Implementing Nursing Care

Implementing Nursing Care
Chapter 19 Implementing Nursing Care Implementation constitutes the fourth step of the nursing process. After the nursing diagnoses have been identified, nurses initiate the nursing interventions most likely to achieve the goals and expected outcomes that support or improve the patient’s health status. Nursing interventions can be direct or indirect. Ideally, nursing interventions should be evidence based and should use the most up-to-date approaches to solving patient problems.

Nursing Intervention A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Interventions include direct and indirect care measures aimed at individuals, families, and/or the community. Interventions include direct and indirect care measures aimed at individuals, families, and/or the community. Direct care interventions are treatments performed through interactions with patients. Indirect care interventions are treatments performed away from the patient but on behalf of the patient or a group of patients. [These are discussed further in a later slide.] [See Box 19-1 Domains of Nursing Practice on text p. 253.]

Case Study Miranda is a nursing student who is assigned to Mr. Bagley. Mr. Bagley is a 52 y/o Asian male admitted to the medical-surgical unit for management of tuberculosis. Mr. Bagley travels internationally because of his executive position with a global company and most likely contracted tuberculosis during his travels. Mr. Bagley’s current symptoms are shortness of breath, night sweats, muscle pain, fatigue, and a productive cough. Miranda reviews Mr. Bagley’s plan of care to determine which interventions are to be implemented first. Throughout the lesson, we will give examples of implementing nursing care with respect to Mr. Bagley’s case. Keep him in mind as we discuss the process.

Critical Thinking in Implementation
Review the set of all possible nursing interventions. Review all possible consequences associated with each possible nursing action. Determine the probability of all possible consequences. Make a judgment of the value of that consequence to the patient. Given the complexity of interventions, critical thinking is necessary in choosing which of a number of alternative approaches to use in the time available to act. The critical thinking model described in Chapter 15 provides a framework for how to make decisions when implementing nursing care. Before nurses proceed with an intervention, they need to consider what they know about the purpose of the interventions, the steps in performing the interventions correctly, and the medical condition of the patient and the patient’s expected response. [See also Fig on text p. 255 Critical thinking and the process of implementing care.]

Standard Nursing Interventions
Clinical practice guidelines and protocols Standing orders NIC interventions ANA Standards of Professional Practice Standards of nursing practice offer guidelines for the selection of interventions. Clinicians within a health care agency sometimes choose to review the scientific literature and their own standard of practice to develop guidelines and protocols in an effort to improve their standard of care. A nursing care plan is unique to the patient. Therefore, interventions are individualized. However, patients do have common health care problems, and standardized interventions for those health problems make it quicker and easier for you to intervene. These interventions are evidence based. NIC interventions offer a level of standardization to enhance communication of nursing care across settings. If your college/university uses NIC and NOC, please spend time explaining how students use this in their plan of care. [See also Box 19-2 on text p. 256 Purposes of the Nursing Interventions Classification.] The ANA Standards of Professional Nursing Practice are to be used as evidence of the standard of care that registered nurses provide their patients.

Protocols and Standing Orders
Guidelines and Protocols Standing Orders Systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations A preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems A guideline guides interventions for specific health care problems or conditions such as low back pain, dizziness, or deep vein thrombosis. The guideline is developed on the basis of an authoritative examination of current scientific evidence. [Ask students what types of standing orders they can think of. ANSWERS may include medications for cardiac dysrhythmias or diabetic emergencies.]

Implementation Process
Reassessing the patient Reviewing and revising the existing nursing care plan Organizing resources and care delivery Anticipating and preventing complications •You will need to prepare to implement your interventions to provide efficient, safe, and effective nursing care. •When you reassess your patient, you collect additional data and identify any new patient needs. At this point, you may need to modify your plan of care. •To organize resources and deliver care to your patient, you need to identify the facility’s resources and personnel. So, an orientation to the facility’s physical layout, equipment, and operations is a necessity. Creating a favorable environment for the patient to receive care is another part of organizing resources. •It is necessary to anticipate and prevent complications that might occur while patients are hospitalized. Risks to patients come from both illness and treatment. Methods used to ensure that you administer physical care techniques appropriately include protecting yourself and the patient from injury, using proper infection control practices, staying organized, and following applicable practice guidelines. [Ask students to identify some complications we can help patients to avoid. ANSWERS may include coughing and deep breathing to prevent atelectasis; turning to prevent pressure ulcers; medicating to reduce pain; and promoting urine and bowel evacuation.] [See also Fig on text p. 257 The concept map for the text’s case study.]

