Nursing foundation: Managing patient care chapter 21

Evaluation

At the end of each day take time to think and reflect about how effectively you used your time. If you are having difficulties, discuss them with an instructor or a more experienced staff member.

Appropriate delegation to assistive personnel

-Assess the knowledge and skills of the person to whom you are delegating -Match tasks to the person's skills -Communicate clearly -Listen attentively -Provide feedback

Nursing manager supports staff involvement

-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

Patient- and family-centered care

1. Dignity and respect, ensuring that the care provided is given based on a patient's and family's knowledge, values, beliefs, and cultural backgrounds 2. Information sharing, meaning that health care providers communicate and share information so that patients and families receive timely, complete, and accurate information to effectively participate in care and decision making 3. Participation, whereby patients and families are encouraged and supported in participating in care and decision making 4. Collaboration, demonstrated by the health care leaders collaborating with patients and families in policy and program development, implementation, and evaluation, as well as by patients who are fully engaged in their health care

Magnet certified

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 (Hume and Hall, 2020). A Magnet hospital empowers a nursing team to make changes and be innovative (Nelson-Brantley et al., 2018). Professional nurse councils at the organizational and unit level help to create an empowerment model. This culture and empowerment combine to produce a strong collaborative relationship among team members and improve patient quality outcomes

Staff communication

A manager's greatest challenge, especially if a work group is large, is communication with staff. It is difficult to make sure that all staff members receive consistent, clear, accurate, and timely information. Lack of communication about planned changes often leads to mistrust among staff members. However, a manager cannot assume total responsibility for all communication. An effective manager uses a variety of approaches to communicate quickly and accurately to all staff. For example, many managers distribute biweekly or monthly newsletters of ongoing unit or agency activities

Contemporary nurse leaders

A nurse manager's leadership style affects the work environment and patient outcomes. Contemporary nurse leaders have a shared vision that leads the team to a common goal. Because nurses have specialized knowledge, they need leaders who value and foster the attainment of new knowledge (Huber, 2018). Nurse managers who use interactional and relationship-based leadership styles create a positive work environment by fostering interaction and generating stability to create the energy a team needs to adapt to and grow with a constantly changing health care environment

Staff education

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. A nurse manager is responsible for making learning opportunities available, so staff members remain competent in their practice and empowered in their clinical decision making. This involves planning in-service programs, sending staff to continuing education classes and professional conferences, and having staff present case studies or evidence-based practice issues during staff meetings. Staff members are responsible for pursuing educational opportunities for relicensure/recertification and changing information regarding their patient population.

Organizational skills

A well-organized nurse approaches any procedure by having all the necessary equipment available and making sure that the patient is prepared. If the patient is comfortable and well informed, the procedure will probably go smoothly. Sometimes you need help from colleagues to perform or complete a procedure. Keep the work area organized and complete preliminary steps before asking colleagues for assistance. Although you plan and deliver care based on established priorities, events sometimes occur that interfere with your plans. For example, just as you begin to bathe a patient, an x-ray technician enters to take a chest x-ray film. Once the technician takes the x-ray, a phlebotomist arrives to draw a blood sample. In this case your priorities conflict with the priorities of other health care personnel. It is important to always keep a patient's needs at the center of attention. If the patient experienced symptoms earlier that required a chest x-ray film and laboratory work, it is important to be sure that the diagnostic tests are completed. In another example a patient is waiting to visit family, and a chest x-ray film is a routine order. The patient's condition is stable, and the x-ray technician is willing to return later to shoot the film. In this case attending to the patient's hygiene and comfort so that family members can visit is the higher priority.

Situation Monitoring

Actively assess any situation to gather information, improve your understanding, or maintain awareness to support the functioning of the team.

Provide feedback

Always give the AP feedback regarding performance, regardless of outcome. Let the AP know of a job well done. A "thank you" increases the likelihood of the AP helping in the future. If an outcome is undesirable, find a private place to discuss what occurred, any miscommunication, and how to achieve a better outcome in the future.

Communicate clearly

Always provide clear directions by describing a task, the desired outcome, and the time within which the AP needs to complete the task. Never give instructions through another staff member. Make APs feel as though they are part of the team. Begin requests for help with please and end with thank you. For example, "I'd like you to please help me by getting Mr. Floyd up to ambulate before lunch. Be sure to check his blood pressure before he stands and record it in his chart. Thank you for your help." Ask the AP to report back to you after completing the task.

