, conversations, or observations).

C. Fraud: Illegal activity and willful and purposeful misrepresentation that

could cause, or has caused, loss or harm to a person or property. Examples
of fraud include.

1. Presenting false credentials for the purpose of entering nursing school,

obtaining a license, or obtaining employment (e.g., falsification of records).

2. Describing a myth regarding a treatment (e.g., telling a client that a

placebo has no side effects and will cure the disease, or telling a client that a
treatment or diagnostic test will not hurt, when indeed pain is involved in the
procedure).

Crime

A. An act contrary to a criminal statute. Crimes are wrongs punishable by the

state and committed against the state, with intent usually present. The nurse
remains bound by all criminal laws.

B. Commission of a crime involves the following behaviors:

1. A person commits a deed contrary to criminal law.

2. A person omits an act when there is a legal obligation to perform such an

act (e.g., refusing to assist with the birth of a child if such a refusal results in
injury to the child).
3. Criminal conspiracy occurs when two or more persons agree to commit a
crime.

4. Assisting or giving aid to a person in the commission of a crime makes

that person equally guilty of the offense (awareness must be present that the
crime is being committed).

5. Ignoring a law is not usually an adequate defense against the commission

of a crime (e.g., a nurse who sees another nurse taking narcotics from the
unit supply and ignores this observation is not adequately defended against
committing a crime).

6. Assault is justified for self-defense. However, to be justified, only enough

force can be used to maintain self-protection.

7. Search warrants are required before searching a person’s property.

8. It is a crime not to report suspected child abuse.

HESI Hint

The nurse has a legal responsibility to report suspected child abuse.

Nursing Practice and the Law

Psychiatric Nursing

A. Civil procedures: Methods used to protect the rights of psychiatric clients.

B. Voluntary admission: The client admits himself or herself to an institution

for treatment and retains civil rights.

C. Involuntary admission: Someone other than the client applies for the
client’s admission to an institution.

1. This requires certification by a healthcare provider that the person is a

danger to self or others. (Depending on the state, one or two healthcare
provider certifications are required).

2. Individuals have the right to a legal hearing within a certain number of

hours or days.

3. Most states limit commitment to 90 days.

4. Extended commitment is usually no longer than 1 year.

D. Emergency admission: Any adult may apply for emergency detention of
another. However, medical or judicial approval is required to detain anyone
beyond 24 hours.

1. A person held against his or her will can file a writ of habeas corpus to try
to get the court to hear the case and release the person.

2. The court determines the sanity and alleged unlawful restraint of a person.

E. Legal and civil rights of hospitalized clients

1. The right to wear their own clothes and to keep personal items and a
reasonable amount of cash for small purchases.

2. The right to have individual storage space for one’s own use.

3. The right to see visitors daily.

4. The right to have reasonable access to a telephone and the opportunity to

have private conversations by telephone.

5. The right to receive and send mail (unopened).

6. The right to refuse shock treatments and lobotomy.

F. Competency hearing: Legal hearing that is held to determine a person’s

ability to make responsible decisions about self, dependents, or property.

1. Persons declared incompetent have the legal status of a minor—they

cannot

a. Vote

b. Make contracts or wills

c. Drive a car

d. Sue or be sued

i. Hold a professional license

2. A guardian is appointed by the court for an incompetent person. Declaring

a person incompetent can be initiated by the state or the family.

G. Insanity: Legal term meaning the accused is not criminally responsible for
the unlawful act committed because he or she is mentally ill.

H. Inability to stand trial: Person accused of committing a crime is not

mentally capable of standing trial. He or she
1. Cannot understand the charge against himself or herself

2. Must be sent to the psychiatric unit until legally determined to be

competent for trial.

3. Once mentally fit, must stand trial and serve any sentence, if convicted.

Patient Identification

A. The Joint Commission has implemented new patient identification

requirements to meet safety goals
(http://www.jointcommission.org/standards_information/npsgs.aspx).

B. Use at least two patient identifiers. Ask the client to tell you his or her
name and date of birth (DOB) whenever taking blood samples, administering
medications, or administering blood products.

C. The patient room number may not be used as a form of identification.

Surgical Permit

A. Consent to operate (surgical permit) must be obtained before any surgical

procedure, however minor it might be.