Anticipate and Prevent Complications
Identify risks to the patient. Adapt interventions to the situation. Evaluate the relative benefit of a treatment vs. the risk. Initiate risk prevention measures. •These four steps help you anticipate and prevent complications. [Ask the class to evaluate the relative benefit of a treatment versus the risk. Discuss.]

Modification of an Existing Written Care Plan
Revise data assessment. Revise the nursing diagnoses. Revise specific interventions. Determine how to evaluate whether you have achieved outcomes. After you reassess your patient, review the care plan, compare assessment data to validate the nursing diagnoses, and determine whether the nursing interventions remain the most appropriate for the clinical situation.

Quick Quiz! 1. Nurse-initiated interventions are A. Determined by state Nurse Practice Acts. B. Supervised by the entire health care team. C. Made in concert with the plan of care initiated by the physician. D. Developed after interventions for the recent medical diagnoses are evaluated. Answer: A

Implementation Skills
Cognitive skills Application of critical thinking in the nursing process Interpersonal skills Developing a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her family Psychomotor skills Integration of cognitive and motor activities These three skills are needed to implement direct and indirect nursing interventions. No intervention should be automatic. Nurses need to think and anticipate how to individualize care for their patients. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the patient and family. Psychomotor skills require the integration of cognitive and motor activities. Remember, it will take time and practice to acquire a psychomotor skill. So, make sure to take advantage of your time in the nursing skills lab—with human patient simulation, with interactive technology and with each other—to hone your skills and confidence.

Direct Care vs. Indirect Care
Treatments performed through interactions with patients Examples: -Medication administration -Insertion of an intravenous (IV) infusion -Counseling during a time of grief Treatments performed away from the patient but on behalf of the patient or group of patients -Managing the patient’s environment (e.g., safety and infection control) -Documentation -Interdisciplinary collaboration Nurses provide a wide variety of direct care measures. All direct care measures require competent and therefore safe practice. Show a caring approach each time you provide direct care. Nurses spend much time in indirect and unit management activities. Communication of information about patients (e.g., change-of-shift report, consultation) is critical, ensuring that direct care activities are planned, coordinated, and performed with the proper resources.

Case Study (cont’d) Miranda searches the hospital’s database for additional information on tuberculosis. True or False: A clinical practice guideline is a collection of institutional policies that assist nurses, physicians, and other health care providers in making decisions about appropriate health care for specific clinical situations, such as the management of tuberculosis. Answer: False! Rationale: A clinical practice guideline or protocol is a systematically developed set of statements that assist nurses, physicians, and other health care providers in making decisions about appropriate health care for specific clinical situations.

Direct Care Activities of Daily Living (ADLs) Instrumental
Activities of Daily Living (IADLs) Physical care techniques Lifesaving measures To complete any nursing procedure, you need to know the procedure, its frequency, the steps, and the expected outcomes. Activities of daily living (ADLs) are activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing, and grooming. You will perform these activities of direct care as you carry out the nursing interventions you have selected for your patients. You will want to be cognitive of mobility, pain, confusion, and fatigue that patients may be experiencing. IADLs: These instrumental ADLs include the day-to-day activities a person performs such as shopping, preparing meals, writing checks to pay the bills, and taking medications. Physical care techniques are the activities that nurses perform while rendering care. These including turning, positioning, and administering care, as well as performing tasks such as Foley catheter insertion, NG tube insertion, IV insertion, and administering medications. Lifesaving measures are those activities you perform when a patient’s physiological or psychological state is threatened. They include CPR, administering emergency medications, and falls prevention. Note that when you delegate aspects of a patient’s care, you are responsible for ensuring that each task is assigned appropriately and is completed according to the standard of care.

Controlling for adverse reactions
Direct Care (cont’d) Counseling Teaching Controlling for adverse reactions Preventive measures Counseling involves providing emotional, intellectual, spiritual, and psychological support to your patients. [Box 19-3 (on text p. 260) presents examples of counseling strategies.] Teaching is a constant part of nursing. Teaching occurs formally and informally and involves patients and their family members. We will further discuss this in Chapter 25, Patient Education. An adverse reaction is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. Before performing any skill or task, you need to know the possible adverse effects or reactions that can occur. Preventive nursing actions promote health and prevent illness to avoid the need for acute or rehabilitative health care. Prevention includes assessment and promotion of the patient’s health potential, application of prescribed measures, health teaching, and identification of risk factors for illness and/or trauma. [Shown is Fig from text p. 261.]

Case Study (cont’d) Mr. Bagley’s plan of care calls for oxygen therapy to improve his respiratory status. A preprinted document that contains orders for the conduct of routine therapies, such as oxygen therapy, is referred to as a __________ _____________. Answer: standing order Rationale: A standing order is a preprinted document that contains orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.