Use of resources

Appropriate use of resources is an important aspect of clinical care coordination. Resources include members of the health care team. In any setting providing patient care occurs more smoothly when staff members work together. 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. For example, you often need assistance in turning, positioning, and ambulating patients when patients have mobility limitations. Having a staff member such as an AP assist with handling equipment and supplies during complicated procedures such as catheter insertion or dressing changes makes procedures more efficient. In addition, you need to recognize personal limitations and use professional resources for assistance. For example, you assess a patient and find relevant clinical signs and symptoms but are unfamiliar with the physical condition. Consulting with an experienced RN confirms findings and ensures that you take the proper course of action for the patient. Leaders know their limitations and seek professional colleagues for guidance and support.

Knowledge building

As a professional and accountable nurse, you are responsible for lifelong learning and maintaining your competency (Kaulback, 2020). Lifelong learning allows you to continuously provide safe, effective, quality care. A leader recognizes that there is always something new to learn. Opportunities for learning occur with each patient interaction, each encounter with a professional colleague, and each meeting or class session in which health care professionals meet to discuss clinical care issues. People always have different experiences and knowledge to share. Listen to the contributions of others, and value the information they share. In-service programs, workshops, professional conferences, professional reading, and taking classes to further your education offer innovative and current information on the rapidly changing world of health care. To be a safe and competent nurse you need to actively pursue learning opportunities, both formal and informal, and to respectfully interact with the professional colleagues you encounter.

Assess the knowledge and skills of the person to whom you are delegating

Assess the person's knowledge and skills by asking open-ended questions that elicit conversation and details about what the person knows (e.g., "How do you usually apply the cuff when you measure a blood pressure?" or "Tell me how you prepare the tubing before you give an enema").

Team Structure

Identify the complex parts of the health care system that work together effectively to promote patient safety.

Staff involvement

Because the work environment promotes participation, all staff members benefit from the knowledge, experience, and skills of the entire work group. If the staff learns to value the pursuit of knowledge and the contributions of colleagues, better patient care results. Recognizing nurses' exceptional work with patients helps reinforce these behaviors, creates a healthy work environment, and reduces nurse burnout (Kelly and Lefton, 2017; Wei et al., 2020). Healthy work environments have nurses who are skilled in communication, promote true collaboration among health care team members, encourage effective decision making, have appropriate levels of staffing to meet patient needs, recognize nurses in a meaningful way, and have an authentic nurse leader (AACN, n.d.). Authentic leadership results in greater nurse empowerment, improved culture and climate, increased implementation of evidence-based practice, better teamwork between nurses and physicians, greater role clarity, and reduced conflict and ambiguity (Baek et al., 2019; Shirey et al., 2019).

SBAR As a Communication Tool

Case Study: You administered 1 tablet of oxycodone HCl 5 mg/ibuprofen 400 mg PO to a patient 30 minutes ago for postsurgical pain. You return to the patient's room to evaluate the effectiveness of the medication 30 minutes later. The patient rates his pain as an 8 on a scale of 0-10. You use SBAR to contact the patient's health care provider. Situation: The patient is rating his pain as an 8 on a scale of 0-10. He had his pain medication 30 minutes ago. Background: The patient had a knee replacement and returned from the postanesthesia care unit 6 hours ago. He has 1 tablet of oxycodone HCl 5 mg/ibuprofen 400 mg PO ordered every 6 hours. This is the first pain medication he has taken since being admitted to the unit. Assessment: His current medication order is not sufficiently managing the patient's pain. He does not want to sit up or move because of the pain he is experiencing. Recommendation: It might be helpful to change the pain medication order for the patient.

Interprofessional collaboration among nurses and health care providers

Competencies needed for effective interpersonal collaboration include: • Values/ethics for interprofessional practice: Work with individuals of other professions to maintain a climate of mutual respect and shared values. • Roles/responsibilities: 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 to promote and advance the health of populations. • Interprofessional communication: Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to promote and maintain health and prevent and treat disease. • Teams and teamwork: Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient- or population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.

Right circumstance

Consider the patient's status. The patient needs to be stable for you to delegate tasks. The delegatee must report changes in patient condition to the licensed nurse. The licensed nurse must reassess and evaluate the situation and appropriateness of delegation when a patient's condition changes.