B. Legally, the surgical permit must be

1. Written

2. Obtained voluntarily

3. Explained to the client (i.e., informed consent must be obtained)

C. Informed consent means the procedure and treatment, or operation has

been fully explained to the client, including

1. Possible complications, risks, and disfigurements

2. Removal of any organs or parts of the body

3. Benefits and expected results

D. Surgery permits must be obtained as follows:

1. They must be witnessed by an authorized person, such as the healthcare

provider or a nurse.

2. They protect the client against unsanctioned surgery, and they protect the
healthcare provider and surgeon, hospital, and hospital staff against possible
claims of unauthorized operations.
3. Adults and emancipated minors may sign their own operative permits if
they are mentally competent.

4. Permission to operate on a minor child or an incompetent or unconscious

adult must be obtained from a legally responsible parent or guardian. The
person granting permission to operate on an adult who lacks capacity to
understand information about the proposed treatment (e.g., because of
advanced Alzheimer disease or unconscious adult) must be identified in a
durable power of attorney or an advance health directive.

HESI Hint

Often an National Council Licensure Examination for Registered Nurses

(NCLEX-RN®) question asks who should explain and describe a surgical
procedure to the client, including both complications and the expected
results of the procedure. The answer is the healthcare provider. Remember
that it is the nurse’s responsibility to be sure that the operative permit is
signed and is in the client’s medical record. It is not the nurse’s responsibility
to explain the procedure to the client. The nurse must document that the
client was given the information and agreed to it.

Consent

A. The law does not require written consent to perform medical treatment.

1. Treatment can be performed if the client has been fully informed about the
procedure.

2. Treatment can be performed if the client voluntarily consents to the

procedure.

3. If informed consent cannot be obtained (e.g., client is unconscious) and

immediate treatment is required to save life or limb, the emergency laws can
be applied. (See the subsequent section, Emergency Care.)

B. Verbal or written consent

1. When verbal consent is obtained, a notation should be made.

a. It describes in detail how and why verbal consent was obtained.

b. It is placed in the client’s record or chart.

2. Verbal or written consent can be given by

a. Alert, coherent, or otherwise competent adults

b. A parent or legal guardian

c. A person in loco parentis (a person standing in for a parent with a parent’s

rights, duties, and responsibilities) in cases of minors or incompetent adults

C. Consent of minors

1. Minors 14 years of age and older must agree to treatment along with their
parents or guardians.

2. Emancipated minors can consent to treatment themselves. Be aware that

the definition of an emancipated minor may change from state to state.

Emergency Care

A. Good Samaritan Act: Protects healthcare providers against malpractice

claims for care provided in emergency situations (e.g., the nurse gives aid at
the scene to an automobile accident victim).

B. A nurse is required to perform in a “reasonable and prudent manner.”

HESI Hint

Often NCLEX-RN questions address the Good Samaritan Act, which is the
means of protecting a nurse when she or he is performing emergency care.

Prescriptions and HealthCare Providers

A. A nurse is required to obtain a prescription (order) to carry out medical

procedures from a healthcare provider.

B. Although verbal telephone prescriptions should be avoided, the nurse

should follow the agency’s policy and procedures. Failure to follow such rules
could be considered negligence. The Joint Commission requires that
organizations implement a process for taking verbal or telephone orders that
includes a read-back of critical values. The employee receiving the
prescription should write the verbal order or critical value on the chart or
record it in the computer and then read back the order or value to the
healthcare provider.

C. If a nurse questions a healthcare provider’s (e.g., physician, advanced

practice RN, physician’s assistant, dentist) prescription because he or she
believes that it is wrong (e.g., the wrong dosage was prescribed for a
medication), the nurse should do the following:

1. Inform the healthcare provider.

2. Record that the healthcare provider was informed, and record the
healthcare provider’s response to such information.

3. Inform the nursing supervisor.

4. Refuse to carry out the prescription.

D. If the nurse believes that a healthcare provider’s prescription was made

with poor judgment (e.g., the nurse believes the client does not need as
many tranquilizers as the healthcare provider prescribed), the nurse should:

1. Record that the healthcare provider was notified and that the prescription
was questioned.

2. Carry out the prescription because nursing judgment cannot be

substituted for a healthcare provider’s judgment.

