Professional Roles and Leadership

Cover letters are a means of introducing a job applicant to a potential employer. Key components of the cover letter include identification of interest in employment, a brief statement of qualifications, and availability for the position being sought. It is important to personalize the cover letter and to emphasize strengths and desired qualities applicable to the position. Cover letters (Figure 57-1) may be mailed to the employer or uploaded as an attachment if the applicant is completing an online application.

Résumé

The résumé is a one- or two-page summary of educational and professional experiences, activities and honors, and concrete skills and interests. A concise, comprehensive, well-prepared résumé will impress future employers; therefore, it should be well-organized, neat, and accurate. The applicant should be certain to use a variety of descriptive terms (e.g., “highly motivated,” “exceptional ability,” or “outstanding skills”) when preparing the résumé.

There are several styles of résumés, including chronologic and functional. In the chronologic résumé, the applicant's job history is listed in reverse chronologic order, with the most recent job listed first. The functional résumé focuses instead on the applicant's experience and skills. The applicant should choose the résumé style that best demonstrates the applicant's strengths and abilities. The employer is seeking the employee with the most potential for the job, and the résumé is likely to be one of the first means by which the employer obtains an impression of the applicant (Figure 57-2).

Contracts and Starting Out

A contract is a promise or a set of promises between two or more people that creates a legal relationship with legal obligation between them. The usual contract that LPN/LVNs encounter is the employment contract. Today the contract between the employee and employer is often verbal and implied. Under the employment contract, it is the nurse's obligation to perform nursing functions with the skill and knowledge that is in accordance with the standards of the profession under that state's nurse practice act. The employer is responsible for providing a safe working environment, sufficient and competent fellow workers, and safe equipment. Failure on the part of the nurse or the employer to perform these duties is a breach of contract. It is possible for breach of contract to result in a lawsuit in which the court may order the breaching party to perform the obligations of the contract or to pay money to the party who suffered damage because of the breach. Because the contract is one for personal services, a nurse is usually not forced to work for the employer. Rather, the nurse may be liable for money damages to an employer for breach of contract.

The employment contract properly specifies the length of the contract period; hours that the nurse is to work; salary; vacation; sick leave pay; medical, maternal, disability, and liability insurance coverage; educational benefits; and any other benefits or working conditions that the nurse and employer agree on. The employment contract can be terminated legally, without a breach, by completion of all obligations under the terms of the contract or by consent of all parties to the termination.

New employees usually find that facilities provide orientation programs, which vary in length, depending on the facility policy. Many facilities also require newly graduated nurses to take examinations or tests to assess competencies in medication and math skills.

Recent graduates are also often required to serve a probationary period before acquiring the status of a benefit-earning member of the staff. Internships or residency programs are sometimes offered by employers to nurses who have recently graduated. An internship helps with the transition to professional nursing. Some facilities provide a mentor or preceptor (person who supports a new or transferred employee through clinical orientation) to assist the new graduate during this internship period. Probationary policies such as internships or orientation should be discussed during the interview process.

Advancement

Advancement (a rise in rank or importance; a promotion; progress; improvement) is a possible result of additional preparation or additional experience. A nurse may achieve advancement by learning the position more thoroughly and by assuming new and greater responsibilities. Advancements, together with the difficulties and obstacles that they bring, stimulate interest and enthusiasm. They are usually based on a person's qualifications, behavior, performance, and preparation.

Terminating Employment

Resigning from a position properly is another skill with which the LPN/LVN should be familiar. Employers sometimes raise questions about a résumé that reflects frequent job changes; therefore, it is in the nurse's best interest to remain at the first place of employment at least 1 year. If this is impossible, the nurse should follow the proper procedure for resignation (the act of resigning to give up a position of employment). A verbal statement and a written resignation, providing at least a 2-week notice, is considered professional courtesy, and maintains a good relationship with the employer. Some facilities have a standard resignation form that must be completed. If the employer expects employees to submit a letter of resignation, the letter should be kept brief, with concise terms stating the reason for leaving the position.

Confidentiality

All patient information must remain confidential. Patient information should be exchanged only with other members of the health care team responsible for the care of the patient. Release of information to anyone other than the health care team without the consent of the patient is a violation of the right to privacy. Refer to Chapter 2 for additional information regarding confidentiality (Box 57-7).

Role of the Licensed Practical/Vocational Nurse in the Community

The LPN/LVN participates in activities that promote the community's positive attitude toward health care. The LPN/LVN uses community resources to promote a better understanding of the health services available to the general public and promotes and participates in community health projects and other health-oriented activities such as maternal and child health clinics, disabled children clinics, mental health clinics, blood pressure clinics, and community health fairs.

Professional Organizations

In order to have a voice in one's profession, it is important to join one's professional organization. No organization has the power to be any more active or effective than its members. Some professional health care organizations provide opportunities for continuing education to their members and associated allied health staff.