Quick Quiz! 2. You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5. Answer: D

Indirect Care Communicating nursing interventions
Written or oral Delegating, supervising, and evaluating the work of other health care team members These measures are actions that support the effectiveness of direct care interventions. Many of these measures may be managerial. Box 19-4 (on text p. 262) presents examples of indirect nursing interventions. Communication is imperative to ensure that direct care activities are planned, coordinated, and performed with the proper resources. Many health care agencies use interdisciplinary care plans. Most important, all interventions must be documented correctly and in the proper time sequence. In Chapter 26, documentation will be discussed more thoroughly. Staff in many institutions develop interdisciplinary care plans—plans that represent the contributions of all disciplines caring for a patient. Oftentimes, nurses who develop the patient’s plan of care do not deliver the care. Some activities are performed by other members of the health care team. Chapter 21 will present the ten principles of delegation as delineated by the American Nurses Association and the National Council of State Boards of Nursing.

Case Study (cont’d) Mr. Bagley is placed on Isolation Precautions.
Isolation Precautions as a treatment intervention are an example of which type of care? A. Direct B. Indirect C. Prevention D. Safety Answer: B Rationale: Indirect care interventions are treatments performed away from the patient but on behalf of the patient or group of patients. Implementing Isolation Precautions is an example of providing indirect care by managing the patient’s environment.

Achieving Patient Goals
Nurses implement care to meet patient goals. At times, multiple interventions may be needed. Priorities help nurses to anticipate and sequence nursing interventions. Patient adherence means that patients and families invest time in carrying out required treatments. Another way to achieve patient goals is to help patients adhere to their treatment plan. When delivering care, it will be necessary for you to incorporate your patient’s health beliefs, culture, lifestyle patterns, and patterns of wellness.

Chapter 20 Evaluation •Evaluation is the final step of the nursing process. In this step, you determine if your patient’s condition or well-being has improved. Nurses conduct evaluation measures to determine whether they have met expected patient outcomes, not whether their nursing interventions were complete. It is important to remember that expected outcomes are the standards against which the nurse judges whether goals have been met and care was successful. •Evaluation is a step of the nursing process that includes two components: examination of a condition or situation and judgment as to whether change has occurred.

Critical Thinking and Evaluation
Evaluation is an ongoing process. If outcomes are met, patient goals are met. Positive evaluations occur when nurses meet desired outcomes. Positive evaluations lead nurses to conclude that interventions were successful. •Evaluation, the final step of the nursing process, is an ongoing process that occurs whenever you have contact with a patient. •Think about the sequence used during evaluations and the conclusions that can be drawn. •Positive evaluations occur when desired outcomes occur, leading you to conclude that the nursing interventions effectively met the patient’s goals. •Unmet or undesirable outcomes indicate that interventions did not minimize or resolve the actual problem or avoid a potential problem. •An unmet outcome reveals that the patient has not responded to interventions as planned. •When expected outcomes do not materialize, the nurse needs to change the plan of care by trying different therapies or changing the frequency or approach of existing therapies. [See Fig on text p. 266 Critical thinking and the evaluation process, and Fig on text p. 267 Critical thinking and evaluation, for further discussion.]

Case Study Miyoko is a nursing student assigned to Mr. Mashoud, a 48-year-old Arab male admitted to the hospital with kidney stones. Upon Mr. Mashoud’s admission to the emergency department (ED) this morning, he was experiencing excruciating pain. The treatment plan for Mr. Mashoud includes keeping him in the hospital until he passes the stones and adjusting his pain medication as needed.

Case Study (cont’d) Miyoko evaluates Mr. Mashoud’s response to the medication therapy to update his care plan. Miyoko assesses Mr. Mashoud’s pain before NSAID administration and then approximately one hour after administration. Miyoko knows that evaluation is an ____________ process that occurs whenever contact with a patient occurs. Answer: ongoing

Standards for Evaluation
Nursing care helps patients Resolve actual health problems Prevent potential problems Maintain a healthy state •The evaluation process is an integral step in achieving these goals. •A nurse must respect the patient and family as core members of the health care team, meaning that the patient and family must be actively involved in the evaluation process.

Standards for Evaluation (cont’d)
American Nurses Association (ANA) Defines standards Competencies include: Being systematic Using criterion-based evaluation Collaborating Using ongoing assessment data to revise care plan Communicating results •The American Nurses Association (ANA) defines standards of professional nursing practice, which include standards for the evaluation step of the nursing process (see Chapter 1). •The standards define the duties that all registered nurses are expected to perform competently. •When evaluating, be systematic and use criterion-based evaluative measures. •Collaborate with patients and other professionals as appropriate. •Use ongoing assessment data to revise the care plan for the best results. •Clearly communicate the results of the plan to your patients and their families. •It is important to ensure that only appropriate interventions are used with each patient.