E. If a nurse is asked to perform a task for which he or she has not been
prepared educationally (e.g., obtain a urine specimen from a premature
infant by needle aspiration of the bladder) or does not have the necessary
experience (e.g., a nurse who has never worked in labor and delivery is
asked to perform a vaginal examination and determine cervical dilation), the
nurse should do the following:

1. Inform the healthcare provider that he or she does not have the education
or experience necessary to carry out the prescription.

2. Refuse to carry out the prescription.

HESI Hint

If the nurse carries out a healthcare provider’s prescription for which he or

she is not prepared and does not inform the healthcare provider of his or her
lack of preparation, the nurse is solely liable for any damages.

3. If the nurse informs the healthcare provider of his or her lack of

preparation in carrying out a prescription and carries out the prescription
anyway, the nurse and the healthcare provider are liable for any damages.

4. The nurse cannot, without a healthcare provider’s prescription, alter the

amount of drug given to a client. For example, if a healthcare provider has
prescribed pain medication in a certain amount and the client’s pain is not, in
the nurse’s judgment, severe enough to warrant the dosage prescribed, the
nurse cannot reduce the amount without first checking with the healthcare
provider. Remember, nursing judgment cannot be substituted for medical
judgment.
Restraints

A. Clients may be restrained only under the following circumstances:

1. In an emergency

2. For a limited time

3. To protecting the client from injury or from harm

B. Nursing responsibilities about restraints

1. The nurse must notify the healthcare provider immediately that the client
has been restrained.

2. It is required and imperative that the nurse accurately document the facts
and the client’s behavior leading to restraint.

C. When restraining a client, the nurse should do the following:

1. Use restraints (physical or chemical) after exhausting all reasonable

alternatives.

2. Apply the restraints correctly and in accordance with facility policies and
procedures.

3. Check frequently to see that the restraints do not impair circulation or

cause pressure sores or other injuries.

4. Allow for nutrition, hydration, and stimulation at frequent intervals.

5. Remove restraints as soon as possible.

6. Document the need for and application, monitoring, and removal of

restraints.

7. Never leave a restrained person alone.

HESI Hint

Restraints of any kind may constitute false imprisonment. Freedom from

unlawful restraint is a basic human right and is protected by law. Use of
restraints must fall within guidelines specified by state law and hospital
policy.

Health Insurance Portability and Accountability Act of 1996

A. Congress passed the Health Insurance Portability and Accountability Act of

1996 (HIPAA) to create a national patient-record privacy standard.
B. HIPAA privacy rules pertain to healthcare providers, health plans, and
health clearinghouses and their business partners who engage in computer-
to-computer transmission of healthcare claims, payment and remittance,
benefit information, and health plan eligibility information, and who disclose
personal health information that specifically identifies an individual and is
transmitted electronically, in writing, or verbally.

C. Patient privacy rights are of key importance. Patients must provide written
approval of the disclosure of any of their health information for almost any
purpose. Healthcare providers must offer specific information to patients that
explains how their personal health information will be used. Patients must
have access to their medical records, and they can receive copies of them
and request that changes be made if they identify inaccuracies.

D. Healthcare providers who do not comply with HIPAA regulations or make

unauthorized disclosures risk civil and criminal liability.

E. For further information, use this link to the Department of Health and
Human Services (DHHS) website, Office of Civil Rights, which contains
frequently asked questions about HIPAA standards for privacy of individually
identifiable health information:
http://aspe.hhs.gov/admnsimp/final/pvcguide1.htm.

Review of Legal Aspects Of Nursing

1. What types of procedures should be assigned to professional nurses?

2. Negligence is measured by reasonableness. What question might the

nurse ask when determining such reasonableness?

3. List the four elements that are necessary to prove malpractice

(professional negligence).

4. Define an intentional tort, and give one example.

5. Differentiate between voluntary and involuntary admission.

6. List five activities a person who is declared incompetent cannot perform.

7. Name three legal requirements of a surgical permit.

8. Who may give consent for medical treatment?

9. What law protects the nurse who provides care or gives aid in an
emergency?
10. What actions should the nurse take if the nurse questions a healthcare
provider’s prescription (i.e., believes the prescription is wrong)?