Two national organizations exist to support and meet the needs of the LPN/LVN: the National Association for Practical Nurse Education and Service (NAPNES) and the National Federation of Licensed Practical Nurses (NFLPN).

The purpose of NAPNES, founded in 1941, is to promote an understanding of practical nursing schools and continuing education for LPN/LVNs. The organization also developed a position on the education of the practical nurse, defines ethical conduct, and publishes standards of practical and vocational nursing practice. The Journal of Practical Nursing is the official publication, and NAPNES Forum is the newsletter that informs members of activities. Membership is open to students, graduates, faculty, and other people who are interested in practical or vocational nursing. NFLPN, founded in 1949, serves the interests specifically of LPN/LVNs. It restricts membership to only LPN/LVN students and graduates. It informs members of the most current issues of interest and makes available to its members insurance coverage for malpractice, personal liability, health, and accident. The NFLPN also lobbies on both the state and national levels for issues that are of interest and concern to its members. Licensed Practical Nurse is the official publication. For further information about NAPNES, visit its website (www.napnes.org) or write to NAPNES, 1940 Duke Street, Suite 200, Alexandria, VA 22314. For further information about NFLPN, visit its website (www.nflpn.org) or write to NFLPN, 111 West Main Street, Suite 100, Garner, NC 27529. Members of these two organizations all share the common goals of the LPN/LVN.

Continuing Education

The health care system is changing constantly as a result of rapidly developing technology and research, and keeping current with nursing trends and issues is crucial. There are abundant avenues by which to gain additional nursing skills and knowledge. Facilities frequently offer employees continuing education through seminars, conferences, or workshops (Box 57-8). Continuing education credit is also available through some nursing journals.

To renew nursing licenses, some states require a given number of hours per year in continuing education units (CEUs). These requirements are intended to improve the quality of patient care by educating nurses about the most recent trends in nursing interventions. Not all continuing education opportunities are accepted by all state boards of nursing for renewal of licensure. The LPN/LVN is responsible for acquiring the required number of CEUs and for ensuring that the credits are attained from approved providers.

Certification Opportunities

Certification is a process by which the nurse is granted recognition for competency in a specific area of nursing. Various certification opportunities are available to LPN/LVNs through seminars or self-guided study courses. Knowledge is the basis for improved nursing skills and safety in patient care. In many states or agencies, certification is also the basis for salary increases and advancement. Information on certification courses for the LPN/LVN can be found on the NAPNES website (www.napnes.org).

Taking the Test

The NCSBN adopted computerized adaptive testing (CAT) for the NCLEX in 1994. The maximum time length for administration of the NCLEX-PN is 5 hours. Some candidates are able to complete the examination in less time.

CAT test centers are quiet and comfortable, with specially designed workstations to enhance security while providing a personal testing environment. The candidate sits at an individual computer terminal and answers questions that appear on the screen. Test staff maintain security by directly observing the testing session, in addition to continuous monitoring. The proctor is able to observe all candidates simultaneously and continuously during testing without entering the room, which eliminates the noise and distraction of people moving about the room.

In April 2005, test administrators revised the test format by introducing alternate format items. An alternate-item format is an examination item that takes advantage of new technology through the use of a format to assess candidate ability that differs from the standard one of four multiple-choice options with one correct response. Possible alternate-item formats include questions with multiple correct responses, fill-in-the-blank questions (including calculation and ordered-response item types), and “hot-spot” items, for which a candidate is to identify an area, picture, or graphic. It is important to note that all NCLEX-PN item formats, including current standard multiple-choice items, sometimes include charts, tables, or graphic images; the intent of alternate-item formats is to assess each candidate's ability to critically think in a way that is more flexible than with standard multiple-choice items.

Each test unfolds in an interactive way as the candidate proceeds through the material, but each one covers the same subject content (each test is based on the test plan). The goal of CAT is to determine competence on the basis of the difficulty of questions, not on how many questions are answered correctly. The interactive computerized format makes it possible to match the test questions posed to each candidate's demonstrated competence level. This makes for greater efficiency in the testing process: The program poses only questions that offer the best measurement of the candidate's competence, rather than a one-size-fits-all set that includes questions not relevant to a given candidate's situation.

Testing experts have ascertained the difficulty level of each of the thousands of questions in the computer's item bank by trying them out on thousands of candidates and then statistically analyzing the results. In the actual testing situation, the program uses a candidate's answers to calculate a competence estimate based on the known level of difficulty. It then scans through the test item bank, classified by test plan area and level of difficulty, and determines the question that will most precisely and appropriately measure the candidate in the next test plan area. It presents this selection on the computer screen as the successive test question to the candidate. This process continues, creating as it goes an examination tailored to the individual candidate's knowledge and skills and at the same time fulfilling all NCLEX-PN plan requirements.