Criterion-Based Standards
Criterion-based standards for evaluation are the physiological, emotional, and behavioral responses that are a patient’s goals and expected outcomes. Note that criterion-based standards are both goals and expected outcomes. They include physiological, emotional, and behavioral responses.

Criterion-Based Evaluation
Goal = Expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state Expected outcome = End result that is measurable, desirable, and observable and translates into observable patient behaviors Nursing-sensitive outcome •You evaluate nursing care by knowing what to look for as described in the criterion-based standards included in a patient’s goals and expected outcomes. The goals and outcomes help you judge a patient’s response to care objectively. •Goals are often based on standards of care established for safe practice. For example, the Infusion Nurses Society (INS) has a standard of care for preventing the IV complication known as phlebitis. When a nurse cares for a patient with an IV line, the goal is to make sure that the IV site remains free of phlebitis. [What other examples of goals can you think of?] •When nurses apply the nursing process, a nursing-sensitive outcome is a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions. [Ask the students: What are some examples of nursing-sensitive outcomes? Examples of nursing-sensitive outcomes include reduction in pain frequency, incidence of pressure ulcers, and incidence of falls.] [See Box 20-1 on text p. 268 Evidence-Based Practice, for further discussion.] •A valuable resource for selecting outcomes is the Nursing Outcomes Classification (NOC) (see Chapter 18). [See Table 20-1 on text p. 268 Linkages Between Nursing Outcomes Classification and Nursing Diagnoses for further discussion.]

Case Study (cont’d) Miyoko determines the patient outcomes for Mr. Mashoud based on his reaction to the medication regimen. Which of the following is an end result that translates into observable patient behaviors that are measurable and desirable? A. Unexpected outcome B. Expected outcome C. Sensitive outcome D. Accomplished outcome Answer: B

Collaborate and Evaluate Effectiveness of Interventions
Collaborate with the patient and family. Use evaluative measures. Interpret and summarize findings. Document results. Revise care plan. •Determining a patient’s response to nursing care requires the use of evaluative measures, which are simply assessment skills and techniques. [See Table 20-2 on text p. 269 Evaluative Measures to Determine the Success of Goals and Expected Outcomes for examples of evaluative findings.] The intent of evaluation is to determine whether known problems have remained the same, improved, worsened, or in any way changed. •Next, you will need to interpret and summarize the findings. [More discussion on this step is provided on the next slide.] •Acute changes occur frequently and chronic changes occur over a period of time and can be subtle. [See also Table 20-3 on text p. 270 Examples of Objective Evaluation of Goal Achievement, for further discussion.] •Documentation and reporting are a most important part of the evaluative process. It will be important to describe the evaluative measures. This can be done via nursing progress notes, assessment flow sheets, and shift reports. •At this juncture, you will be able to adjust the plan of care or discontinue it. Unmet or partially met goals require you to continue the interventions. Your choice will be to discontinue or modify the plan of care. The question you will ask is, “Do the goals and expected outcomes or interventions need to be modified?” [Image is Fig on text p. 269.]

Objective Evaluation 1. Examine the outcome criteria.
2. Evaluate the patient’s actual response. 3. Compare the established outcome criteria with the actual response. 4. Judge the degree of agreement between the outcome criteria and the response. 5. If no or only partial agreement, what are the barriers? [What are the steps needed to objectively evaluate the degree of success in achieving outcomes of care?] •The steps are (1) Examine the outcome criteria to identify the exact desired patient behavior or response; (2) evaluate the patient’s actual behavior or response; (3) compare the established outcome criteria with the actual behavior or response; (4) judge the degree of agreement between outcome criteria and the actual behavior or response; and (5) if there is no agreement (or only partial agreement) between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? Why did they not agree?

Case Study (cont’d) Miyoko follows which steps to objectively evaluate the degree of success in achieving outcomes of care for Mr. Mashoud? (Select all that apply.) A. Identify the exact desired patient behavior. B. Evaluate the patient’s actual behavior. C. Compare the outcome criteria with the actual behavior. D. Assess the desired behavior and anticipated outcome. E. Judge the degree of agreement between the outcome criteria and the actual behavior. Answer: A, B, C, E To objectively evaluate the degree of success in achieving outcomes of care, perform the following steps: 1. Examine the outcome criteria to identify the exact desired patient behavior or response. 2. Evaluate the patient’s actual behavior or response. 3. Compare the established outcome criteria with the actual behavior or response. 4. Judge the degree of agreement between outcome criteria and the actual behavior or response. 5. If there is no agreement (or only partial agreement) between the outcome criteria and the actual behavior or response, identify the barriers and the rationale for the barriers.