11. Describe the nurse’s legal responsibility when asked to perform a task for
which he or she is unprepared.

12. Describe nursing care of the restrained client.

13. Describe six patient rights guaranteed under HIPAA regulations that
nurses must be aware of in practice.

See Answer Key at the end of this text for suggested responses.

Disaster Nursing and Crisis Intervention

Disaster Nursing

A. The role of the nurse takes place at all three levels of disaster
management:

1. Disaster preparedness.

2. Disaster response.

3. Disaster recovery.

B. To achieve effective disaster management,

1. Organization is the key.

2. All personnel must be trained.

3. All personnel must know their roles.

Levels of Prevention in Disaster Management

A. Primary prevention

1. Participate in the development of a disaster plan.

2. Train rescue workers in triage and basic first aid.

3. Educate personnel about shelter management.

4. Educate the public about the disaster plan and personal preparation for
disaster.

B. Secondary prevention
1. Triage

2. Treatment of injuries

3. Treatment of other conditions, including mental health

4. Shelter supervision

C. Tertiary prevention

1. Follow-up care for injuries

2. Follow-up care for psychological problems

3. Recovery assistance

4. Prevention of future disasters and their consequences

Triage

A. A French word meaning “to sort or categorize”.

TABLE 2.9

Triage Color Code System

Red Yellow Green Black

Urgency Most urgent, first priority Urgent, second priority Third

priority Dying or dead

Injury Type Life-threatening injuriesInjuries with systemic effects and

complications Minimal injuries with no systemic complications
Catastrophic injuries

May Delay Treatment? No For 30–60 mins Several hours No hope for
survival, no treatment

B. Goal: Maximize the number of survivors by sorting the injured according to

treatable and untreatable victims (Table 2.9).

C. Primary criteria used:

1. Potential for survival

2. Availability of resources

Clinical Judgment and Roles in Triage

A. Triage duties using a systematic approach such as the simple triage and
rapid treatment (START) method (Fig. 2.1).

B. Treatment of injuries

1. Render first aid for injuries.

2. Provide additional treatment as needed in definitive care areas.

C. Treatment of other conditions, including mental health

1. Determine health needs other than injury.

2. Refer for medical treatment as required.

3. Provide treatment for other conditions based on medically approved

protocols.

Shelter Supervision

A. Coordinate activities of shelter workers.

B. Oversee records of victims admitted and discharged from the shelter.

C. Promote effective interpersonal and group interactions among victims in

the shelter.

D. Promote independence and involvement of victims housed in the shelter.

Bioterrorism

A. Learn the symptoms of illnesses that are associated with exposure to likely
biologic and chemical agents.

B. Understand that the symptoms could appear days or weeks after

exposure.

C. Nurses and other healthcare providers would be the first responders when
victims seek medical evaluation after symptoms manifest. First responders
are critical in identifying an outbreak, determining the cause of the outbreak,
identifying risk factors, and implementing measures to control and minimize
the outbreak.

D. Possible agents (Table 2.10)

1. Biologic agents:

a. Anthrax

b. Pneumonic plague
c. Botulism

d. Smallpox

e. Inhalation tularemia

f. Viral hemorrhagic fever

2. Chemical agents:

a. Biotoxin agents: ricin

b. Nerve agents: sarin

3. Radiation

HESI Hint

In a disaster the nurse must consider both the individual and the community.

Clinical Nursing Judgment

A. Community-disaster risk assessment

B. Measures to mitigate disaster effect

C. Exposure symptom identification

Clinical Nursing Judgment and Interventions

A. Participate in development of a disaster plan.

B. Educate the public on the disaster plan and personal preparation for
disaster.

C. Train rescue workers in triage and basic first aid.

D. Educate personnel on shelter management.

E. Practice triage.

F. Treat injuries and illness.

G. Treat other conditions, including mental health.

H. Supervise shelters.

I. Arrange for follow-up care for injuries.

J. Arrange for follow-up care for psychological problems.

K. Assist in recovery.
L. Work to prevent future disasters and their consequences.

Ebola

A. The risk of contracting Ebola in the United States is very low, even when
working with West African communities in the United States.

B. Ebola is spread by direct contact with blood or body fluids of a person who
is ill with Ebola or has died from Ebola or has had contact with objects such
as needles that have been contaminated with the virus.

