Topic 5: Managing Client Care

5 Rights of Delegation

- Right Task (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) - Right Circumstance (Appropriate patient setting, available resources, and other relevant factors) - Right Person (delegating the right tasks to the right person to be performed on the right person) - Right Direction (clear, concise description of the task, including its objective, limits, and expectations) - Right Supervision (appropriate monitoring, evaluation, intervention as needed, and feedback are provided)

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

A new nurse graduate is in orientation on a surgical unit and is being mentored by an experienced nurse. Which action completed by the new nurse graduate requires intervention by the experienced nurse? (Select all that apply.) 1. The new nurse stops documenting about a dressing change to take a patient some water. 2. The new nurse gathered the medications for two different patients at the same time. 3. The new nurse asked an AP to help transfer a patient from the bed to a wheelchair before discharge. 4. The new nurse educates a patient about pain management when administering a pain medication to a patient. 5. The new nurse gathers all equipment necessary to start a new IV site before entering a patient's room.

1,2

A nurse asks an AP to help the patient in Room 418 walk to the bathroom right now. The nurse tells the AP that the patient needs the assistance of one person and the use of a walker. The nurse also tells the AP that the patient's oxygen can be removed while he goes to the bathroom but to make sure that when it is put back on the flowmeter is still at 2 L. The nurse also instructs the AP to make sure the side rails are up and the bed alarm is reset after the patient gets back in bed. Which of the following components of the "Five Rights of Delegation" were used by the nurse? (Select all that apply.) 1. Right task 2. Right circumstance 3. Right person 4. Right directions and communication 5. Right supervision and evaluation

1,2,3,4

The nurse manager from the surgical unit was awarded the nursing leadership award for practice of transformational leadership. Which of the following are characteristics or traits of transformational leadership displayed by the award winner? (Select all that apply.) 1. The nurse manager regularly rounds on staff to gather input on unit decisions. 2. The nurse manager sends thank-you notes to staff in recognition of a job well done. 3. The nurse manager sends memos to staff about decisions that the manager has made regarding unit policies. 4. The nurse manager has an "innovation idea box" to which staff are encouraged to submit ideas for unit improvements. 5. The nurse manager develops a philosophy of care for the staff.

1,2,4

A nurse received change-of-shift report on these four patients and starts rounding. Which patient does the nurse need to focus on as a priority? 1. The patient who had abdominal surgery 2 days ago who is requesting pain medication 2. A patient admitted yesterday with atrial fibrillation who now has a decreased level of consciousness 3. A patient with a wound drain who needs teaching before discharge in the early afternoon 4. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery

2

A nurse is calling a patient's health care provider about a problem the patient is having following surgery. The health care organization uses the SBAR system in reporting patient problems. Put the statements in order according to the SBAR system. 1. Would it be possible to give the patient an antiemetic to help with the patient's nausea and comfort? 2. The patient is experiencing nausea right now. The nausea has worsened over the past hour. He states he feels as though he is going to get sick. 3. The patient had surgery earlier today to remove a tumor in the colon. He was admitted to the surgical unit 4 hours ago. He has a nasogastric (NG) tube in place. There is no postoperative order for an antiemetic. 4. The patient denies pain and vital signs are stable. B/P 114/68; pulse 76; respiratory rate 20; temperature 98.6° F. The surgical dressing is dry and intact. The NG tube is intact and draining light brown fluid. It flushes well, and placement was confirmed using pH testing of gastric contents. The patient does not want to roll onto his side because of the nausea.

2,3,4,1

At 1200 the registered nurse (RN) says to the assistive personnel (AP), "You did a good job walking Mrs. Taylor by 0930. I saw that you recorded her pulse before and after the walk. I saw that Mrs. Taylor walked in the hallway barefoot. For safety, the next time you walk a patient, you need to make sure that the patient wears slippers or shoes. Please walk Mrs. Taylor again by 1500." Which characteristics of positive feedback did the RN use when talking to the AP? (Select all that apply.) 1. Feedback is given immediately. 2. Feedback focuses on one issue. 3. Feedback offers concrete details. 4. Feedback identifies ways to improve. 5. Feedback focuses on changeable things. 6. Feedback is specific about what is done incorrectly only.