Questions are ranked by the level of difficulty from easiest to hardest. If asked the easiest questions, most candidates answer most of them correctly. If asked only the hardest, they probably answer most incorrectly. As the examination questions progress from easy to hard, there comes a point at which an individual candidate is answering 50% of the questions correctly. Questions further along the difficulty continuum are likely to receive wrong answers (i.e., although some answers will be right, more will be wrong), and easier questions are likely to elicit correct answers. The goal of CAT is to find that point, which is different for everyone. That point is the competence level.

The minimum number of questions for the NCLEX-PN is 85 (60 “real” questions and 25 pilot, or “try-out,” questions). The scores on the try-out questions are not counted toward the competence level of the candidate. If a candidate is able to answer the difficult questions correctly, there is no point wasting the candidate's time with a lot of easy questions. Likewise, if a candidate is not able to answer the easy ones correctly, there is no point in continuing with the difficult ones because the candidate is unlikely to be able to answer them. In fact, the system often has enough data to make a decision after less than the minimum of 60 questions, but a minimum of 60 scored questions is necessary to ensure coverage of the test plan. It is important that the candidates get the opportunity to answer several questions in each of the test plan content areas.

After the candidate has answered 85 questions, the system compares the competence level with the passing standard and determines (1) whether the candidate is clearly above the passing standard (the candidate passes), (2) whether the candidate is clearly below the passing standard (the candidate fails), or (3) whether the competence level is not clear. If it is not clear whether the candidate has passed, the system continues to ask questions. The system stops asking questions when the competence level is clearly above or clearly below the passing standard, when the maximum number of questions has been answered (265 for the NCLEX-RN and 205 for the NCLEX-PN), or when the candidate runs out of time.

There is no random selection of which candidates get a long examination. The length of the NCLEX-PN is based on the performance of the individual candidate.

Candidates who are accustomed to knowing most of the answers on tests sometimes find a CAT test difficult because they know the answers to only about half the questions. However, it is in fact possible that these candidates are doing quite well: Because they are answering the most difficult questions in the item bank, even 50% correct scores reflect a high competence level.

The most current and complete information about the NCSBN and the NCLEX-PN is available from its website (www.ncsbn.org).

After the Test

The test scores are pass or fail. Test administrators print score reports and send them to the board of nursing in each jurisdiction within 24 hours. Each board of nursing schedules its own notification timetable. Most test results are received by candidates in 1 week or less.

Candidates who have failed their licensure examination in most states are allowed to retake the test after waiting 45 days. Additional guidelines from the state board of nursing include (1) the number of times a candidate is allowed to retake the test before being required to seek reeducation and (2) the amount of time allowed between graduation from nursing school and taking the licensure examination.

On successful completion of the examination, the candidate has the right to practice as an LPN/LVN. The licensed LPN/LVN is responsible for license renewal and keeping the state board informed of any changes of address, name, and employment (i.e., active or inactive) status. The LPN/LVN is not allowed to practice without a license. Licensure permits nurses to offer special skills to the public, but it also provides legal guidelines for protection of the public.

Endorsement and Reciprocity

The NCLEX-PN makes it possible to practice nursing in states other than the one in which the nurse first qualifies (see Chapter 2). If the nurse moves after successfully passing the examination and fulfilling the educational requirements, it is necessary to apply for a license or temporary practice permit before practicing nursing. Licensure that transfers this way from one state to another is called endorsement (a statement of recognition of the license of a health practitioner in one state by another state; the applicant needs to meet the current state's licensing requirements). Some states called this licensure reciprocity; this is a mutual agreement to exchange privileges, dependence, or relationships, such as an agreement between two governing bodies to accept the credentials of caregivers licensed in each other's state. True reciprocity means that an individual licensed in one state can automatically receive licensure in the other, even if the licensing requirements of the states differ. In either case, the nurse must have a license that is unencumbered. Some states also offer temporary licensure to individuals seeking endorsement in that state. This allows the applicant endorsement to work while the application for licensure is being reviewed.

Hospitals

Because of health care economics, hospitals are responsible for providing quality care as economically as possible. Under the supervision of an RN, the LPN/LVN is legally able to provide most bedside care to patients in the hospital setting. Because the LPN/LVN salary is lower than that of the RN, it makes economic sense to employ a number of LPN/LVNs. It also makes sense because the LPN/LVN is prepared to give excellent bedside care.

The LPN/LVN has opportunities in various departments throughout the hospital, including coronary care, intensive care, emergency department, surgery scrub, outpatient surgery, and pediatrics. Policies vary by facility and locality. In the hospital setting, the LPN/LVN has responsibility for supervising nursing assistants, whereas overall management of a unit is the responsibility of an RN.