1. It is also possible that Ebola virus can be transmitted through the semen
of men who have survived infection.

FIG. 2.1 Simple Triage and Rapid Treatment (START) Method of Triage.

A flowchart for start adult triage algorithm is as follows:• Able to walk’ If yes,
it’s categorized in minor (green) and secondary triage (light blue).• If not
able to walk, then is there spontaneous breathing’ If no, position airway after
which if spontaneous breathing found, then it’ categorized as immediate
(red) and if after position airway apnea diagnosed then they’e categorized as
expectant. • If able to breathe, the respiratory rate is checked and if it’
greater than 30 then it’ categorized as immediate (red) and if it’ less than 30
then perfusion is checked.• If in perfusion radial pulse is absent or C R is
greater than 2 seconds then it’ categorized as immediate (red) and if radial
pulse is present or capillary refill is less than 2 seconds, then mental status is
checked.• In mental status, if the adult doesn’t obey commands, then they’e
categorized as immediate (red) and if the adult obeys commands, then
they’e categorized as delayed (yellow).

C. The Centers for Disease Control and Prevention (CDC) implemented entry
screening at five US airports for travelers arriving from Guinea, Liberia, and
Sierra Leone, as well as other African countries. The CDC strongly
recommends that travelers from these countries be actively monitored for
symptoms by state or local health departments for 21 days after returning
from any of these countries.

D. People of West African descent are not at more risk than other Americans
if they have not recently traveled to the region. Neither ethnic nor racial
backgrounds have anything to do with becoming infected with the Ebola
virus.
E. Even if travelers were exposed, they are only contagious after they start to
have symptoms (e.g., fever, severe headache, muscle pain, diarrhea,
vomiting, and unexplained bleeding).

F. Symptoms:

1. Fever of greater than 38.6°C or 101.5°F

2. Severe headache

3. Muscle pain

TABLE 2.10

Signs, Symptoms, and Treatments of Biologic and Chemical Agents and

Radiation

BIOLOGIC AGENTS

Anthrax Pneumonic Plague Botulism

Agent

• Bacillus anthracis

• Bacterium that forms spores

• Three types:

• Cutaneous

• Inhalation

• Digestive

• Yersinia pestis

• Bacterium found in rodents and their fleas

• Clostridium botulinum

• Toxin made by a bacterium

Transmission

• Inhalation of powder form

• Inhalation of spores from infected animal products (e.g., wool)

• Handling of infected animals

• Eating undercooked meat from infected animals

• Not spreadable from person to person

• Aerosol release into the environment

• Respiratory droplets from an infected person (6-ft range)

• Untreated bubonic plague sequelae

• Food: a person ingests preformed toxin

• Wound: infection by C. botulinum that secretes the toxin

• Not spreadable from person to person

Incubation Period

• Within 7 days (all types)

• Inhalation incubation: period extends to 42 days

• 1–6 days

• A few hours to a few days

• Foodborne: most commonly 12–36 h, but range is 6 h to 2 weeks

Signs and Symptoms

• Cutaneous: sores that develop into painless blisters, then ulcers with black
centers

• Gastrointestinal: nausea, anorexia, bloody diarrhea, fever, severe stomach

pain

• Inhalation: cold and flu symptoms, including sore throat, mild fever, muscle
aches, cough, chest discomfort, shortness of breath, tiredness, muscle aches

• Fever

• Weakness

• Rapidly developing pneumonia

• Bloody or watery sputum

• Nausea, vomiting

• Abdominal pain

• Without early treatment, will see shock, respiratory failure, and rapid death
• Double and/or blurred vision

• Drooping eyelids

• Slurred speech

• Difficulty swallowing

• Descending muscle weakness

Treatment

• Prevention after exposure consists of the use of antibiotics, such as

ciprofloxacin, doxycycline, or penicillin, and vaccination

• Treatment after infection is usually a 60-day course of antibiotics

• Success of treatment after infection depends on the type of anthrax and

how soon the treatment begins

• If close contact with infected person and within 7 days of exposure,

treatment is with antibiotics prophylactically

• Recommended antibiotic treatment within 24 h of first symptom; treat for

at least 7 days

• Oral: tetracyclines, fluoroquinolones

• IV: streptomycin or gentamycin

• Antitoxin to reduce severity of disease (most effective when administered

early in course of disease)

