Ati case study teamwork and collaboration

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NURSING LEADERSHIP AND MANAGEMENT I

Nursing Leadership and Management REVIEW MODULE EDITION 8.0

Contributors Honey C. Holman, MSN, RN

Debborah Williams, MSN, RN

Sheryl Sommer, PhD, RN, CNE

Janean Johnson, MSN, RN, CNE

Brenda S. Ball, MEd, BSN, RN

Terri Lemon, DNP, MSN, RN

Consultants Tracey Bousquet, BSN, RN

Julie Traynor, MSN, RN

INTELLECTUAL PROPERTY NOTICE ATI Nursing is a division of Assessment Technologies Institute®, LLC.

Copyright © 2019 Assessment Technologies Institute, LLC. All rights reserved.

The reproduction of this work in any electronic, mechanical or other means, now known or hereafter

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graphics, and text, are subject to trademark, service mark, trade dress, copyright, and/or other intellectual

property rights or licenses held by Assessment Technologies Institute, LLC, one of its affiliates, or by

third parties who have licensed their materials to Assessment Technologies Institute, LLC.

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II CONTENT MASTERY SERIES

IMPORTANT NOTICE TO THE READER Assessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for

informational and educational purposes only and may be modified or updated by the publisher at any time. This

publication is not providing medical advice and is not intended to be a substitute for professional medical advice,

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in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect

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the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice,

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in this book to procedures to be employed when rendering emergency care to the sick and injured are provided solely

as a general guide. Other or additional safety measures may be required under particular circumstances. This book

is not intended as a statement of the standards of care required in any particular situation, because circumstances

and a patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this book

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Director of content review: Kristen Lawler

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NURSING LEADERSHIP AND MANAGEMENT USER’S GUIDE III

User’s Guide Welcome to the Assessment Technologies Institute®

Nursing Leadership and Management Review Module Edition 8.0. The mission of ATI’s Content Mastery Series®

Review Modules is to provide user-friendly compendiums of nursing knowledge that will:

● Help you locate important information quickly. ● Assist in your learning efforts. ● Provide exercises for applying your nursing knowledge. ● Facilitate your entry into the nursing profession as a

newly licensed nurse.

This newest edition of the Review Modules has been redesigned to optimize your learning experience. We’ve fit more content into less space and have done so in a way that will make it even easier for you to find and understand the information you need.

ORGANIZATION Chapters in this Review Module use a nursing concepts organizing framework, beginning with an overview describing the central concept and its relevance to nursing. Subordinate themes are covered in outline form to demonstrate relationships and present the information in a clear, succinct manner. Some chapters have sections that group related concepts and contain their own overviews. These sections are included in the table of contents.

ACTIVE LEARNING SCENARIOS AND APPLICATION EXERCISES

Each chapter includes opportunities for you to test your knowledge and to practice applying that knowledge. Active Learning Scenario exercises pose a nursing scenario and then direct you to use an ATI Active Learning Template (included at the back of this book) to record the important knowledge a nurse should apply to the scenario. An example is then provided to which you can compare your completed Active Learning Template. The Application Exercises include NCLEX-style questions (multiple- choice and multiple-select items), providing you with opportunities to practice answering the kinds of questions you might expect to see on ATI assessments or the NCLEX. After the Application Exercises, an answer key is provided, along with rationales.

NCLEX® CONNECTIONS To prepare for the NCLEX, it is important to understand how the content in this Review Module is connected to the NCLEX test plan. You can find information on the detailed test plan at the National Council of State Boards of Nursing’s website, www.ncsbn.org. When reviewing content in this Review Module, regularly ask yourself,

“How does this content fit into the test plan, and what types of questions related to this content should I expect?”

To help you in this process, we’ve included NCLEX Connections at the beginning of each unit and with each question in the Application Exercises Answer Keys. The NCLEX Connections at the beginning of each unit point out areas of the detailed test plan that relate to the content within that unit. The NCLEX Connections attached to the Application Exercises Answer Keys demonstrate how each exercise fits within the detailed content outline.

These NCLEX Connections will help you understand how the detailed content outline is organized, starting with major client needs categories and subcategories and followed by related content areas and tasks. The major client needs categories are: ● Safe and Effective Care Environment

◯ Management of Care ◯ Safety and Infection Control

● Health Promotion and Maintenance ● Psychosocial Integrity ● Physiological Integrity

◯ Basic Care and Comfort ◯ Pharmacological and Parenteral Therapies ◯ Reduction of Risk Potential ◯ Physiological Adaptation

An NCLEX Connection might, for example, alert you that content within a chapter is related to:

● Management of Care ◯ Advance Directives

■ Provide clients with information about advance directives.