Salaries in a hospital setting may include shift differential and extra pay for holidays and perhaps weekends. Benefits tend to be good in hospitals, and some provide for 12-hour shifts and special schedule plans such as a 3-day weekend work schedule. Other opportunities in the hospital setting include work in infection control and employee health, as well as serving on various committees.

When seeking employment, the LPN/LVN should consider a number of different types of hospitals. Some have a wide range of services, and some are more specialized. Common specialized hospitals include pediatric facilities, orthopedic facilities, and rehabilitation facilities. Some hospitals operate in conjunction with a university and are the site of a great deal of teaching and research.

Long-Term Care Facilities

LPN/LVN work is the backbone of long-term care facilities (previously called nursing homes). LPN/LVNs in this setting frequently advance to charge nurse and supervisory capacity with RN supervision. The LPN/LVN in the long-term care setting is often involved in staff development and recruitment, and serves on various committees. Management and leadership skills have ample opportunity for development in the long-term care setting (Figure 57-3).

Salaries for LPN/LVNs in long-term care facilities are currently similar to those in the hospital setting (Bureau of Labor Statistics, 2012). Shift differential pay and scheduling alternatives may be available. Benefit packages also tend to be good in the long-term care setting.

Many positive changes have occurred in the facilities. The long-term care facility is just that: a facility for patients who require long-term care. Hospitals no longer are an option for patients after the period of acute illness. Alternatives include rehabilitation hospitals if patients meet the qualifications, home health care, or a long-term care facility. Residents are of any age, and the level of care depends on the unit. Subacute units provide care that in years past was possible only in the hospital setting. Physical, speech, occupational, and other therapies are available. Many patients receive therapy and are able to return home.

Home Health

The degree to which home health care opportunities are available to LPN/LVNs varies in different parts of the United States. The LPN/LVN is capable of providing much of the care required, but RN supervision must be available. The advantages of home health care include patient preference, nurse autonomy, and the lower cost of care in comparison with hospital stays. Home health care also allows for continuity of care inasmuch as the nurse is often assigned a caseload that he or she follows during the entire time the patient is receiving home health care.

Health Care Provider's Office or Clinic

Health care providers' offices and clinics are a common place of employment for LPN/LVNs. It is important for the LPN/LVN to be aware that certain skills may be required in these settings that were not included in his or her educational program, such as phlebotomy and electrocardiography. In some cases, the health care provider teaches these skills, or certification classes may be available. The LPN/LVN should check his or her state's nurse practice act to ensure that any additional skills are within the scope of practice. Computer skills are essential in virtually every health care setting, and insurance coding skills may be necessary in smaller offices.

Salary in offices tends to be lower than that in hospitals and long-term care facilities. Often the benefits package is not as complete as in the other settings. The schedule of primarily days with minimal weekend work is a definite advantage. There is an opportunity to focus on prevention in these settings, as well as opportunities for patient teaching.

Insurance Companies

Insurance companies may employ LPN/LVNs in their preadmission and claims departments. These positions are office positions with few requirements involving manual dexterity. Companies usually require prior experience in medical-surgical nursing. The nurse's role may include performing basic physical examinations for potential policyholders or consultation for current policyholders. Practice environments largely determine the earning potential of the LPN/LVN in this field. Regional variables also determine earning capabilities.

Temporary Agencies

There are opportunities to work for staffing agencies. These agencies provide nurses to meet the staffing needs in a variety of health care facilities. The salary is usually very good, but sometimes the benefits package is limited. The LPN/LVN must be very flexible in order to adjust to various work settings when working for a temporary agency.

Advantages of employment with a temporary agency are the right to refuse an assignment and the variety of assignments available. When employed by a temporary agency, the LPN/LVN has the right to say no on a given day when called upon to work, which provides flexibility in one's personal schedule. The nursing experiences are more varied than when work­ing every day at the same facility on the same unit.

A disadvantage is the uncertainty that work is available. If the number of patients is low in a facility, temporary employees are not called to work, and so it is important for the new LPN/LVN to budget appropriately in the event of no work. Another disadvantage is that it may be difficult to create friendships or obtain the feeling of being the part of a team.

Travel Opportunities

Experienced nurses may explore opportunities to travel and work for specified periods in areas in need of nurses through a type of temporary agency with an expanded area of service. These agencies match employers' needs with nurses' experience and interest in living in that area for a time. Lodging is usually provided in addition to salary. This affords nurses who have the flexibility to travel the chance to visit an area and work there for a period of time.

Pharmaceutical Sales

Pharmaceutical sales companies sometimes employ nurses as sales representatives. These companies usu­ally require experience in specific areas and an expertise in science and pharmacology. Salary is usually based on sales. There is no direct patient care. Sales representatives contact health care providers, pharmacists, and nurses in various clinical settings to present the advantages of products and to teach about side effects and precautions.