Skills

Critical Thinking • Consider different health care solutions, conclusions, or approaches to problems Therapeutic Communication • Adapt one's communication style and demonstrate sensitivity to build rapport with others Therapeutic Communication • Adapt one's communication style and demonstrate sensitivity to build rapport with others Documenting • Document clearly, concisely • Follow documentation standards and policies Focused Assessment • Select appropriate assessment type based on patient problems, symptoms, or diagnosis Clinical Judgment • Recognize cues • Take action • Evaluate outcomes Active Listening • Give full attention and repeat back to clarify information • Ask appropriate questions Patient Education • Help patients interpret health information • Provide information at a level that patients can understand Patient Monitoring • Recognize changes in patient condition • Anticipate complications or adverse outcomes Problem Solving • Develop and evaluate interventions • Resolve complex problems Professional Communication • Communicate clearly and concisely • Use appropriate communication styles based on situation

Team communication

Effective communication is critical to all teams (QSEN Institute, 2020). As part of a health care team, you are responsible for using open, professional communication. Regardless of the setting, an enriching professional environment is one in which staff members respect one another's ideas, share information, and keep one another informed (Kaiser and Westers, 2018). Some health care agencies use evidence-based teamwork principles to improve communication, teamwork, and patient safety. The TeamSTEPPS® system provides training for all health care staff to guide communication, increase team awareness, and eliminate barriers to patient safety

Leadership

Ensure that all members of the health care team understand the team's actions, receive information about changes, and have the resources needed to perform their jobs.

Interruption control

Everyone needs time to socialize or discuss issues with colleagues. However, do not let this interrupt important patient care activities such as medication administration (see Chapter 31), ordered treatments, or teaching sessions. Use time during report, mealtime, or team meetings to your advantage. In addition, plan time to help fellow colleagues so that it complements your patient care schedule.

Case management

For example, a case manager coordinates a patient's acute care in the hospital and follows up with the patient after discharge, either to home, rehabilitation, or a long-term care setting. Case managers do not provide direct care. Instead, they collaborate with direct-care providers and actively coordinate patient discharge planning, ensuring necessary services and resources are available (e.g., home aides, physical therapy) and making cost-efficient choices (e.g., selection of medical equipment or long-term care facilities). Ongoing communication with team members facilitates a patient's transition to home or another health care setting.

Delegation

For example, asking a staff member to obtain an ordered specimen while you administer a patient's pain medication effectively prevents a delay in the patient gaining pain relief. Delegation also provides job enrichment. You show trust in colleagues by delegating tasks to them and showing staff members that they are important players in the delivery of care (Riisgaard et al., 2017). Successful delegation is important to the quality of the relationship you have with all team members, including LPNs and APs (Lyman et al., 2017). Delegating a task that you dislike doing or would not do yourself creates negative feelings and poor working relationships. For example, if a patient asks to be placed on a bedpan and there are no urgent care issues, you assist the patient rather than leave the room to find the LPN or AP. Remember that even though the delegation of a task transfers the responsibility and authority to another person, you are accountable for the delegated task.

Right directions and communication

Give a clear, concise description of a task, including its objective, limits, and expectations. Communication needs to be ongoing between the licensed nurse and delegatee. The delegatee is responsible for asking questions to clarify information.

Time management

Good time management also involves setting goals to help you complete one task before starting another. You will always deliver care to a group of patients, moving back and forth between patients as needs and priorities change. If possible, complete an activity started with one patient before moving on to the next. Care is less fragmented, and you are better able to focus on what you are doing for each patient. As a result, you will be less likely to make errors. Time management requires you to anticipate the activities of the day and combine activities when possible. When you practice good time management, you focus on organization and setting priorities. Other strategies include keeping your work area clean and clutter free and trying to decrease interruptions as you are completing tasks.

Interprofessional collaboration among nurses and health care providers

Interprofessional collaboration among nurses and health care providers (e.g., medical doctors, physical therapists, respiratory therapists) is critical to the delivery of quality, safe patient care and the creation of a positive work culture for practitioners (McBeth et al., 2017; Interprofessional Education Collaborative [IPEC], 2016). Interprofessional collaboration involves bringing various disciplines together to work with patients and families to deliver quality care (IPEC, 2016). 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

Establishing nursing practice through problem-solving committees or professional shared governance councils

It is important for the committees to balance their focus between patient outcomes and work issues to ensure quality care on the unit. Quality of care is improved when nurses control their own practice. The committee establishes methods to ensure that all staff have input on practice issues. Managers do not always sit on a committee, but they receive regular reports of committee progress. The nature of work on the nursing unit determines committee membership. At times members of other disciplines (e.g., pharmacy, respiratory therapy, or clinical nutrition) participate in practice committees or shared governance councils.

Match tasks to the person's skills

Know which tasks and skills the training program includes for APs in your agency. Determine whether APs have learned critical thinking, such as recognizing when a patient is in harm or understanding the difference between normal clinical findings and changes to report.

Listen attentively

Listen to an AP's response after you provide directions. Does the AP feel comfortable in asking questions or requesting clarification? Does the AP understand your request? Ask the AP for suggestions in patient care and listen to the response. Be especially attentive if the AP is helping another nurse. Help sort out priorities.