• Supportive care

• May require mechanical ventilation

Miscellaneous

• Vaccine available, but not to the general public

• Given to those who may be exposed, such as certain members of the US

armed forces, laboratory workers, and workers who enter or reenter
contaminated areas

• Easily destroyed by sunlight and drying

• In air can survive up to 1 h

• No vaccine available
• No vaccine available

Smallpox Inhalation Tularemia Viral Hemorrhagic Fever

Agent

• Variola virus

• Orthopoxvirus

• Francisella tularensis

• Highly infectious bacterium

• Five families of viruses (e.g., Ebola, Lassa, dengue, yellow, Marburg)

• RNA viruses enveloped in a lipid coating

Table Continued

Smallpox Inhalation Tularemia Viral Hemorrhagic Fever

Transmission

• Aerosol release into the environment

• Contact with infected person (direct and prolonged, face to face)

• Bodily fluids

• Contaminated objects

• Air in enclosed settings (rare)

• Insect (usually tick or deerfly) bites

• Handling of sick or dead infected animals

• Consuming of contaminated food or water

• Inhalation of airborne bacterium

• Cannot be spread from person to person

• From viral reservoirs such as rodents and arthropods or an animal host;

some hosts remain unknown

• May be transmitted person to person via close contact or bodily fluids

• Objects contaminated by bodily fluids

Incubation Period
• 7–17 days

• Most commonly 3–5 days, but may range from 1 to 14 days

• 2–21 days (varies according to virus)

Signs and Symptoms

• High fever

• Head and body aches

• Vomiting

• Rash that progresses to raised bumps and pus-filled blisters that crust and
scab, then fall off in about 3 weeks, leaving a pitted scar

• Skin ulcers

• Swollen and painful lymph glands

• Sore throat

• Mouth sores

• Diarrhea

• Pneumonia

• If inhaled: abrupt onset of fever and chills, headache, muscle aches, joint
pain, dry cough, and progressive weakness

• If pneumonia develops: may exhibit chest pain, difficulty breathing, bloody

sputum, and respiratory failure

• Varies by individual virus but common symptoms exist:

• Marked fever

• Exhaustion

• Muscle aches

• Loss of strength

• As disease worsens, more severe symptoms emerge:

• Bleeding under skin, in internal organs, or from body orifices (mouth, eyes,
ears)

• Shock
• Central nervous system malfunction

• Seizures

• Coma

• Renal failure

Treatment

• No proven treatment

• Supportive therapy

• Antibiotic treatment for secondary infections

• Research being done with antivirals

• Antibiotics for 10–14 days

• Oral: tetracyclines, fluoroquinolones

• IM or IV: streptomycin, gentamicin

• Supportive therapy

• Generally no established cure

• May use ribavirin with Lassa fever

Miscellaneous

• A fragile virus; if aerosolized, dies within 24 h (quicker if in sunlight)

• Vaccine available

• Can remain alive in water and soil for 2 weeks

• No vaccine available

• Need a reservoir to survive; humans are not the natural reservoir, but once
infected by the host, can transmit to one another

• Once geographically restricted to where the host lived; increasing

international travel brings outbreaks to places where the viruses have never
been seen before

• No vaccines available except for Argentine and yellow fever

Chemical Agents and Radiation

Ricin Sarin Radiation

Agent

• Poison made from waste left over from processing castor beans

• Forms include powder, mist, pellet

• Dissolved in water or weak acid

• Human-made chemical

• Similar to, but far more potent than, organophosphate pesticides

• Clear, odorless, and tasteless liquid that can evaporate into a gas and
spread into the environment

• Form of energy both human-made and natural

Table Continued

Chemical Agents and Radiation

Ricin Sarin Radiation

Transmission

• Deliberate act of poisoning by inhalation or injection (need minuscule

amount [500 mcg] to kill)

• Deliberate act of contamination of food and water supply (requires greater

amount to kill)

• Cannot be spread from person to person through casual contact

• Agent in air: exposed through skin, eyes, inhalation

• Ingested in water or food

• Clothing can release sarin for approximately 30 mins after contact

• External exposure comes from the sun or from human-made sources such
as x-rays, nuclear bombs, and nuclear disasters (e.g., Chernobyl)

• Small quantities in air, water, food, cause internal exposure

Incubation Period

• Inhalation: within 8 h

• Ingestion: <6 h

• Vapor: a few seconds

• Liquid: a few minutes to 18 h

• Exposure is cumulative; low-dose exposure effects may not be seen for

several years.

