1. Chapter 21 Managing Patient Care
The National Council of State Boards of Nursing (NCSBN) identified competencies that registered nurses (RNs) and licensed practical nurses (LPNs)/licensed vocational nurses (LVNs) need on entry to practice
[Review Box 21-1, Entry-Level Nurse Competencies, with students.]
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.
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2. Building a Nursing Team
A strong nursing team works together to achieve the best outcomes for patients.
Effective team development requires team building and training, trust, communication, and a workplace that facilitates collaboration.
As a nurse it is also important to work in an empowering environment as a member of a solid and strong nursing team.
Patient care units where teamwork is stronger had fewer reports and incidents of missed nursing care, leading to improved quality and safety of nursing care for patients.
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3. Building a Nursing Team (Cont.)
Building an empowered nursing team begins with the nurse executive.
Transformational leadership
TEEAMS (Time, Empowerment, Enthusiasm, Appreciation, Management, and Support) approach
The nurse executive is a clinical and business leader who is concerned with maximizing quality of care and cost-effectiveness while maintaining relationships and professional satisfaction of the staff. He or she establishes a philosophy for nursing that enables managers and staff to provide quality nursing care.
[Review Box 21-2, Characteristics of an Effective Leader, with students.]
The nurse manager who uses transformational leadership is focused on change and innovation through team development, motivates and empowers staff to function at a high level of performance, and serves as a role model for the nurses on the unit.
Increased level of patient satisfaction
Lower patient mortality rate
Lower rate of medication errors
Increased staff satisfaction
Decreased stress and burnout in nurses
Increased overall staff well-being
Increased staff retention
In the TEEAMS (Time, Empowerment, Enthusiasm, Appreciation, Management, and Support) approach, the nurse manager spends time on the unit with the staff sharing ideas, empowers the staff, is enthusiastic about seeking opportunities to enhance the team, shows appreciation and recognizes team members for a job well done, manages the team and holds team members accountable, and provides support in the stressful health care environment.
[Review Box 21-3, Evidence-Based Practice: Nurses Work Engagement, with students.]
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4. Magnet Recognition Based on five model components
Transformational leadership
Structural empowerment
Exemplary professional practice
New knowledge, innovation, and improvements
Empirical quality results
A hospital that is Magnet certified has a transformed culture with a practice environment that is dynamic, autonomous, collaborative, and positive for nurses.
The culture focuses on concern for patients.
Typically a Magnet hospital has clinical promotion systems and research and evidence-based practice programs. The nurses have professional autonomy over their practice and control over the practice environment.
Professional nurse councils at the organizational and unit level are one way to create an empowerment model. This culture and empowerment combine to produce a strong collaborative relationship among team members and improve patient quality outcomes.
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5. Nursing Care Delivery Methods
Traditional models
Team nursing
Primary nursing
Today’s models
Patient-centered care
Total patient care
Case management
Nursing care delivery models contain the common components of nurse-patient relationship, clinical decision making, patient assignments and work allocation, interprofessional communication, and management of the environment of care.
In team nursing the registered nurse (RN) is the leader who leads a team of other RNs, practical nurses, and nursing assistive personnel (NAP) who provide direct patient care.
Primary nursing supports a philosophy regarding nurse and patient relationships. It is typically not practiced today because of the high cost of an all RN staffing model.
Today’s models are discussed on following slides.
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6. Nursing Care Delivery Methods (Cont.)
Patient- and family-centered care
Respect and dignity
Information sharing
Participation
Collaboration
Patient- and family-centered care is a model of nursing care in which mutual partnerships among the patient, family, and health care team are formed to plan, implement, and evaluate the nursing and health care delivered. At the center of patient-centered care is the patient or family member as the source of control and full partner in providing care. Core concepts:
Respect and dignity, ensuring that the care provided is given on the basis of the patient’s and family’s knowledge, values, beliefs, and cultural backgrounds.
Information sharing, meaning that health care providers communicate and share information so patients and families receive timely, complete, and accurate information to effectively participate in care and decision making.
Participation, whereby the patients and families are encouraged and supported in participating in care and decision making.
Collaboration, demonstrated by the health care leaders collaborating with patients and families in policy and program development, implementation, and evaluation, and patients who are fully engaged in their health care.