Nursing team

Nurses who work in health care agencies and on units that have cultures that promote autonomy, quality, and collaboration are more satisfied and experience lower levels of moral distress (Hiler et al., 2018; Shimp, 2017). Professional nurses are self-directed and, with proper leadership and motivation, work together to solve complex problems. Your education and commitment to practice nursing within established standards and guidelines help you become part of a cohesive and strong nursing team that values mentoring, integrity, and teamwork. A strong nursing team works together to achieve the best outcomes for patients. Patient care units where teamwork is stronger are associated with improved patient safety and nurse well-being (Rosen et al., 2018). Stronger levels of teamwork often contribute to higher levels of job satisfaction among nurses

Time management

Make efficient and effective use of your time by remaining focused on your patient's outcomes. However, you also need to learn how to establish personal goals and realistic time frames. For example, you are caring for two patients on a busy surgical nursing unit. One had surgery the day before, and the other will be discharged the next day. The first patient's outcomes center on restoring physiological function that is impaired because of surgery. The second patient's outcomes focus on adequate preparation to assume self-care at home. In reviewing the therapies required for both patients, you learn how to organize your time so that you complete your nursing care, and your patients achieve their outcomes. Anticipate when care will be interrupted for medication administration and diagnostic testing and determine the best time for planned therapies such as dressing changes, patient education, and patient ambulation. Delegating tasks is another way to help improve time management.

Interprofessional rounding

Many agencies that focus on patient- and family-centered care conduct interprofessional rounding to encourage patient and family involvement in planning care, to improve patient care coordination, and to enhance communication among the health care team (Bigani and Correia, 2018). During rounding, members of the team meet and share patient information, answer questions asked by other team members, discuss a patient's clinical progress and plans for discharge, and focus all team members on the same patient outcomes and goals (Prystajecky et al., 2017; McBeth, 2017). Interprofessional rounding improves decision making, nurses' job satisfaction, and quality of care (Ashcraft et al., 2017). For interprofessional rounding to be successful, health care team members need to be flexible and open to ideas, questions, and suggestions offered by others.

Staff communication

Minutes of committee meetings are usually in an accessible location for all staff to read or are sent to individuals via e-mail. When the team needs to discuss important issues regarding the operations of the unit, the manager conducts staff meetings. When the unit has practice- or quality-improvement committees, each committee member has the responsibility to communicate directly to a select number of staff members. Thus, all staff members are contacted and given the opportunity to provide input.

Patient- and family-centered care

More common models used today are patient- and family-centered care and case management. promotes mutual partnerships among the patient, family, and health care team to plan, implement, and evaluate nursing and health. At the center of patient-centered care is the patient or family member as the source of control and full partner in providing care (QSEN Institute, 2020). An RN is the health care leader who assesses patient needs, identifies mutual outcomes, monitors patients for clinical changes, and directs care. The Institute for Patient- and Family-Centered Care identified four core concepts for patient-centered care Nurses support and promote patient engagement and empowerment when using patient- and family-centered communication, bedside shift report, and patient- and family-centered interprofessional rounds

Priority setting

Set the priorities that you have established for patients within set time frames. For example, determine when the best time is to have teaching sessions, plan ambulation, and provide rest periods based on what you know about a patient's condition. For instance, if a patient is nauseated or in pain, it is not a good time for a teaching session.

Knowledge

Nursing Process • Steps Professional Responsibilities • Ethical principles • Scope of practice • Error reporting and follow-up Documentation • Medical terminology and abbreviations • Information to document Focused Assessment • Types of assessments • Evaluation of effectiveness Plan of Care • Methods • Changes in patient conditions Patient Needs Assessment • Methods • Topics Patient, Family, and Caregiver Education • Teaching techniques • Evaluation of effectiveness Vital Signs Collection • Techniques and types • Normal and abnormal values • Interventions based on patient values Patient-Centered Care • Holistic principles • Integrating care including patients, families, and caregivers

Servant leadership

One contemporary relationship-based leadership style is servant leadership. Servant leaders choose to serve others before they decide to become leaders. Their priority is to put the needs of others first and to promote personal growth and autonomy by ensuring their individual employees' highest priority needs are met (Huber, 2018; Tatsumi, 2019). Servant nurse leaders work closely with their team to understand individual members' strengths and weaknesses. A servant leader creates teams based on this understanding and ensures that the nurses on a unit are working in the positions that best use their strengths (Tatsumi, 2019). Servant nurse leaders also practice humility. They understand that although they possess a great deal of knowledge, they do not know all the answers. They remain modest and calm, and they give credit to their staff members for successes (Tatsumi, 2019). Effective nurse leaders use a variety of evidence-based strategies to create healthy work environments and lead their teams through change