Other Medical Sales

Opportunities are also available for nurses with companies selling medical supplies. Responsibilities and compensation are similar to those in pharmaceutical sales. Sometimes nurses in this line of work hold in-service programs at facilities to demonstrate product use. Products vary widely, from such items as incontinence products to surgical equipment.

The Military

Opportunities are available for the LPN/LVN in military service. Active duty and the reserves are options. Local recruiters can provide information regarding a military career. Benefits of serving in the military as a nurse include the opportunity to serve one's country and educational opportunities. Various programs assist with tuition if the LPN/LVN chooses to further his or her education.

Adult Day Services

Some communities may provide adult day services that require nursing supervision. These facilities are designed for individuals who require medical supervision while their family members work or take a break from the responsibility of care. The pace is relaxed, and the schedule is excellent. Many nurses find it to be a rewarding experience to work in a facility providing this kind of service to the adults and their family members who need it.

Schools

Opportunities are available in some communities to work as a school nurse. Health screening, emergency care, and health teaching are the major responsibilities. The nurse may work in one school or travel to different schools. Working only during the school year and during school hours is an advantage for nurses who themselves have children.

Public/Community Health

There are sometimes opportunities for LPN/LVNs with the public health department. Responsibilities usually include working in clinics and home visits. The nurse sometimes also participates in health inspections. Teaching is a major area of responsibility. The focus is on prevention. Day schedules are usually available. Salaries tend to be lower than in hospitals and long-term care facilities. In addition, community health opportunities include employment in areas such as weight-loss clinics, Head Start programs, and camp programs.

Outpatient Surgery

Work in a large number of outpatient facilities, especially for outpatient surgery, is available. The LPN/LVN is sometimes employed to prepare patients for surgery, as a scrub nurse, or to work in the recovery room under the supervision of an RN. This is typically a Monday-through-Friday position. Some facilities are freestanding, and others are part of a hospital complex.

Private Duty

The private duty nurse gives total care to one patient. The setting for the private duty nurse changes from patient to patient, but the job description is basically the same. This type of nursing is totally independent nursing care service when the nurse self-contracts. Private duty nursing takes place in the hospital, the home, or other facility and during travel abroad or in the United States. When performing private duty nursing, the LPN/LVN cares not only for the patient but also for the family. The nurse is paid directly by the patient or responsible person. When the setting for private duty nursing is in a health care facility, the nurse is expected to follow the policies and procedures of that facility.

In private duty nursing, the nurse is legally responsible for his or her own actions. If the nurse ever has any doubt about an order or procedure, he or she must obtain clarification from the health care provider before carrying out the order or procedure. It is important to keep charts carefully. In the home, the nurse can set up a type of record in which to list necessary items, such as medications given, vital sign measurements, and the conditions of the patient. This home record is sometimes requested by and released to the health care provider. The nurse returns any narcotics not used to the health care provider before leaving the assignment.

The major disadvantages of private duty nursing are the irregularity of assignments and the economic aspects. In private duty nursing, there is no certainty of work or payment. Also, the private duty nurse must keep accurate records for tax and Social Security purposes.

An advantage of private duty nursing is the option of working as many days as desired and the opportunity to accept an assignment for as long a period as desired. There are also more freedom and fewer restrictions in the workday.

Government (Civil Service)

Some LPN/LVNs work in a Veterans Administration (VA) hospital or other government hospitals. Advantages are competitive salary, benefits, retirement plans, and tuition reimbursement programs. In addition, many VA nurses feel rewarded by caring for veterans who have served their country in the military (U.S. Department of Veterans Affairs, 2012).

Occupational Health

The focus in occupational health nursing is on promoting wellness and preventing accidents. The emphasis is on safety, and administering first aid care. Job responsibilities include physical assessment, health surveys, insurance form preparation, and health education, as well as nursing intervention for patients injured in industrial accidents. The LPN/LVN works under the supervision of an RN or a health care provider. Depending on the size of the industrial or facility site, this type of nursing sometimes offers shifts and benefits different from those of other career opportunities.

Rehabilitation

This field requires responsibility for guiding the patient toward health and independence. The role of the rehabilitation nurse includes assisting patients to meet maximum functioning capabilities, caring for patients with disabilities or chronic disease, and working closely with not only the patient but the patient's family. An important aspect of rehabilitation nursing is collaboration with the rehabilitation team (Association of Rehabilitation Nurses, 2012).

Mental Health-Psychiatric Nursing

Mental health–psychiatric facilities employ LPN/LVNs in a variety of settings. Venues for this type of nursing vary from inpatient units in a general hospital to outpatient clinics, mental health agencies, and psychiatric hospitals. Residential rehabilitation facilities are another site in which the LPN/LVN works with patients experiencing mental health or psychiatric issues.