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IV USER’S GUIDE CONTENT MASTERY SERIES

QSEN COMPETENCIES As you use the Review Modules, you will note the integration of the Quality and Safety Education for Nurses (QSEN) competencies throughout the chapters. These competencies are integral components of the curriculum of many nursing programs in the United States and prepare you to provide safe, high-quality care as a newly licensed nurse. Icons appear to draw your attention to the six QSEN competencies.

Safety: The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others.

Patient-Centered Care: The provision of caring and compassionate, culturally sensitive care that addresses clients’ physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values.

Evidence-Based Practice: The use of current knowledge from research and other credible sources, on which to base clinical judgment and client care.

Informatics: The use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically based nursing practice.

Quality Improvement: Care related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients’ needs.

Teamwork and Collaboration: The delivery of client care in partnership with multidisciplinary members of the health care team to achieve continuity of care and positive client outcomes.

ICONS Icons are used throughout the Review Module to draw your attention to particular areas. Keep an eye out for these icons.

This icon is used for NCLEX Connections.

This icon indicates gerontological considerations, or knowledge specific to the care of older adult clients.

This icon is used for content related to safety and is a QSEN competency. When you see this icon, take note of safety concerns or steps that nurses can take to ensure client safety and a safe environment.

This icon is a QSEN competency that indicates the importance of a holistic approach to providing care.

This icon, a QSEN competency, points out the integration of research into clinical practice.

This icon is a QSEN competency and highlights the use of information technology to support nursing practice.

This icon is used to focus on the QSEN competency of integrating planning processes to meet clients’ needs.

This icon highlights the QSEN competency of care delivery using an interprofessional approach.

This icon appears at the top-right of pages and indicates availability of an online media supplement (a graphic, animation, or video). If you have an electronic copy of the Review Module, this icon will appear alongside clickable links to media supplements. If you have a hard copy version of the Review Module, visit www.atitesting.com for details on how to access these features.

FEEDBACK ATI welcomes feedback regarding this Review Module. Please provide comments to comments@atitesting.com.

As needed updates to the Review Modules are identified, changes to the text are made for subsequent printings of the book and for subsequent releases of the electronic version. For the printed books, print runs are based on when existing stock is depleted. For the electronic versions, a number of factors influence the update schedule. As such, ATI encourages faculty and students to refer to the Review Module addendums for information on what updates have been made. These addendums, which are available in the Help/FAQs on the student site and the Resources/eBooks & Active Learning on the faculty site, are updated regularly and always include the most current information on updates to the Review Modules.

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NURSING LEADERSHIP AND MANAGEMENT TABLE OF CONTENTS V

Table of Contents

NCLEX® Connections 1

CHAPTER 1 Managing Client Care 3

Leadership and management 3

Critical thinking 4

Assigning, delegating, and supervising 7

Staff education 10

Quality improvement 11

Performance appraisal, peer review, and disciplinary action 13

Conflict resolution 14

Resource management 17

NCLEX® Connections 21

CHAPTER 2 Coordinating Client Care 23

NCLEX® Connections 33

CHAPTER 3 Professional Responsibilities 35

Client rights 35

Advocacy 35

Informed consent 36

Advance directives 37

Confidentiality and information security 38

Information technology 40

Legal practice 40

Disruptive behavior 45

Ethical practice 45

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VI TABLE OF CONTENTS CONTENT MASTERY SERIES

NCLEX® Connections 49

CHAPTER 4 Maintaining a Safe Environment 51

Culture of safety 51

QSEN competencies in nursing programs 52

Handling infectious and hazardous materials 52

Safe use of equipment 53

Specific risk areas 53

Home safety 55

Ergonomic principles 58

NCLEX® Connections 63

CHAPTER 5 Facility Protocols 65

Reporting incidents 65

Disaster planning and emergency response 65

Security plans 71

References 75

Active Learning Templates A1 Basic Concept A1

Diagnostic Procedure A3

Growth and Development A5

Medication A7

Nursing Skill A9

System Disorder A11

Therapeutic Procedure A13

Concept Analysis A15

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NURSING LEADERSHIP AND MANAGEMENT NCLEX® CONNECTIONS 1

NCLEX® Connections

When reviewing the following chapter, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:

Management of Care ASSIGNMENT, DELEGATION AND SUPERVISION Evaluate delegated tasks to ensure correct completion of activity.

Evaluate effectiveness of staff members� time management skills.

CASE MANAGEMENT: Practice and advocate for cost effective care.

CONCEPTS OF MANAGEMENT Manage conflict among clients and health care staff.

Identify roles/responsibilities of health care team members.

ESTABLISHING PRIORITIES Apply knowledge of pathophysiology when establishing priorities for interventions with multiple clients.

Prioritize the delivery of client care.

PERFORMANCE IMPROVEMENT (QUALITY IMPROVEMENT): Participate in performance improvement projects and quality improvement processes.

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NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 MANAGING CLIENT CARE 3

CHAPTER 1 Managing Client Care

Managing client care requires leadership, management skills, and knowledge to effectively coordinate and carry out client care.