Time management

One useful time-management skill involves making a to-do list. When you begin to work with patients, it helps to make a list that sequences the nursing activities you need to perform. The hand-off report at the change of shift helps you prioritize activities based on what you learn about a patient's condition and the care provided before you arrived on the unit. Consider activities that have specific time limits in terms of addressing patient needs such as administering a pain medication before a scheduled procedure or instructing patients before their discharge home. You also analyze the items on the list that are scheduled by agency policies or routines (e.g., medications or intravenous [IV] tubing changes). Note which activities need to be done on time and which activities you can do at your discretion. Administer medication within a specific schedule, but you can also perform other activities while in the patient's room. Finally, estimate the amount of time needed to complete the various activities. Activities requiring the assistance of other staff members usually take longer because you need to plan around their schedules.

Magnet recognition program

One way of creating an empowering work environment is through the Magnet Recognition Program® (see Chapter 2). The Magnet Recognition Program's Pathway to Excellence Framework® is based on six standards that are crucial to creating a positive practice environment for nurses • Shared decision making • Leadership • Safety • Quality • Well-being • Professional development

Abilities

Oral Comprehension • Listen to and understand information and ideas that are spoken Dependability • Be reliable, responsible, and accountable • Be punctual and on time Written Expression • Use appropriate words in writing so that others can understand Oral Expression • Use appropriate words in speaking • Speak in a way that others can understand Task and Information Ordering • Implement actions in an order that follows policies and procedures • Set priorities appropriately Self-sufficiency • Work independently with little assistance from others • Seek assistance appropriately Speech Clarity • Communicate clearly • Ensure that others can understand what you say Social Confidence • Display self-confidence when working with others Written Comprehension • Read and understand written information and ideas

Priority setting

Priority setting is not the ordering of a list of care tasks but rather a way to organize your care. Recognizing cues from your assessment database and your knowledge helps you understand which diagnoses require intervention and the associated time frame to intervene effectively. It is important to set priorities whenever you provide patient care because it allows you to see the most important issues, as well as the relationships among patient problems, and to avoid delays in taking action, which could lead to serious complications for a patient. When a patient is experiencing a serious physiological or psychological problem, the priority becomes clear. You need to act immediately to stabilize the patient's condition. Nurses prioritize care in different ways. If you use Maslow's hierarchy of needs, you meet a patient's physiological needs such as oxygen, food, water, sleep, and elimination first. Once physiological needs are met, you help patients meet their higher-level needs, such as safety, security, belonging, esteem, and self-actualization.

Shared governance

Progressive agencies achieve more when employees at all levels are empowered and actively involved in decision making. As a result, the role of a nurse manager is critical in the management of effective nursing units or groups. To make shared governance work, managers move decision making down to the lowest level possible. On a nursing unit it is important for all nursing staff members (RNs, LPNs, and LVNs), assistive personnel (AP), and unit secretaries to become engaged and provide input on practice issues and unit operations. They need to be kept well informed of unit and agency initiatives. Giving staff the opportunity to participate in problem-solving activities related to direct patient care and unit activities promotes a high level of employee engagement—a key factor in promoting teamwork and collaboration and a healthy work environment (Olender et al., 2020). Important elements of the decision-making process are responsibility, autonomy, authority, and accountability.

Right supervision and evaluation

Provide appropriate monitoring, evaluation, intervention as needed, and feedback. The licensed nurse must follow up with the delegatee at the end of the activity to evaluate patient outcomes, be available and ready to intervene when appropriate, and ensure appropriate documentation.

Establishing nursing practice through problem-solving committees or professional shared governance councils

Staff committees establish and maintain care standards for nursing practice on their unit. Shared governance is a dynamic process that promotes decision making, accountability, and empowerment in staff nurses and enables them to make meaningful and sustainable changes in patient care (Huber, 2018; Porter-O'Grady, 2019). The committees review ongoing clinical care issues, identify problems, apply evidence-based practice in establishing standards of care, develop policy and procedures, implement new practice approaches, resolve patient satisfaction issues, or develop new documentation tools.

Time analysis

Reflect on how you use your time. While taking care of patients, keep track of how you use your time in different activities. This helps you become more aware of how well organized you really are and areas you may need to improve upon.

Goal setting

Review a patient's outcomes and care that needs to be accomplished for the day as well as any goals you have for activities, such as completing documentation, attending a patient care conference, giving a hand-off report, or preparing medications for administration.