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7. 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 students: If you were Jennifer, which patient would be your first priority? Discuss.]
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8. Nursing Care Delivery Models (Cont.)
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 RNs needed.
Patient satisfaction is high.
Total patient care emphasizes a high degree of collaboration with other health care professionals.
Total patient care is when the RN is responsible for all aspects of care for one or more patients during a shift of care, working directly with patients, families, and health team members.
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9. Nursing Care Delivery Models (Cont.)
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 (APN), 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.
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10. 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
Decision making is a critical component of an effective leader and manager.
Decentralization is a component of the hierarchical level of decision making found in health care institutions.
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.
[Review Box 21-4, Responsibilities of the Nurse Manager, with students.]
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 students: What are some advantages and disadvantages of a decentralized management structure? Discuss.]
Responsibility reflects ownership. An individual who manages employees has to distribute responsibility, and the employees have to accept the manager’s direction. Managers have to be sure that staff clearly understand their responsibilities, particularly in the face of change.
Autonomy consistent with the scope of professional nursing practice maximizes the nurse’s effectiveness. In work autonomy, a nurse makes independent decisions about the work of the unit such as scheduling or unit governance. Autonomy is not an absolute; it occurs in degrees.
With authority, the nurse is able to choose and recommend appropriate teaching strategies for the patient on behalf of the other health care team members. The nurse has the final authority in selecting the best course of action for the patient’s care.
Accountability means that as a nurse you are responsible for providing excellent patient care by following standards of practice and institutional policies and procedures. You assume responsibility for the outcomes of the actions, judgments, and omissions in providing that care.
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11. 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
Rationale: 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 the professional relationships among staff members. Primary nursing supports a philosophy regarding nurse and patient relationships.
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12. Decision Making (Cont.)
Staff involvement
Transformational leadership
All staff benefit from knowledge and skills of entire work group
Requires skilled communication
When transformational leadership and decentralized decision making exist on a nursing unit, all staff members actively participate in unit activities.
Because the work environment promotes participation, all staff members benefit from the knowledge and skills of the entire work group.
The use of transactional leadership practices positively impacts the work environment, resulting in greater nurse empowerment, improved culture and climate, increased nurses’ research utilization, better teamwork between nurses and physicians, greater role clarity, and reduced conflict and ambiguity.
[Ask students: What is shared governance? Discuss.]
[Shown is Figure 21-1: Staff collaborating on practice issues.]
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13. Decision Making (Cont.)
Nursing manager supports staff through:
Establishing nursing practice through problem-solving committees or professional shared governance councils
Interprofessional collaboration among nurses and health care providers
Interprofessional rounding
Staff communication
Staff education
Nursing practice is established through problem-solving committees or professional shared governance councils. Chaired by senior clinical staff nurses, these groups establish and maintain care standards for nursing practice on their work unit. Shared governance is a dynamic process that promotes decision making, accountability, and empowerment in staff nurses and enables them to control their nursing practice. The committee establishes methods to ensure that all staff have input or participation on practice issues. Managers do not always sit on a committee, but they receive regular reports of committee progress.
Interprofessional collaboration among nurses and health care providers is critical to the delivery of quality, safe patient care, and the creation of a positive work culture for practitioners. Interprofessional collaboration involves all professions bringing different points of view to the table to identify, clarify, and solve complex patient problems together, providing integrated and cohesive patient care.
Competencies needed for effective interpersonal collaboration include:
Work with individuals of other professions to maintain a climate of mutual respect and shared values.
Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and populations served.
Communicate with patients, families, communities, and other health care professionals in a responsive and responsible manner that supports patient-centered care and a team approach to the maintenance of health and treatment of disease.
During rounding, members of the team meet and share patient information, answer questions asked by other team members, discuss patients’ clinical progress and plans for discharge, and focus all team members on the same patient goals. This decreases medical errors, decrease patient readmission rates, impact patient satisfaction, and improve quality of care.
A manager’s greatest challenge, especially if a work group is large, is communication with staff. An effective manager uses a variety of approaches to communicate quickly and accurately to all staff, through newsletters, minutes of meetings accessible, conducting staff meetings.