Hospice

Hospice nursing offers the opportunity to care for terminally ill patients in either an institution or a home setting. The qualifications for hospice nurses are to have a clear understanding of their own feelings concerning death and to understand the philosophy of the hospice setting. The nurse closely supports the patient and family without interfering with family interpersonal relationships. Advantages of hospice nursing are steady employment, an environment that is less formal, and opportunities to provide good bedside care that is concerned with pain relief and comfort measures. Disadvantages are the fact that the nurse cares only for dying patients and the possibility of having to travel to more than one home each shift (see Chapter 39).

Correctional Facility Nursing

Employment in correctional facilities is a growing field for nursing. Nurses work in county and city jails, as well as state and federal prisons. Duties vary from basic first aid care to extensive nursing care. Some larger state and federal prisons are finding it more beneficial and economical to house all medical services within the facility rather than transporting inmates to surrounding hospitals and clinics. This trend will increase the number of correctional nurses needed to adequately staff such units. Certifications in correctional nursing are available for nurses and nurse managers.

Autocratic Style

The autocratic leader retains all authority and responsibility and is concerned primarily with tasks and goal accomplishment. This type of leader assigns clearly defined tasks and establishes one-way communication with the group. The autocratic leader is firm, insistent, and dominating. Such a leader stresses prompt, orderly performance and uses power to intimidate or pressure employees who fail to adhere to expectations. This leader displays little trust or confidence in employees and therefore makes all the decisions. Because employees generally fear this type of manager, there tends to be some stifling of individual initiative and creativity (Cherry and Jacob, 2011; Yoder-Wise, 2011).

The autocratic style of leadership is appropriate in certain situations. In situations in which immediate action is required and there is no time for group decisions, the autocratic leader is able to take quick action. Autocratic leaders excel in times of crisis (e.g., cardiac arrest) and in situations of disorder (e.g., natural disaster); they often have the reputation for being able to get difficult assignments completed.

Democratic Style

The democratic style is a people-centered approach that allows employees more control and individual participation in the decision-making process. The emphasis is on team building and on collaboration through the joint effort of all team members. Democratic leaders function to facilitate goal accomplishment while stressing the self-worth of each individual. These leaders treat each staff member as an adult and expect the same in return. Criticism focuses on behaviors, not on personality, and its purpose is to promote growth and development of the staff.

The democratic style works best with mature employees who work well together in a group. This style sometimes does not work as well with ancillary staff, who in many cases need more direction. The group decision-making process sometimes seems slow and frustrating to those who expect prompt action on an issue. Disagreements are more likely and sometimes require more time to resolve. This style tends to demand more of the leader, but many employees value it for the sake of the professional growth and development of the staff that it facilitates. The results of the democratic leadership style in health care settings are evident in shared governance (an organized, systematic approach to decision making that enables nurses at all levels to participate), self-directed work teams, and staff committees concerned with quality improvement.

Laissez-Faire Style

This leadership style is often referred to as the “free-run style” or “permissive leadership.” This type of leader relinquishes control completely and chooses to avoid responsibility by delegating all decision making to the group. Laissez-faire leaders want everyone to feel free to “do their own thing,” and as a result there is no sense of direction unless provided by the group or an informal leader. This style sometimes works well with highly motivated professional groups (e.g., a research staff, but it seldom works well in health care settings because of the complexity of the work environment.

Situational Leadership

Situational leadership is a comprehensive approach to the issue of management that takes into account the style of the leader, the group being managed, and the situation at hand. Supporters of situational leadership contend that no single leadership style is best but rather that the best style for the manager to use is contingent on the situation at hand.

The basis of situational leadership theory is the flexibility of the manager in adapting to the needs of the individual or the work group. In a typical work setting, the manager may be directive in dealing with staff who are in orientation and simultaneously act as a coach for those on another shift who are more experienced but still need some guidance. For seasoned staff nurses, the manager is more of a support person. The situational leadership style enables professional growth for both manager and staff (Hill and Howlett, 2013).

Team Leading

Sometimes an LPN/LVN is assigned the role of team leader. This role entails assisting and guiding the nursing team in providing care for a select group of patients. The team leader assigns patients to each team member and takes responsibility for the delivery of care to patients, as well as for supervision of all members of the team, including nursing assistants. Duties of a team leader include the following:

An advantage of team nursing is the collaborative style that encourages each member of the team to help others.

Delegation

Delegation of tasks is an important aspect of patient care. Delegation of care refers to the act of making another individual responsible for a specific task. One of the benefits of delegation is that licensed personnel are allowed more time to focus on higher level tasks.