Revising a Care Plan Has the goal been met? Does the patient agree?
Discontinuing a care plan: Has the goal been met? Does the patient agree? Document the discontinued plan. •Each time you evaluate a patient, you determine whether the plan of care continues or if revisions are necessary. •If your patient meets a goal successfully, discuss your evaluation with the patient. If you and the patient agree, discontinue that portion of the care plan. [Ask the class: Why is it important to document a discontinued plan? To keep other nurses informed so they don’t unnecessarily continue interventions for that part of the plan.] •Documentation of evaluative findings allows all members of the health care team to know whether or not a patient is progressing.

Quick Quiz! 1. Your patient has met the goals set for improvement of ambulatory status. You would now A. Modify the care plan. B. Discontinue the care plan. C. Create a new nursing diagnosis that states goals have been met. D. Reassess the patient’s response to care and evaluate the implementation step of the nursing process. Answer: B

Revising a Care Plan (cont’d)
Modifying a care plan: Reassessment Redefining diagnoses Goals and expected outcomes It sometimes becomes necessary to collect evaluative measures over time to determine whether a pattern of change exists. •If goals are unmet or are only partially met, you should continue the intervention. •You may need to create a new plan of care and redefine priorities to achieve goals. For example, if the original goal was to teach the patient to correctly prepare and self-administer insulin, but the patient develops a tremor that makes it impractical for him to administer the medication himself, the care plan could be revised so that a family member assumes this task to meet the goal of care. •When modifying a plan, a complete reassessment is necessary. Reassessment requires critical thinking. •An important step in critical thinking is noting how the patient is progressing and how problems are resolving or worsening. •After reassessment, determine which nursing diagnoses are accurate for the situation. •Then, review the goals and expected outcomes for necessary changes.

Modifying a care plan: Interventions Appropriateness of the intervention Based on the standard of care Correct application of the intervention A patient’s nursing diagnoses, priorities, and interventions sometimes change as a result of evaluation. •The evaluation of interventions examines two factors: the appropriateness of the intervention selected, and the correct application of the intervention. Appropriateness is based on the standard of care for a patient’s health problem. •Increasing or decreasing the frequency of interventions is another approach to ensure appropriate application of an intervention. You adjust interventions on the basis of the patient’s actual response to therapy and your previous experience with similar patients. •During evaluation, you may find that some planned interventions are designed for an inappropriate level of nursing care. If you need to change the level of care, substitute a different action verb, such as assist in place of provide, or demonstrate in place of instruct. •Remember that Evaluation is a continuous process. [Ask the class: Why is it a good idea to consult with other, especially more experienced, nurses? Consulting with other nurses often yields suggestions for improving the care delivery approach.]

Quick Quiz! 2. You have finished with several nursing interventions. To evaluate interventions, you need to examine the: A. Appropriateness of the interventions and the correct application of the implementation process. B. Nursing diagnoses to ensure that they are not medical diagnoses. C. Care planning process for errors in other health care team members’ judgments D. Interventions of each nurse to enable the nurse manager to correctly evaluate performance. Answer: A

Modifying a care plan: Unmet patient needs When a goal is not met, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to identify necessary changes to the plan. By consistently incorporating evaluation into practice, you minimize errors and ensure that the patient’s plan of care is appropriate and relevant. •Occasionally during evaluation, you discover unmet patient needs. This is normal. The nursing process is a systematic, problem-solving approach to individualized patient care, but many factors can affect each patient with health care problems. •For unmet patient needs, reassess the patient, determine accuracy of the nursing diagnosis, establish new goals and expected outcomes, and select new interventions. •Patients with the same health care problem are not treated the same way. As a result, you sometimes make errors in judgment. •Determining that each goal and expected outcome is realistic for the problem, the cause, and the time frame is particularly important. Unrealistic expected outcomes and time frames make goal achievement difficult. •The systematic use of evaluation provides a way for you to catch these errors.

Chapter 21 Managing Patient Care
Regardless of the type of setting in which you eventually choose to work as a staff nurse, you will be responsible for using organizational resources, participating in organizational routines while providing direct patient care, using time productively, collaborating with all members of the health care team, and using certain leadership characteristics to manage others on the nursing team.