2,3,4,5

Which example demonstrates a nurse performing the skill of evaluation? 1. The nurse explains the side effects of the new blood pressure medication ordered for the patient. 2. The nurse asks a patient to rate pain on a scale of 0 to 10 before administering a pain medication. 3. After completing a teaching session, the nurse observes a patient drawing up and administering an insulin injection. 4. The nurse changes a patient's leg ulcer dressing using aseptic technique.

3

While administering medications, a nurse realizes that a prescribed dose of a medication was not given. The nurse acts by completing an incident report and notifying the patient's health care provider. Which of the following is the nurse exercising? 1. Authority 2. Responsibility 3. Accountability 4. Decision making

3

A nurse performs the following four steps in delegating a task to an AP. Place the steps in the order of appropriate delegation. 1. Do you have any questions about walking Mr. Malone? 2. Before you take him for his walk to the end of the hallway and back, please take and record his pulse rate. 3. In the next 30 minutes please assist Mr. Malone in Room 418 with his afternoon walk. 4. I will make sure that I check with you in about 40 minutes to see how the patient did.

3,2,4,1

Which task is appropriate for a registered nurse (RN) to delegate to an AP? 1. Explaining to the patient the preoperative preparation before the surgery in the morning 2. Administering the ordered antibiotic to the patient before surgery 3. Obtaining the patient's signature on the surgical informed consent 4. Helping the patient to the bathroom before leaving for the operating room

4

Low priority

Actual or potential problems that are not directly related to a patient's illness or disease.

evaluation

Apply to: - ___ process - patient response - therapy efficacy - patient and expected outcomes ongoing process when expected outcomes are not met, ___ reveals the need to continue current therapies for a long period, revise approaches to care, or introduce new therapies keep a focus on ___ of the patient's progress lessens the chance of becoming distracted by tasks of care

Steps to Effective Delegation

Assess knowledge and skills of delegatee Match tasks to delegatee's skills Communicate clearly - task, outcome, time Listen attentively Provide feedback *evaluation of the staff member's performance, achievement of the patient's outcomes, the communication process used, and any problems or concerns that occurred.

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.

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.

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.

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.

Magnet Recognition

Based on 5 model components - Transformational leadership - Structural empowerment - Exemplary professional practice - New knowledge, innovation, and improvements - Empirical quality results hospital that is certified has a transformed culture with a practice environment that is dynamic, autonomous, collaborative, and positive for nurses 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.

Leadership skills for nursing students

Clinical Care Coordination Team Communication Knowledge Building Delegation

Decision Making

Critical component of an effective leader and manager Encompasses: - Responsibility - Autonomy (occurs in degrees) - Authority - Accountability

Priority setting

Decide priorities after forming picture of patient's total needs 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 Patients can have all 3 priorities, so make careful judgment identify which patient requires assessment first by relying on info from: - change of shift report - your own most recent assessment of patient - information from medical record

Organizational skills

Do the right things - effective Do things right - efficient Inform and prepare patient Clean and organize work area Keep patient's needs at the center of attention

Intermediate priority

Nonemergency, non-life-threatening actual or potential needs that a patient and family members are experiencing.

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. •emphasizes a high degree of collaboration with other health care professionals. •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.

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

Team communication

Respect others' ideas. Share information. Stay informed. Strive to improve your communication. Share expectations of communication. Use structured communication techniques communication tools: - briefings or short discussions among team members - Group rounds on patients - Callouts to share critical info - check backs to restate what person says - two-challenge rule allows concerns to be voiced twice - "I'm Concerned, Uncomfortable, don't feel Safe" (CUS) - SBAR

TEEAMS approach

Time, Empowerment, Enthusiasm, Appreciation, Management, and Support •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.