• High dose received in a matter of minutes results in ARS

Signs and Symptoms

• Inhalation: respiratory distress, fever, nausea, tightness in chest, heavy

sweating, pulmonary edema, decreased blood pressure, respiratory failure,
death

• Ingestion: vomiting and diarrhea that becomes bloody, severe dehydration,

decreased blood pressure, hallucinations, seizures, hematuria; within several
days, liver, spleen, and kidney failure occur

• Skin and eyes: redness and pain

• Runny nose

• Watery eyes

• Pinpoint pupils

• Eye pain and blurred vision

• Drooling

• Excessive sweating

• Respiratory symptoms

• Diarrhea

• Altered level of consciousness

• Nausea and vomiting

• Headache

• Decreased or increased blood pressure

• In large doses: loss of consciousness, convulsions, paralysis, respiratory

failure, death

• ARS: nausea, vomiting, diarrhea; then bone marrow depletion, weight loss,
loss of appetite, flulike symptoms, infection, and bleeding

• Mild effects include skin reddening

• May lead to cancers (with low dose and in those surviving ARS)

Treatment

• Supportive care

• Remove from body as soon as possible

• Supportive care

• Antidote available: most effective if given as soon as possible after

exposure

• Dependent on dose and type of radiation

• Supportive care

Miscellaneous

• Stable agent; not affected by very hot or very cold temperatures

• Death usually occurs in about 36–72 h

• If victim survives for 3–5 days, usually recovers

• No vaccine available

• A heavy vapor, this agent sinks to low-lying areas

• Mildly or moderately exposed people usually recover completely

• Severely exposed people usually do not survive

• May experience neurologic problems lasting 1–2 weeks after exposure

• Survival dependent on dose

• Full recovery may take a few weeks to a few years

Note: For further information, go to

https://emergency.cdc.gov/agent/agentlist-category.asp.

ARS, Acute radiation syndrome; IM, intramuscular; IV, intravenous.

4. Vomiting

5. Diarrhea
6. Abdominal pain

7. Unexplained hemorrhage

G. Diagnosis

1. Centers for Disease Control recommends testing for all persons with onset
of fever within 21 days of having a high-risk exposure. A high-risk exposure
includes any of the following:

a. Percutaneous or mucous membrane exposure or direct skin contact with

body fluids of a person with a confirmed or suspected case of Ebola without
appropriate personal protective equipment (PPE).

b. Laboratory processing of body fluids of suspected or confirmed Ebola

cases without appropriate PPE or standard biosafety precautions.

c. Participation in funeral rites or other direct exposure to human remains in

the geographic area where the outbreak is occurring without appropriate
PPE.

H. Clinical Judgement interventions

1. Obtain a thorough history, including recent travel from areas where the
virus is present.

2. Monitor vital signs.

3. Place the client in strict isolation for 21 days, using special precautions
identified by the CDC and state.

4. Notify the CDC.

I. Healthcare provider protection

1. Healthcare providers should wear gloves, gown (fluid resistant or

impermeable), shoe covers, eye protection (goggles or face shield), and a
facemask.

2. Additional PPE might be required in certain situations (e.g., copious

amounts of blood, other body fluids, vomit, or feces present in the
environment), including but not limited to double gloving, disposable shoe
covers, and leg coverings.

3. Avoid aerosol-generating procedures. If performing these procedures, PPE

should include respiratory protection (N95 filtering face piece respirator or
higher), and the procedure should be performed in an airborne isolation
room.

4. Diligent environmental cleaning, disinfection, and safe handling of

potentially contaminated materials is paramount because blood, sweat,
emesis, feces, and other body secretions represent potentially infectious
materials.

Coronavirus disease (COVID-19)

A. COVID-19 information

1. CDC Guidelines: https://www.cdc.gov/coronavirus/2019-ncov/index.html

B. Agent

1. Coronavirus disease (COVID-19) is an infectious disease caused by the

SARS-CoV-2 virus.