A professional nursing staff needs to always grow in knowledge. It is impossible to remain knowledgeable about current medical and nursing practice trends without ongoing education.
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14. Leadership Skills for Nursing Students
Clinical Care Coordination
Team Communication
Delegation
Knowledge Building
It is important that as a nursing student you prepare yourself for leadership roles.
Learn to become a leader by consulting with instructors and nursing staff to obtain feedback in making good clinical decisions, learning from mistakes and seeking guidance, working closely with professional nurses, and trying to improve your performance during each patient interaction.
These skills require you to think critically and solve problems in the clinical setting. Thinking critically allows nurses to provide higher-quality care, meet the needs of patients while considering their preferences, consider alternatives to problems, understand the rationale for performing nursing interventions, and evaluate the effectiveness of interventions.
Important leadership skills to learn include clinical care coordination, team communication, delegation, and knowledge building.
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15. Clinical Care Coordination
Clinical Decisions
Priority Setting
Organizational Skills
Use of Resources
Time Management
Evaluation
Clinical care coordination includes clinical decision making, priority setting, use of organizational skills and resources, time management, and evaluation.
The activities of clinical care coordination require use of critical reflection, critical reasoning, and clinical judgment.
They are important first steps in developing a caring relationship with a patient. Use a critical thinking approach, applying previous knowledge and experience to the decision-making process.
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16. Clinical Decisions Apply the nursing process Know your patient
Use clinical decision making practices
Accurate clinical decision-making keeps you focused on the proper course of action
Your ability to make clinical decisions depends on application of the nursing process.
Knowing the patient involves more than gathering formal assessment data. It requires learning a patient’s typical patterns of responses and his or her current situation and knowing the patient as an individual.
If you do not make accurate clinical decisions about a patient, undesirable outcomes will probably occur. The patient’s condition worsens or remains the same when you lose the potential for improvement.
Never hesitate to ask for assistance when a patient’s condition changes.
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17. 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
After forming a picture of the patient’s total needs, you set priorities by deciding which patient needs or problems need attention first. Classify patient problems in three priority levels:
High priority—An immediate threat to a patient’s survival or safety.
Intermediate priority—Nonemergency, non-life-threatening actual or potential needs that a patient and family members are experiencing.
Low priority—Actual or potential problems that are not directly related to a patient’s illness or disease.
Many patients have all three types of priorities, requiring you to make careful judgments in choosing a course of action. Obviously high-priority needs demand immediate attention.
To identify which patients require assessment first, rely on information from the change-of-shift report, your own most recent assessment of the patient, and information from the medical record.
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18. Case Study (Cont.)
Mrs. Sinclair’s surgery is scheduled for 1 p.m. 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 students: After reading these details about Mrs. Sinclair, do you have enough information to know which patient Jennifer should attend first? Discuss.]
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19. Case Study (Cont.)
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 students: With this information, would you make the same decision about which patient first needs Jennifer’s attention? Discuss.]
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20. Case Study (Cont.)
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 students: Of the three patients assigned, which patient should Jennifer help first? Discuss.]
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21. Case Study (Cont.)
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 students: Is this the order of priority you would have used? Discuss.]
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22. Organizational Skills
Do the right things.
Do things right.
Inform and prepare patient.
Clean and organize work area.
Keep patient’s needs at the center of attention.
Implementing a plan of care requires you to be effective and efficient. Effective use of time means doing the right things, whereas efficient use of time means doing things right.
A well-organized nurse approaches any planned procedure by having all of the necessary equipment available and making sure that the patient is prepared. If the patient is comfortable and well informed, the likelihood that the procedure will go smoothly increases.
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23. Use of Resources
Appropriate use of resources is an important aspect of clinical care coordination.
Administration of patient care occurs more smoothly when staff members work together.
Appropriate use of resources is an important aspect of clinical care coordination. Resources in this case include members of the health care team.
Never hesitate to have staff help you, especially when there is an opportunity to make a procedure or activity more comfortable and safer for patients.
Consulting with an experienced RN confirms findings and ensures that you take the proper course of action for the patient.
A leader knows his or her limitations and seeks professional colleagues for guidance and support.