Key TeamSTEPPS Principles

Team Structure Communication Leadership Situation Monitoring Mutual Support

Right person

The licensed nurse, employer, and delegatee are all responsible for ensuring the delegatee has the knowledge and skills required to perform the activity.

Interprofessional collaboration among nurses and health care providers

The nurse plays a unique role within the team and is often viewed as the team leader because it is the nurse who takes on the responsibilities of coordination of communication and patient care (QSEN Institute, 2020). Open communication, cooperation, trust, mutual respect, and understanding of team member roles and responsibilities are critical for successful interprofessional collaboration (QSEN Institute, 2020; IPEC, 2016). The IPEC (2016) identified four competencies needed by health care practitioners to be effective team members in interprofessional collaboration. The development of these competencies comes through interprofessional education

Time management

These skills involve learning how, where, and when to use your time. Because you have a limited amount of time with patients, it is essential to remain goal oriented and use time wisely. Managing yourself better leads to better time management and reduces the risk of developing burnout (de Oliveira et al., 2019). Effective time management includes being prepared, being organized, and managing priorities.

Clinical care coordination

To coordinate the clinical care of patients safely and effectively, you need to learn how to recognize and analyze your patient's assessment cues, generate solutions to patient problems, make clinical decisions, set priorities, delegate safely, gain organizational skills, use resources, manage time, and evaluate your patient's outcomes (Dickison et al., 2019). Clinical care coordination requires you to use critical reflection and reasoning and clinical judgment (Benner et al., 2010). These 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

Philosophy of care

Together a manager and the nursing staff share a philosophy of care for their work unit. A philosophy of care includes the professional nursing staff's values and concerns for the way they view and care for patients. For example, a philosophy addresses the purpose of the nursing unit, how staff members work with patients and families, and the standards of care for the work unit. The selection of a nursing care delivery model and a management structure that both support professional nursing practice is essential to the philosophy of care.

Mutual Support

Understand the responsibilities and workload of all team members so that you can anticipate and support their needs.

Priority setting

Use information from the change-of-shift or hand-off report, the patient acuity classification system, and information from the medical record to determine which patient to assess first. Over time you learn to spontaneously rank patients' needs by priority or urgency. Priorities do not remain stable but change as a patient's condition changes. It is important to think about the resources available, to be flexible in recognizing that priority needs often change, and to consider how to use time wisely. You also set priorities based on your patient's expectations. Sometimes you establish an excellent plan of care; however, if a patient resists certain therapies or disagrees with your approach, your care will not be effective or safe. Be caring and work closely with a patient and family caregiver when setting priorities to establish trust and cooperation.

Communication

Use structured processes to exchange information clearly and accurately among members of the health care team.

Priority setting

When prioritizing care, you need to understand the "big picture" of your patient's problems and expected outcomes. Once you know all your patient's problems, determine the relationships among the problems. 1. Assign high priority to first-level problems using ABC+VL (airway, breathing, cardiac and circulation problems, vital signs concerns, and life-threatening laboratory values), and attend to these immediately. 2. Next address second-level problems, which immediately follow the first level and include concerns such as changes in mental status, untreated medical issues, acute pain, acute elimination problems, abnormal laboratory results, and risks. 3. Then tend to third-level problems, which are health problems other than those at the first two levels, such as long-term issues in health management, rest, and family coping.

Clinical judgment

You begin caring for a patient by conducting a focused but complete assessment so that you know your patient and can make accurate clinical judgments (see Chapter 16). Knowing the patient involves more than gathering formal assessment data. Knowing develops over time after caring for patients with similar patterns of responses to illness and being able to anticipate health problems. Your initial contact with a patient is an important first step in developing a caring relationship. Encouraging patients to share their stories about their health problems is very useful (e.g., say, "Tell me how you are dealing with . . ." or "Can you share what has been your biggest problem since becoming ill?"). After obtaining a thorough assessment and analyzing assessment data for cues to identify a patient's nursing diagnoses and problems, you develop a plan of care, implement nursing interventions, and evaluate patient outcomes. The process requires clinical decision making using a critical thinking approach Sound clinical judgment ensures therapeutic nursing care, especially when a patient's condition changes. It is important to be thorough. Learn to attend and listen to the patient, look for any cues (obvious or subtle) that point to a pattern of findings, and direct your assessment to explore the pattern further. Never hesitate to ask for assistance when a patient's condition changes.

Nursing care delivery models

is designed to help your patients achieve desirable outcomes. Nursing care delivery models contain the common components of nurse-patient relationship, clinical decision making, methods for patient assignments and work allocation, interprofessional communication, and management of the environment of care (Huber, 2018). Two classic nursing models used to provide patient care in health care agencies are team nursing and primary nursing.

transformational leadership

is focused on change and innovation through team development, serves as a mentor for staff, and develops and supports the moral agency of nurses. Spend time on the unit with the staff sharing ideas, empowering the staff, supporting opportunities to enhance the team, showing appreciation, recognizing team members for a job well done, and holding team members accountable.