Entry Level Competencies
The National Council of State Boards of Nursing (NCSBN) identified competencies that registered nurses (RNs) and licensed practical/ vocational nurses need on entry to practice. Three of these are: Demonstrate nursing knowledge and display confidence in knowledge base. Demonstrate knowledge of roles, responsibilities, and functions of a nurse. Recognize own limitations and see support of validation of decisions as needed. [Ask the class: What other competencies do you think would be important for an entry level nurse? Discuss the other nine competencies listed below and in Box 21-1 on text p. 275.] •Possess a systems focus to see the big picture. •Understand the environment of care. •Be able to manage the care of patients. •Be able to critically think as demonstrated by assessment of problem, identification of solution, implementation of solution, evaluation of care, and follow-up of care. •Communicate effectively with physicians and health care team members. •Work as a team member collaborating with health care team members. •Have a patient orientation and focus, with actions focused on patient and patient needs. •Respect the rights, beliefs, wishes, and values of patients. •Be a patient advocate.

Empowered Nursing Team
Includes nurse executive, nurse manager, and nursing staff Nurse executive possesses many roles: Ethical leader Business leader Quality of care promoter Cost-effectiveness promoter Building a nursing team starts with a nurse executive, who is often vice president or director of nursing. Box 21-2 (on text p. 275) identifies the characteristics of an effective leader. Perhaps the most important responsibility of the nurse executive is to establish a philosophy for nursing that enables managers and staff to provide quality nursing care.

Empowered Nursing Team (cont’d)
Philosophy of care Professional nursing staff’s values and concerns for the way they view and care for patients Selection of nursing care delivery model that supports professional nursing practice Selection of a management structure that supports professional nursing practice Selection of a nursing care delivery model and a management structure that supports professional nursing practice are essential to the philosophy of care. Philosophy of care focuses on nursing unit purpose; patient, family, and staff involvement; and work unit standards of care. Work unit standards of care consist of selecting a management structure that supports professional nursing practice.

Magnet Recognition Magnet hospitals typically have clinical promotion systems and research and evidence-based practice. Nurses have professional autonomy over their practice and control over the practice environment. Magnet hospitals empower the nursing team to make changes and be innovative. This results in a strong collaborative relationship among team members and improved patient quality of care outcomes. One way of creating an empowering work environment is through the Magnet Recognition Program. A Magnet hospital has a transformed culture with a practice environment that is dynamic, autonomous, collaborative, and positive for nurses. The culture focuses on concern for patients. Professional nurse councils at the organizational and unit levels are one way to create an empowerment model. An effective empowerment model leads to a staff that feels valued and has increased autonomy and a work environment that promotes job satisfaction. [See Box 21-3 on text p. 275 Evidence-Based Practice: Magnet Hospital Work Environment Characteristics and Outcomes.]

Case Study Jennifer is a nursing student who is assigned the following three patients: Mrs. Sinclair, who is scheduled for surgery to repair a fractured right hip Mr. Timmons, who has finished lunch and is ready for pain medication Mr. Dodson, who has a postoperative wound infection and is due for antibiotic medication [Ask the class: If you were Jennifer, which patient would be your first priority? Discuss.]

Nursing Care Delivery Model
Assists nurses in achieving desirable outcomes for their patients Results in success via the following factors: Decision-making authority for nurses Effective methods of communicating with colleagues In effective nursing models, the registered nurse is able to provide faster diagnosis and intervention, which promotes a safer patient environment.

Nursing Care Delivery Models (cont’d)
Team Nursing Total Patient Care Primary Nursing Case Management [Refer to Table 21-1 on text p. 276.] Three common models are team nursing, total patient care, and primary nursing. Team nursing developed in response to the severe nursing shortage following World War II. Total patient care delivery was the original care delivery model developed during Florence Nightingale’s time. This model disappeared in the 1930s and became popular again during the 1970s and 1980s, when the number of RNs increased. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and professional relationships among staff members. The model became more popular in the 1970s and early 1980s as hospitals began to employ more RNs. Primary nursing supports a philosophy regarding nurse and patient relationships. Case management is a care management approach that coordinates and links health care services to patients and their families while streamlining costs and maintaining quality.

Team Nursing Collaborative care style that encourages each member of team to work with and help the other members Hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members Decision making occurs at clinical level Emphasis in the Team Nursing model is on a high level of autonomy for team leader. [See also first row in Table 21-1 on text p. 276.]

Total Patient Care Registered nurse works directly with patient, family, and health care team members. RN is responsible for patients during shift of care, although care can be delegated. Approach may not be cost-effective owing to high number of registered nurses needed. Patient satisfaction is high. Total patient care emphasizes a high degree of collaboration with other health care professionals. [See also second row in Table 21-1 on text p. 276.]