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24. Time Management Remain goal oriented. Identify priorities.
Establish personal goals.
One useful time-management skill involves making a priority to-do list. Good time management also involves setting goals to help you complete one task before starting another.
Time management requires the ability to anticipate the activities of the day and combine activities when possible.
[Review Box 21-5, Principles of Time Management, with students.]
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25. Evaluate Evaluate process. Evaluate patient response.
Evaluate therapy efficacy.
Evaluate patient and expected outcomes.
Evaluation is ongoing, just like other steps of the nursing process. Once you assess a patient’s needs and begin therapies directed at a specific problem area, immediately evaluate whether therapies are effective and the patient’s response.
When expected outcomes are not met, evaluation reveals the need to continue current therapies for a longer period, revise approaches to care, or introduce new therapies.
Keeping a focus on evaluation of the patient’s progress lessens the chance of becoming distracted by the tasks of care.
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26. Case Study (Cont.)
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.
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27. Team Communication Respect others’ ideas. Share information.
Stay informed.
Strive to improve your communication.
Share expectations of communication.
Use structured communication techniques
As a part of a nursing team, you are responsible for using open, professional communication.
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.
Part of good communication is clarifying what others are saying and building on the merits of co-workers’ ideas.
Sharing expectations of what, when, and how to communicate is a step toward establishing a strong work team.
Examples of communication tools that improve communication include:
Briefings or short discussions among team members.
Group rounds on patients.
Callouts to share critical information such as vital signs with all team members at the same time.
Check backs to restate what a person has said to verify understanding of information.
The two-challenge rule that allows concerns to be voiced twice, which allows all team members to voice concerns about safety.
“CUS” words, which means “I’m Concerned, I’m Uncomfortable, I don’t feel this is Safe”.
The use of Situation-Background-Assessment-Recommendation (SBAR) when sharing information.
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28. Delegation
Transfers responsibility while remaining accountable for outcomes
Requires knowing which skills are transferable
Results in improved quality, safe patient care, improved efficiency, increased productivity, an empowered staff, and skill development of others
The Nurse Practice Act of your state, along with principles of authority, accountability, and responsibility, is the basis for effective delegation.
Delegation is an essential part of management.
Never delegate a task that you dislike doing or would not do yourself because this creates negative feelings and poor working relationships.
As a nurse you are responsible and accountable for providing care to patients and delegating care activities to the nursing assistive personnel (NAP). However, you do not delegate the steps of the nursing process of assessment, diagnosis, planning, and evaluation because these steps require nursing judgment.
Patient teaching is also the responsibility of an RN and should not be delegated.
As an RN, you are always responsible for the assessment of a patient’s ongoing status; but if a patient is stable, you delegate vital sign monitoring to the NAP.
Appropriate delegation begins with knowing which skills you are able to delegate. Know your state’s Nurse Practice Act.
As a professional nurse you cannot simply assign the NAP tasks without considering the implications. Assess the patient and determine a plan of care before identifying which tasks someone else is able to perform.
Efficient delegation requires constant communication.
[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.]
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29. Delegation (Cont.) The Five Rights of Delegation Right Task
Right Circumstance
Right Person
Right Direction
Right Supervision
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.
[Review Box 21-6, The Five Rights of Delegation, with students.]
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30. Delegation (Cont.) 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.
Provide clear instructions and desired outcomes when delegating tasks. These instructions initially focus on the procedure itself, what will be accomplished, when it should be completed, and the unique needs of the patient.
Important steps in delegation are evaluation of the staff member’s performance, achievement of the patient’s outcomes, the communication process used, and any problems or concerns that occurred.
As an RN, you may be delegating tasks to 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 within 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.
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31. 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
Rationale: The reason for ascertaining the nursing assistant’s knowledge and skills is because the nurse does not want to delegate tasks that the assistant may not be able to do, thus, putting the patient’s care in jeopardy.
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32. 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.
Lifelong learning allows you to continuously provide safe, effective, quality care.
In-service programs, workshops, professional conferences, professional reading, and collegiate courses offer innovative and current information on the rapidly changing world of health care.
Ongoing development of skills in delegation, communication, and teamwork helps maintain and build competency!
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