Delegation mandates clear communication of all aspects of the delegated care to the person completing the task. The nurse must take into account the job description, the legal responsibility, the educational level, the ability, and the licensure of the person to whom he or she is delegating complete care. The staff member performing the care must be able to perform tasks independently and must have the ability and knowledge to complete the task (see Coordinated Care box on the five rights of delegation). It is important not to assign care to an unqualified staff member. For example, the LPN/LVN may delegate ambulation of a patient to a certified nursing assistant, but the LPN/LVN is responsible for determining the degree of assistance necessary for the patient.

Time Management

Time management is an aspect that is sometimes difficult for the new LPN/LVN. For a new nurse, the patient load is often heavier than that during nursing school and there are added responsibilities as a licensed professional. It is important for the new LPN/LVN to evaluate his or her time management to determine whether time is being utilized effectively. Suggestions for time management are listed in the Coordinated Care box on prioritization and time management.

Nursing Informatics

Nursing informatics has become a well-recognized term since it was first introduced. The American Nurses Association (2008) recognized nursing informatics as a specialty that “integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice.” Numerous computer systems are available in the health care setting, and so nurses are trained on the particular system used at their place of employment. Nurses incorporate nursing informatics into the daily routine in various ways, including entering health care information into the patient's electronic medical record (EMR), docu­menting medication administration, and researching medical information from online sources. Both certifications and graduate degrees in nursing informatics are available.

Transcribing Health Care Providers' Orders

Health care providers convey orders for patient care through writing, telephoning, or verbalizing the orders to the nurse. The health care providers' order may be handwritten in the patient's records by the health care provider. In an attempt to prevent errors in transcription, many facilities are now requiring the health care provider to submit orders directly into the computer system of the facility. Some acute care facilities employ ward clerks, ward secretaries, or unit secretaries to transcribe the health care providers' orders. Conversely, in most long-term care facilities, there are no unit secretaries. In facilities that do employ unit secretaries, the secretaries usually do not work at night. In many facilities an expectation of the nurse is to transcribe the order from the patients' record if it was not submitted electronically. Some orders are difficult to read. If the nurse is in doubt, the best action is to clarify the order with the health care provider. It is advisable to review the orders while the health care provider is on the unit so that clarification can be obtained in person immediately rather than later over the phone (Figure 57-4). Also, if the written order seems unusual or does not seem congruous with the patient's condition, the nurse must clarify the order with the health care provider. It is imperative to understand each order before carrying it out.

The health care provider is in charge of directing the patient care, and nurses carry out these orders for care, unless the nurse believes that the orders are in error or will be harmful to the patient. In this case, it is necessary to contact the health care provider to confirm or clarify the orders. If the nurse still believes the orders to be inappropriate, the appropriate procedure is to immediately contact the nursing supervisor and put in writing why the orders are not being carried out. A nurse who carries out an erroneous or inappropriate order is at risk of being held liable for harm experienced by the patient. Nurses are responsible for their actions regardless of who told them to perform those actions.

The policies for verbal or telephone orders vary in different facilities. The nurse must check the facility's policy for accepting verbal or telephone orders. Orders given by telephone or verbal communication are more subject to error. If the nurse is responsible for accepting this type of order, he or she must be certain of its accuracy. The nurse should clarify the order by repeating it back to the person giving it and should document that this was done. This gives both people a chance to hear the order. A telephone or verbal order must always be written down immediately. If the order is given too rapidly, the nurse should ask the giver to repeat it more slowly. When the correct spelling of a medication is questionable, the nurse can refer to a list of commonly ordered medications or to the Physicians' Desk Reference. The nurse must be cautious about medications whose spellings look alike or similar and those that sound alike. Several medications sound alike but have very different actions (e.g., Xanax [alprazolam] and Zantac [ranitidine]; Xanax is an antianxiety agent, and Zantac is a histamine antagonist for the treatment of ulcers).

When the nurse transcribes (writes or types a copy of) health care providers' orders, a number of precautions must be used to prevent errors (see Medication Safety Alert box on precautions for transcribing orders).

When there is an order to discontinue or change a medication, the nurse should take the steps in the Medication Safety Alert box on the procedure for discontinuing or changing a medication (this procedure varies in different facilities).

Orders requiring transcription are those concerning diet, preoperative and postoperative instructions, all medical treatments, activity, procedures, medications, diagnostic imaging and other diagnostic studies, and laboratory tests. When a patient undergoes surgery, all preoperative orders are automatically canceled. The health care provider must rewrite the orders post­operatively if continuation of the orders is desired. Many health care providers have routine postoperative orders, which have been prepared beforehand. There is a protocol for each order according to the facility's policy. When the nurse transcribes any order, he or she must follow through all steps completely as described previously with medication orders.