Delegation

Transfers responsibility while remaining accountable for outcomes Requires knowing which skills are transferable >Know your state's Nurse Practice Act. Results in improved quality, safe patient care, improved efficiency, increased productivity, an empowered staff, and skill development of others essential part of management constant communication required

Staff involvement

Transformational leadership All staff benefit from knowledge and skills of entire work group Requires skilled communication

Nurse Practice Act

along with principles of authority, accountability, and responsibility, is the basis for effective delegation.

clinical decisions

apply nursing process know your patient -requires learning a patient's typical patterns of responses and his or her current situation and knowing the patient as an individual accurate clinical decision-making keeps you focused on proper course of action -undesirable outcomes will occur if inaccurate use clinical decision making practices - never hesitate to seek for assistance if patient's conditions change

Use of Resources

appropriate ___ is important aspect of clinical care coordination - include members of health care team in this case never hesitate to have staff help you Consulting with experienced RN Leader knows his or her limitations; seek guidance and support administration of patient care occurs more smoothly when staff members work together

Nurse responsibilities with delegation

can delegate care activities to NAP, but do not delegate nursing process of assessment, diagnosis, planning, and evaluation to NAP responsible for patient teaching responsible for assessment of patient's ongoing status if patient is stable, can delegate vitals to NAP

nurse executive

clinical and business leader concerned with maximizing quality of care and cost-effectiveness while maintaining relationships and professional satisfaction of the staff establishes philosophy for nursing that enables managers and staff to provide quality nursing care building empowered nursing team begins with ___

Interprofessional Collaboration

critical among nurses and health care providers to the delivery of quality, safe patient care, and the creation of a positive work culture for practitioners. 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 - work with individuals of other professions - use knowledge of one's own role and those of other professions - communicate with patients, families, communities, and other health care professionals

problem solving committees or professional shared governance councils

establish nursing practice chaired by senior clinical staff nurses; these groups establish and maintain care standards for nursing practice on their work unit.

the committee

establishes methods to ensure that all staff have input or participation on practice issues managers are not always on this, but receive regular reports of ___ progress

High priority

immediate threat to patient survival or safety

Time management

make priority to-do list setting goals to help you complete one task before starting another requires ability to anticipate the activities of the day and combine activities when possible - remain goal oriented - identify priorities - establish personal goals

Building a Strong Nursing Team

nursing team works together to achieve the best outcomes for patients requires team building and training, trust, communication, and a workplace that facilitates collaboration results in fewer reports of missed nursing care; leads to improved quality and safety for patients begins with nurse executive - transformational leadership - TEEAMS approach

Wherever you practice nursing you

use critical thinking use health care resources use time productively set priorities collaborate with the health care team apply leadership skills

Patient and family centered care

• 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 is the patient or family member as the source of control and full partner in providing care. Core concepts - respect and dignity (care provided is given on the basis of the patient's and family's knowledge, values, beliefs, and cultural background) - information sharing (HCPs communicate and share info, so it's received timely, complete, and accurate) - participation (encouraged and supported to participate) - collaboration (patients fully engaged and health care leaders work with pts and families)

Case management

•a care management approach that coordinates and links health care services to patients and their families while streamlining costs and maintaining quality. •emphasizes supervision, not necessarily providing direct care, but overseeing the care delivered by other staff and health care professionals. •Communication and use of available resources promote quality cost-effective outcomes in this model. 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.

Decentralized management

•component of the hierarchical level of decision making found in health care institutions. decision making occurs at the level of the staff. •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. manager directs and supports decision making

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. Traditional models - team nursing - primary nursing Today's models - Patient-centered care - total patient care - case management

shared governance

•dynamic process that promotes decision making, accountability, and empowerment in staff nurses and enables them to control their nursing practice. typical decentralized structure used within health care organizations today creates an environment in which managers and staff become more actively involved in making decisions to shape identity and determine he success of a health care organization

Clinical care coordination

•includes clinical decision making, priority setting, use of organizational skills and resources, time management, and evaluation. activities require use of critical reflection, critical reasoning, and clinical judgement important first step in developing a caring relationship with a patient use critical thinking approach

Primary nursing

•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. developed to place RNs at the bedside and improve accountability of nursing for patient outcomes and professional relationships among staff members

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.

Nurse manager

•uses transformational leadership and 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. Transformational Leadership causes: •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 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 greatest challenge is communication with staff - try various approaches to communicate