Primary Nursing One primary registered nurse assumes responsibility for caseload. Communication is lateral from nurse to nurse and from caregiver to caregiver. Flexible model uses a variety of staffing levels and mixes. RN works with a limited number of patients. Although an emphasis on continuity of care can be facilitated with this model, one disadvantage is that an associate nurse cannot change the care plan without discussing with primary nurse. [See also third row in Table 21-1 on text p. 276.]

Case Management Collaborative process of assessing, planning, facilitating, and advocating for options and services to meet an individual’s health needs Clinicians oversee the management of patients with specific, complex health problems and are usually held accountable for some standard of cost management and quality. Often the case manager is an advanced practice nurse, who helps improve patient outcomes via specific interventions. Case management is a care management approach that coordinates and links health care services to patients and their families while streamlining costs and maintaining quality. Communication and use of available resources promote quality cost-effective outcomes in this model. The case management model emphasizes supervision, not necessarily providing direct care, but overseeing the care delivered by other staff and health care professionals.

Decision Making Decentralized management means that decision making occurs at the level of the staff. Encompasses Responsibility: duties and activities an individual is employed to perform Autonomy: independent decisions about patient care Authority: legitimate power to give commands and make final decisions specific to a given position Accountability: answerable for the actions Decentralized management structure has the advantage of creating an environment in which managers and staff become more actively involved in shaping the identity and determining the success of a health care organization. Thus, it is the manager who directs and supports decision making—an important tool for nurses. [See Box 21-4 on text p. 277 Responsibilities of the Nurse Manager.] Working in a decentralized structure has the potential for greater collaborative effort, increased competency of staff, increased staff motivation, and ultimately a greater sense of professional accomplishment and satisfaction. [Ask the class: What are some advantages and disadvantages of a decentralized management structure?]

Quick Quiz! 1. A travel nurse has taken an assignment at a health care facility where nurses assume responsibility for a caseload of patients over a period of time. This type of nursing exemplifies A. Team nursing. B. Primary nursing. C. Functional nursing. D. Decentralized management. Answer: B

Staff Involvement Establishing nursing practice or problem-solving committees or professional shared governance councils Nurse/physician collaborative practice Interdisciplinary collaboration Staff communication Staff education Staff involvement results in promoting empowerment, synthesizing shared perspectives, enhancing mutual respect, and growing in knowledge. An open communication system that fosters respect, trust, shared decision making, and teamwork among all team members is critical for achieving quality patient care. Interdisciplinary collaboration leads to decreased patient mortality, decreased health care costs, and increased nurse job satisfaction. A manager’s greatest challenge, especially if a work group is large, is communication with staff. The nurse manager is responsible for making learning opportunities available so staff members remain competent in their practice. [Figure 21-1 from text p. 278 is shown.] [Discuss shared governance.]

Leadership Qualities Dependable Problem Solver Communicator Competent
Evaluator Delegator Accountable Coordinator Educator Respect is a quality a leader must extend and receive, in addition to the following qualities.

Clinical Care Coordination
Leadership Skills Clinical Care Coordination Team Communication Delegation Knowledge Building Integrating leadership qualities into the nursing role results in these skills, contributing to high-quality patient care, reflecting on individual needs, considering alternatives, and evaluating interventions. These leadership skills lead to timely and effective patient care, starting with clinical care coordination.

Clinical Care Coordination
Clinical Decisions Priority Setting Organizational Skills Use of Resources Time Management Evaluation Activities of clinical care coordination require the use of critical reflection, critical reasoning, and clinical judgment. Clinical decision making begins with a complete patient assessment. This process is covered in Chapters 16 through 20. Implementing a plan of care requires you to be effective and efficient. Organizational skills are crucial to implementation. The process of evaluation compares actual patient outcomes with expected outcomes.

Priority Setting Determine which patient’s needs should be addressed first: High priority: immediate threat to patient survival or safety Intermediate priority: nonemergent, non–life threatening Low priority: actual or potential problems may or may not be directly related to patient’s illness or disease Priority setting allows nurses to attend to situations in the proper sequence, without jeopardizing patient care.

Case Study (cont’d) Mrs. Sinclair’s surgery is scheduled for 1 pm. She has never had surgery before and is very nervous and moving restlessly in bed. She is reluctant to talk, but her preoperative checklist is not yet completed, and she needs to be escorted to surgery in 30 minutes. [Ask the class: After reading these details about Mrs. Sinclair, do you have enough information to know which patient Jennifer should attend first?]

Case Study (cont’d) Mr. Timmons had abdominal surgery 2 days ago for colon tumor removal. He has finished his lunch and is ready for pain medication. He is preparing to get out of bed to walk down the hall. [Ask the class: With this information, would you make the same decision about which patient first needs Jennifer’s attention?]

