Step 2: Write about this experience using the following frame (painting the picture).

It is important to me to continue to discuss the Pediatric Unit, because so much of what I do occurs there. In comparison to my high score as the mentor, I automatically shift into the service/provider role at times rather than the initiator role because of my tendency to assume tasks myself. My intuition and my personal knowledge of belief is that if I do it myself it is done the way it should be done. With the objectives of what needs to be completed, the assessment of my staff's competencies, effective delegation, the assumption of a fair assignment, and the acknowledgment of a "weak line," I am placed at risk in this role. My reason for taking on tasks myself is primarily a time saving measure, and of course I am reassured that assessments or procedures are done at the highest level of care. I am aware that my reasoning may not be agreeable with everyone, but it was vividly demonstrated on today's shift. The admission, a "frequent flyer," on night shift. was a teenage female who is a diabetic and who had been placed on an insulin pump on one of her prior admissions. With straight-forward written orders from the attending physician of blood sugars to be checked every two hours and before every meal, she warranted more intense observation because of her non-compliant history. In the morning report her blood sugar was recorded as 108 mg/dl at 5 am. At about 7 am her blood sugar was 70 mg/dl and breakfast was served with a 2000 k/cal American Diabetic Association diet. I checked her tray for a proper breakfast, and as the nurse reported the result of the patient's blood sugar, I asked the nurse to serve her tray. After completing some of my other duties I made my usual rounds at approximately 8 am. Upon entering the room and approaching her bed I found her asleep and she had not touched her breakfast. I gently shook her as I introduced myself and offered her a chance to use the bathroom prior to consuming her breakfast. She responded at that time and gave me no reason to be concerned. The primary nurse was informed of my findings and my brief interaction with the patient, and I asked her again to monitor the patient closely. At approximately 9 am the patient needed another blood sugar check so I asked the primary nurse how her patient was doing and told her that she should prepare for a finger-stick. I also instructed the primary nurse to let the patient perform her own testing for teaching purposes. The call-light went off in the patient's room. Upon my arrival at the patient's room the primary nurse was stuttering and nervously stated that she was unable to get a clear answer from the patient and asked what she should do now. I felt my pulse racing as I surveyed the situation. I called for the glucometer, which should have been at the bedside. I asked the nurse to obtain a sample of blood quickly and to run the results while I roused the patient...with success. She did appear lethargic but with no signs indicating slurred speech. She just seemed rather incoherent as if she had been awakened from a deep sleep. There was a good reason for this. Her glucose level now was 58 mg/dl. With the quick response from another staff nurse orange juice was rushed to the bedside, and the patient drank 118 ml of it. After re-checking her blood glucose approximately 20 minutes later with a result of 69 mg/dl, I was temporarily satisfied with the outcome. The patient was coherent and made casual conversation while consuming her breakfast as I turned her back over to her primary nurse. I instructed the nurse at that time to remain with the patient and monitor her closely. I also asked her to perform some patient education while I would inform the morning attending physician of the hypoglycemic episode.

Later that morning I asked the primary nurse to come and talk with me in regard to this particular event. Initially I was furious because of the incompetence. I was also frustrated because her work was not well organized, as was evidenced by the fact that there was no glucometer at the patient's bed side. Her charting was not updated, and again she needed to be told what to do. I needed to know if she felt that she was competent to work on a pediatric floor, and what her plan of action would have been if it would have been a true emergency. Some time went by as I prepared...

Actually, by the time we met I was calm and able to keep my emotions under control. I inquired what she was actually thinking when asking me what to do. Did she not read the orders, was it her lack of knowledge, did she get scared, or honestly did she simply not have a clue of what to do? I listened to some of her reasons and justifications, which I found to be ridiculous, and I informed her of the unacceptable nursing care that she delivered in this instance. I told her that I would have to initiate a 4106 (unusual occurrence report). This is not a bad thing; rather it requires remedial education within the facility to sharpen forgotten or enhance present skills. The clearly written physician's order and the importance of a diabetic being on a schedule, particularly with nutrition, does not require one to be a genius. I directed her to our patient education cabinet, and also asked her to consider the patient's multiple admissions prior to this one, consider the thought of any correlation of non-compliance and asked her also to consider the thought of peer pressure which most likely complements the patient's non-compliance leading to this admission Her parents are also not involved with her care. I strongly believe that this would be common sense. Her superficial nursing care jeopardized the entire team this morning. Looking back on this particular situation in the "Initiator" (Quinn, et al., 2003), by defining the problem and establishing clear objectives I became the service/care provider (Quinn, et al., 2003) since I assumed the brief care for that particular patient. I accepted the personal and professional responsibility (Nursing, 2003) as I assessed the risk and achieved my immediate goal, which was to stabilize the patient. Obviously, I failed to delegate effectively. I also shifted partly into the Facilitator role by counseling the staff nurse and initiating an unusual occurrence report. In the Facilitator role I became an effective team player, as I depended on my team and applied a definite decision.
After studying the subject matter, I began to realize that my nursing practice from the early eighties is not old or unacceptable (Covey, 1989), it is merely different from a more empathetic and caring work environment that caters to our younger nurses. There are several frameworks developed by researchers in the eighties and nineties that deal with caring when it comes to nursing (McCance, McKenna, & Boore, 1999; Watson, 1988; Roach, 1987), which indicates how important it was and how important it remains. We are now implementing teaching strategies and mentorship on the job to 'season' the new generation of graduating nurses. The need for this is so evident with this problematic team member. The tasks delegated to her are completed to my dissatisfaction, yet I am accountable and responsible for the care she delivers (Nursing, 2003). I am also the authority with the right of determining, influencing, or evaluating the care provided. Delegation is not merely distributing nursing care amongst staff members, but it also involves the matching aspects of the work required to be carried out by the nurse while maintaining the highest professional standards of care (Covey, 1989; Donaldson & Fralic, 2000, Lane, 1990). My multilevel experience from various settings over the years made me realize that textbooks are a wonderful resource, but in real life situations sometimes we get so overwhelmed with our patient's bedside care that there is absolutely no time to analyze, rationalize, and explain.

Part Three

Task 3: Analysis of a management event using the eight-role management model.

Step 1: Identify a management issue/experience from your recent practice, e.g. The implementation of staff appraisal.

Actively involved as a member of the infection control committee, I was asked to implement the alcohol-base hand gel on my ward with a given deadline of January 31, 2004. This hand gel should serve primarily as a cost-saving factor replacing the present soap and lotion dispensers. It has also been approved by the Center for Disease Control and supported with respectable evidence of decreasing nationwide nosocomial infections. Our ward along with the Neonatal Intensive Care Unit was to implement the product since our ward especially included the Acute Gastroenteritis…