C. Transmission

1. Close personal contact

2. Droplet infection

3. Heating and ventilation ductwork spread

D. Signs and symptoms

1. Fever

2. Nasal and sinus congestion

3. Cough

a. Stomach upset and nausea/vomiting

b. Chills

E. Treatment

1. Primary and secondary prevention with vaccination

2. Tertiary prevention depends on symptoms and patient age

3. For most children and adults with symptomatic SARS-CoV-2, the virus that
causes COVID-19, infection, isolation, and precautions can be discontinued
10 days after symptom onset and after resolution of fever for at least 24
hours and improvement of other symptoms.
4. For people who are severely ill (i.e., those requiring hospitalization,
intensive care, or ventilation support) or severely immunocompromised,
extending the duration of isolation and precautions up to 20 days after
symptom onset and after resolution of fever and improvement of other
symptoms may be warranted.

5. For people who are infected but asymptomatic (never develop symptoms),
isolation and precautions can be discontinued 10 days after the first positive
test.

F. Miscellaneous: Patients who have recovered from COVID-19 can continue

to have detectable severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) RNA in upper respiratory specimens for up to 3 months after illness
onset. However, replication-competent virus has not been reliably recovered
and infectiousness is unlikely.

Review of Disaster Nursing

1. List the three levels of disaster management.

2. List examples of the three levels of prevention in disaster management.

3. Define triage.

4. Identify three bioterrorism agents.

5. Identify three infection control measures for Ebola.

6. Identify the agency to notify when providing care for a client with a
suspected diagnosis of Ebola virus.

See Answer Key at the end of this text for suggested responses.

For more review, go to http://evolve.elsevier.com/HESI/RN for HESI’s online

study examinations.

Next-Generation NCLEX (NGN) Examination-Style Question: Bowtie Question

Case Record

Sarah Lee, a 32-year-old emergency room nurse, was on her way home from
the hospital when a major hurricane began to hit her hometown. Her car was
pushed into the oncoming lane; however, she did not hit another victim;
rather, she waited at the side of the road until most of the wind and rain
receded. Because of her experience as a triage nurse, she immediately
checked for her own injuries and began to assess her surroundings. She
noted that several other people were walking around and were injured while
others were laying in the middle of the road. Sara began to review her
disaster training to initiate assistance to others in the area.

Disaster Principles

Invoke disaster training protocol.

Instructions

Complete the diagram by selecting from the choices below to specify which
potential condition the client is most likely experiencing, 2 actions to take,
and 2 parameters the nurse would monitor to assess the client's progress.

A chart shows potential condition at the center connected to 2 boxes labeled

nursing actions on left and 2 boxes labeled parameters to monitor at right.

Actions to Take Potential Conditions Parameters to Monitor

Disaster preparedness, response, recovery Blunt chest injuries

Infection control principles should be used

Monitor vital signs Hypotension Note any frank bleeding on any

person

Initiate cardiopulmonary resuscitation (CPR) Infection disease exposure

Monitor individuals who are treatable

Render first aid to injured Constipation Assess pain and monitor

response

Provide water to the injured Monitor bowel movements

Answers highlighted in Answer Key at the end of this text

References and Bibliography∗

1. Caputti L. Think like a nurse: A handbook . Rolling Meadows, IL: Windy

City Publishers; 2020 (Revised Edition 2020).
10. George B, Sims P, McLean A, Mayer D. Discovering your authentic
leadership . Harvard Business Review; 2007 3–4.

2. Hersey P. Situational leadership® model. Escondido, CA: The Center for

Leadership Studies, Inc; 2006. http://www.situational.com.

3. Morriss A, Ely R.J, Frei F. Stop holding yourself back. Harvard Business
Review OnPoint; 2014,
Fall. http://www.necf.org/whitepapers/HBR_Managing_Yourself.pdf.

4. Roussel, L. T., Thomas, P. L., & Harris, J. L. (2020). Management and

leaderhip for nurse administrators (8th ed.). Burlington, MA: Jones & Bartlett,
p. 4.

5. Yoder-Wise P. Leading and managing in nursing . 7th ed. St. Louis,

MO: Elsevier; 2019.

∗ asterics are used so reader knows it was first or to refer the reader to a
specific note such as to refer to the first component of the topic or list.