Team nursing

care is provided by a group of people led by an RN. The team often includes other RNs, licensed practical nurses, and assistive personnel (APs). To be successful, this model requires effective team leadership, collaboration, and communication

Case management

coordinates and links health care services across all levels of care for patients and their families while streamlining costs and maintaining quality (see Chapter 2). The case-management system is focused on achieving patient outcomes within effective time frames and with available resources (Huber, 2018). Case managers work with patients and families to identify issues and overcome barriers to help patients become healthier (ACMA, n.d.). Current evidence shows case managers link and coordinate health care services with patients and their families while achieving quality cost-effective outcomes (Brown et al., 2017). Case managers, either individually or as part of a team, oversee the management of patients with complex nursing and medical problems (e.g., patients with diabetes mellitus or traumatic brain injury) across all levels of care. Case managers are often advanced practice nurses who, through specific interventions, help to improve patient outcomes, optimize patient safety by facilitating care transitions, decrease length of stay, and lower health care costs. They are accountable for cost management and quality.

Responsibility

efers to the duties and activities that you are employed to perform. A position description outlines your responsibilities as a professional nurse and your expected level of participation as a member of a nursing unit. Responsibility reflects ownership and obligation. An individual who manages employees distributes responsibility, and the employees accept it. Managers need to ensure that staff clearly understand their responsibilities, particularly in the face of change. For example, when health care agencies participate in work redesign, patient care delivery models change significantly. A manager is responsible for clearly defining an RN's role within a new care delivery model. If decentralized decision making is in place, the professional nursing staff needs to be engaged to define the new RN role. Each RN on the team is responsible for knowing how to communicate with all team members and the process for making decisions on the busy nursing unit. For example, nurses are responsible for completing a nursing assessment of all assigned patients and developing a plan of care that is accessible to all team members (see Chapters 16 to 20). As the staff implements the plan of care, the nurse evaluates whether the plan is successful. This responsibility becomes a work ethic for the nurse in delivering excellent patient care.

Principles of Time Management

goal setting, time analysis, priority setting, interruption control, evaluation

Examples of effective team communication strategies

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, and check-backs to restate what a person has said to verify understanding of information. The two-challenge rule allows concerns about safety to be voiced twice. Some patient care settings use different tools to communicate a change in a patient's condition. For example, some use the CUS Tool, which means I am Concerned, I am Uncomfortable, and this is a Safety issue (AHRQ, 2019). Another tool often used by health care agencies to share information is Situation-Background-Assessment-Recommendation (SBAR) (Box 21.6; see Chapter 27) (AHRQ, 2019). When using electronic communication, it is important to communicate the appropriate information to the correct person, always maintaining patient privacy and confidentiality.

Decentralization

is a component of the hierarchical level of decision making found in health care agencies. This management approach allows decisions to be made at the staff level.

Decision making

is a critical skill for an effective leader and manager (Huber, 2018). A nurse executive supports nurse managers by advocating a nursing governance structure that incorporates staff involvement in forming policies and procedures for decision making needed to achieve agency goals. A skilled nurse manager directs and supports a group of staff in applying an agency's nursing philosophy. Thus, it takes a committed nurse executive, excellent nurse managers, and an empowered nursing staff to create an enriching work environment.

Evaluation

is an ongoing process. It does not occur only at the end of an activity. Once you assess a patient's needs and implement interventions for a patient's problem, immediately evaluate whether the interventions were effective and the patient's response. The process of evaluation compares actual patient outcomes with expected outcomes. For example, you assess a foot ulcer of a patient who has diabetes mellitus to determine whether healing has progressed since the last clinic visit. 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. As you care for a patient throughout the day, anticipate when to return to the bedside to evaluate care (e.g., 30 minutes after an oral medication was administered, 15 minutes after an IV fluid has begun infusing, or 60 minutes after discussing discharge instructions with the patient and family caregiver). Focusing on evaluation of a patient's progress lessens the chance of becoming distracted by the tasks of care. It is common to assume that staying focused on planned activities ensures that you will perform care appropriately. However, task orientation does not ensure positive patient outcomes. Learn that at the heart of good organizational skills is the constant inquiry into a patient's condition and progress toward an improved level of health.