Case Study (cont’d) Mr. Dodson has a postoperative wound infection. His wet-to-dry abdominal dressing needs to be changed, and he needs his next dose of antibiotic. [Ask the class: Of the three patients assigned, which patient should Jennifer help first?]

Case Study (cont’d) Jennifer stays with Mrs. Sinclair to assess her new symptoms and complete her preoperative checklist. She sends a unit clerk to check on Mr. Timmons. Once Mrs. Sinclair’s checklist is completed, she stops by Mr. Timmons’ room to assess his pain and administer his medication. She then verifies Mr. Dodson’s identification and administers the antibiotic, and next completes the dressing change. [Ask the class: Is this the order of priority you would have used? Discuss.]

Organizational Skills
Perform tasks correctly. Perform the correct tasks. Utilize resources. Manage time. Evaluate outcomes. Progress to an improved level of health. Organizational skills enable the nurse to proceed with patient care in an orderly manner.

Time Management Remain goal oriented. Identify priorities.
Establish personal goals. Coming full circle, priority surfaces again in meeting patient needs in a timely manner. Time management requires ability to anticipate daily activities, continue these activities, and avoid interruptions. Thus, one must remain goal oriented. [See Box 21-5 Principles of Time Management on text p. 281.]

Evaluate Evaluate process. Evaluate patient response.
Evaluate therapy efficacy. Evaluate patient and expected outcomes. At the heart of good organizational skills is constant inquiry into the patient’s condition and progress toward an improved level of health. Just staying focused on a task does not guarantee an effective outcome, so evaluation is key.

Case Study (cont’d) When Jennifer assesses Mr. Timmons’ pain, she discovers that his pain is still 8 out of 10 following Percodan 20 mg every 6 hours. Patient-controlled analgesia (PCA) with morphine was removed 4 hours ago. She determines that his current pain medication is insufficient to control his pain and requests a change in his medication. The evaluation of a process often leads to a new intervention.

Team Communication Respect others’ ideas. Share information.
Stay informed. Strive to improve your communication. Share expectations of communication. Use structured communication techniques Communication is important in any realm, especially in the health care setting. Strategies you can use to improve your communication with physicians include addressing the physician by name, having the patient and chart available when discussing patient issues, focusing on the patient problem, and being professional and not aggressive. Sharing expectations of what, when, and how to communicate is a step toward establishing a strong work team. Structured communication techniques that improve communication include briefings or short discussions among team members, group rounds on patients, and the use of situation-background-assessment-recommendation (SBAR) when sharing information.

Delegation Transfers responsibility while remaining accountable for outcomes Requires knowing which skills are transferable Results in improved quality of patient care, improved efficacy, increased productivity, and an empowered staff Delegation is an essential part of management. Recall that Jennifer in the Case Study was able to delegate a unit clerk to check on one patient while she finished caring for another.

The Five Rights of Delegation
Right Task Right Circumstance Right Person Right Direction Right Supervision [Review Box 21-6 on text p. 282 The Five Rights of Delegation.] The right task is one that can be delegated for a specific patient, such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have potential minimal risk. Appropriate patient setting, available resources, and other relevant factors are considered in determining the right circumstance. The right person is delegating the right tasks to the right person to be performed on the right person. Right direction/communication indicates that a clear, concise description of the task, including its objective, limits, and expectations, is given. Right supervision/evaluation means that appropriate monitoring, evaluation, intervention as needed, and feedback are provided.

Steps to Effective Delegation
Assess the knowledge and skills of the delegatee. Match tasks to the delegatee’s skills. Communicate clearly: Task, outcome, time Listen attentively. Provide feedback. As an RN, you may be delegating tasks to nursing assistive personnel (NAP). To assess knowledge and skills, ask open-ended questions that elicit conversation and details about what he or she knows. You will need to know which tasks and skills are in the scope of practice and job description for team members to whom you delegate. Always provide clear directions by describing a task, the desired outcome, and the time period within which NAP should complete the task. Listen to the response of NAP after you provide directions. Help sort out priorities if needed. Always give NAP feedback regarding performance, regardless of outcome.

Quick Quiz! 2. A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to A. Assign only bed-making and feeding skills. B. Assess the knowledge of the certified nursing assistant. C. Remind the staff member that she is working under the license of the RN. D. Allow the staff member to perform only skills that the RN is able to teach certified nursing assistants to perform. Answer: B

Knowledge Building Remain competent. Pursue lifelong learning.
Share the knowledge. To become a leader, actively pursue learning opportunities, both formal and informal, and learn to share knowledge with the professional colleagues you encounter. Remaining competent provides the foundation for further skill building. Ongoing development of skills in delegation, communication, and teamwork helps maintain and build competency!

Implementing Nursing Care

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