Some drugs may be distributed as floor stock. Floor stock are medications that are distributed to the nursing unit in bulk (either individually wrapped or in bottles). In general, medications that are appropriate for floor stock are those that health care providers tend to prescribe routinely on an as-needed (prn) basis. Medication dispensing systems, such as computer-assisted or electronic devices, are variations of unit-dose and floor stock systems. For example, the Pyxis MedStation (Care Fusion Products) (Figure 57-5) has the capacity to carry a variety of medications, housed in individual compartments that the nurse can access after requesting the medication from a computerized screen. The MedStation often houses medications that are frequently used, such as floor stock and narcotics, as well as individual patient medication bins. All medications that nurses retrieve from the MedStation must be recorded in the system's computer. (See Chapter 21 for more detailed discussion of medication administration.)

Change-of-Shift Report

The LPN/LVN is often responsible for giving a change-of-shift report. The purpose of the change-of-shift report is to provide the staff on the next shift with pertinent information about the patient. The quality of nursing care that the patient receives is contingent on how well the staff on each shift communicate with the staff on other shifts.

The change-of-shift report may be given in person or documented on a recording device, or the report may be given by making rounds from patient to patient (Figure 57-6). Oral reports are given in a conference room with nurses from both shifts participating. When a recording device is used, the report is recorded before the end of the shift. This allows the nurses who are preparing to leave to finish last-minute tasks while the oncoming staff listens to the report. It is beneficial to allow time for clarification or updates before nurses leave the unit. Giving reports in person or on rounds allows immediate feedback. In all cases, patient confidentiality must be maintained.

Before beginning the report, the nurse should consider what information regarding the patient is important to communicate and should avoid reporting unnecessary information.

Typically, information that is considered important includes vital sign measurements (if abnormal), type of IV fluids (including rate of infusion, amount left to infuse, and IV site), intake, and output of feces, urine, and gastric secretions. Output from all drainage tubes and appearance of drainage should be reported. Any prn medications should be reported, including the time of administration and the effect, as well as the presence of and amount of patient-controlled analgesia used. Assessment data that are pertinent to the patient should be reported. Dressing changes, amount and color of exudate, and the condition of any incisions or wounds should be reported. Any abnormal signs and symptoms, such as dyspnea, tachycardia, or abnormal mental status or level of consciousness, as well as neurologic deficits, must be communicated to the oncoming shift. Accepted medical and nursing terminology should be used in the report (Boxes 57-10 and 57-11).

Malpractice Insurance

Malpractice insurance for nurses is becoming increasingly important in a society that has become litigious. Paying for the defense of a lawsuit and any possible judgment is beyond the ability of most people. To protect their employees and themselves against any legal and financial consequences that have potential to arise from provision of services, institutional employers carry malpractice liability insurance. Because individuals are responsible for their own actions, it is still possible for an employee to be sued personally. This is true even in states in which charitable immunity—the protection of nonprofit hospitals from legal liability—applies.

Some nurses choose to obtain a personal professional liability (malpractice) insurance policy separate from the employer's policy. The decision about whether to carry malpractice insurance is a personal choice. When making this decision, the nurse should consider his or her state's malpractice compensation law, as well as the amount and type of malpractice insurance that his or her facility carries. It is advisable to enlist the help of a knowledgeable expert to determine what, if any, additional amounts (dollar value) and type (occurrence or claims-based) of personal coverage is necessary or desired. (See Chapter 2 for further discussion of liability and professional liability insurance.)

Burnout

The term burnout has been used frequently over the years in health care. Maslach and Jackson (1986) identified burnout as a state of emotional exhaustion, depersonalization (responding in an impersonal manner toward patients/clients), and reduced sense of personal accomplishment in one's work, seen among human service, education, business, and government professions. Burnout in nursing today is often attributed to higher acuity levels in facilities, less available support staff, and the nursing shortage. Burnout may lead to more job turnover and patients' dissatisfaction with care being received from nurses (Vahey et al., 2004). It is important for nurses to be aware of their feelings and emotional state in order to be alert to signs of burnout.

Chemically Impaired Nurses

The number of nurses who illegally use drugs and abuse alcohol will continue to increase as addiction to drugs and alcohol increases in the general population. Some of the excuses that nurses give for resorting to using drugs, alcohol, or both include job-related stress, inability to cope with changes in the workplace, overwhelming personal responsibilities, a feeling of frustration and helplessness in their personal and professional lives, and easy access to drugs.

Each state's board of nursing has implemented nurses assistance programs to meet the needs of chemically impaired nurses. It is believed that nurses should receive the same care and support that other people with an addiction receive. With proper treatment, nurses can remain employed in their field and be able to provide quality care to their patients.

It is the nurse’s responsiblity to himself or herself and to the patients being cared for to avoid the abuse of prescription or nonprescription medications. If a nurse or a coworker does become addicted to drugs or alcohol, the only option is to seek immediate assistance. Referring oneself or someone else to the state board of nursing for voluntary treatment and a rehabilitation program may not only save a career; it may also save a life. See Chapter 35 for further discussion of chemical dependency.