Autonomy

is freedom of choice and responsibility for the choices. Autonomy consistent with the scope of professional nursing practice maximizes a nurse's effectiveness (Huber, 2018). With clinical autonomy you make independent decisions about patient care, plan patient care within the scope of professional nursing practice, and implement independent nursing interventions (see Chapter 19). Another type of autonomy for nurses is work autonomy. 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. For example, you have the autonomy to develop and implement a discharge teaching plan based on specific patient needs for your patients and their family caregivers. However, if your unit does not use self-scheduling, you do not have the autonomy to create your own schedule.

Delegation

is the process of assigning part of your responsibility to another qualified person in a specific situation (NCSBN and ANA, 2019). Your state's Nurse Practice Act, along with principles of authority, accountability, and responsibility, provides the basis for effective delegation. Effective delegation results in the achievement of quality, safe patient care; improved efficiency; increased productivity; empowered staff; and skill development

Shared governance

is the typical decentralized structure used within health care agencies today (Huber, 2018). This structure creates an environment in which managers and staff become more actively involved in making decisions to shape the identity and determine the success of a health care agency. 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

Primary nursing

one RN assumes the responsibility for a caseload of patients from admission to discharge. The same nurse provides care for the same patients throughout their hospitalization. When the nurse is not scheduled to work on the unit, directions are left (e.g., in the plan of care) for other RNs to follow. The model became more popular in the 1970s and early 1980s as hospitals began to employ more RNs. It is typically not practiced today because of the high cost of an all-RN staffing model (Huber, 2018). Total patient care is similar to primary nursing. In this model an 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.

Accountability

refers to individuals being answerable for their actions. It involves follow-up and a reflective analysis of decisions and an evaluation of their effectiveness. It means that as a nurse you take responsibility to provide excellent patient care by following standards of practice and agency policies and procedures. You assume responsibility for the outcomes of the actions, clinical judgments, and omissions in providing patient care. You are not accountable for the overall outcomes of patient care, but you are accountable for what you do (i.e., performing the nursing process, performing nursing procedures correctly, communicating effectively with health care team colleagues, and staying current on nursing practice issues). You will sometimes delegate responsibility, but you remain accountable for the care you delegated. For example, you delegate taking your patient's vital signs to an AP. You are responsible for knowing what your patient's vital signs are normally, for recognizing when the vital signs are in the expected range, and for providing appropriate care (e.g., verifying the temperature and giving acetaminophen as ordered when your patient's temperature is elevated).

Authority

refers to the legal ability to perform a task (Huber, 2018). It provides the power for a nurse to make final decisions and give instructions related to the decisions. You use authority to determine whether collaboration was successful. For example, while managing the care of a patient, you discover that one of the members of the health care team, the registered dietitian, did not follow through on a discharge teaching plan. You have the authority to consult with the registered dietitian to understand why the recommendations on the plan of care were not implemented and to review the established plan to ensure that recommended patient teaching is completed.

Effective team development

requires team building and training, trust, communication, and a workplace that facilitates collaboration (

The Five Rights of Delegation

right task right circumstance right person right direction/communication right supervision/evaluation

Right task

to delegate are ones that are included in the delegatee's job description or are included in the health care agency's policies and procedures. Policies and procedures need to describe expectations, limits, and required competency training for the activity.

Responsibilities of a Nurse Manager

• Collaborate with staff to establish annual goals for the unit and the systems needed to accomplish goals (e.g., assignment methods, quality improvement activities, patient education methods). • Monitor professional nursing standards of practice on the unit. • Develop an ongoing staff development plan, including one for new employees. • Recruit new employees (interview and hire). • Conduct routine staff evaluations. • Serve as a role model for positive customer service (customers include patients, families, and other health care team members). • Submit staffing schedules for the unit. • Advocate for the nursing staff to the administration of the agency. • Conduct regular patient rounds and problem solve patient or family complaints. • Establish, monitor, and implement a quality improvement (QI) plan for the unit. • Review and recommend new equipment for the unit. • Conduct regular staff meetings. • Make rounds with health care providers. • Establish and support staff and interprofessional committees.

Characteristics of Effective Leaders

• Develop interpersonal trust and ensure effective communication with individuals and teams. • Have awareness of personal strengths and weaknesses, allowing vulnerabilities to show. • Take initiative and sustain motivation, especially during times of uncertainty. • Seek multiple perspectives and opinions to generate options and solutions when problem solving. • Rebound from setbacks with positivity. • Understand what they can and cannot change. • Schedule time and space to regularly reflect, recharge, and reframe. • Take responsibility for decisions. • Display caring, understanding, and empathy for others. • Motivate and empower others. • Identify need to change and support change effectively. • Use different leadership styles (e.g., transformational, authentic, value-based) appropriately.