To effectively manage client care, a nurse must develop knowledge and skills in several areas, including leadership, management, critical thinking, clinical reasoning, clinical judgment, prioritization, time management, assigning, delegating, supervising, staff education, quality improvement, performance appraisal, peer review, disciplinary action, conflict resolution, and cost-effective care.

Leadership and management ● Management is the process of planning, organizing,

directing, and coordinating the work within an organization.

● Leadership is the ability to inspire others to achieve a desired outcome.

● Effective managers usually possess good leadership skills. However, effective leaders are not always in a management position.

● Managers have formal positions of power and authority. Leaders might have only the informal power afforded them by their peers.

● One cannot be a leader without followers.

LEADERSHIP

LEADERSHIP STYLES Most can be categorized as authoritative, democratic, or laissez-faire. The nurse might need to use any of these leadership styles depending on the situation.

Authoritative ● Makes decisions for the group. ● Motivates by coercion. ● Communication occurs down the chain of command, or

from the highest management level downward through other managers to employees.

● Work output by staff is usually high: good for crisis situations and bureaucratic settings.

● Effective for employees with little or no formal education.

Democratic ● Includes the group when decisions are made. ● Motivates by supporting staff achievements. ● Communication occurs up and down the chain

of command. ● Work output by staff is usually of good quality when

cooperation and collaboration are necessary.

Laissez-faire ● Makes very few decisions, and does little planning. ● Motivation is largely the responsibility of individual

staff members. ● Communication occurs up and down the chain of

command and between group members. ● Work output is low unless an informal leader evolves

from the group. ● Effective with professional employees.

CHARACTERISTICS OF LEADERS ● Initiative ● Inspiration ● Energy ● Positive attitude ● Communication skills ● Respect ● Problem-solving and critical-thinking skills ● A combination of personality traits and leadership skills ● Leaders influence willing followers to move

toward a goal. ● Leaders have goals that might differ from those of

the organization. ● Transformational leaders empower and inspire

followers to achieve a common, long-term vision. ● Transactional leaders focus on immediate problems,

maintaining the status quo and using rewards to motivate followers.

● Authentic leaders inspire others to follow them by modeling a strong internal moral code.

Emotional intelligence ● Emotional intelligence is the ability of an individual to

perceive and manage the emotions of self and others. ● The nurse must be able to perceive and understand their

own emotions and the emotions of the client and family in order to provide client-centered care.

● Emotional intelligence is also an important characteristic of the successful nurse leader.

● Emotional intelligence is developed through understanding the concept and applying it to practice in everyday situations.

The emotionally intelligent leader: ● Has insight into the emotions of members of the team. ● Understands the perspective of others. ● Encourages constructive criticism and is open to

new ideas. ● Manages emotions and channels them in a positive

direction, which in turn helps the team accomplish its goals.

● Is committed to the delivery of high-quality client care. ● Refrains from judgment in controversial or emotionally-

charged situations until facts are gathered.

CHAPTER 1

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MANAGEMENT The five major management functions are planning, organizing, staffing, directing, and controlling.

PLANNING: The decisions regarding what needs to be done, how it will be done, and who is going to do it

ORGANIZING: The organizational structure that determines the lines of authority, channels of communication, and where decisions are made

STAFFING: The acquisition and management of adequate staff and staffing mix

DIRECTING: The leadership role assumed by a manager that influences and motivates staff to perform assigned roles

CONTROLLING: The evaluation of staff performance and evaluation of unit goals to ensure identified outcomes are being met

CHARACTERISTICS OF MANAGERS ● Hold formal positions of authority and power ● Possess clinical expertise ● Network with members of the team ● Coach subordinates ● Make decisions about the function of the organization,

including resources, budget, hiring, and firing

Critical thinking Critical thinking is used when analyzing client issues and problems. Thinking skills include interpretation, analysis, evaluation, inference, and explanation. These skills assist the nurse to determine the most appropriate action to take.

● Critical thinking reflects upon the meaning of statements, examines available data, and uses reason to make informed decisions.

● Critical thinking is necessary to reflect and evaluate from a broader scope of view.

● Sometimes one must think “outside the box” to find solutions that are best for clients, staff, and the organization.

Clinical reasoning ● Clinical reasoning is the mental process used when

analyzing the elements of a clinical situation and using analysis to make a decision. The nurse continues to use clinical reasoning to make decisions as the client’s situation changes.

● Clinical reasoning supports the clinical decision-making process by: ◯ Guiding the nurse through the process of assessing

and compiling data. ◯ Selecting and discarding data based on relevance. ◯ Using nursing knowledge to make decisions

about client care. Problem solving is a part of decision-making.

Clinical judgment ● Clinical judgment is the decision made regarding a

course of action based on a critical analysis of data. ● Clinical judgment considers the client’s needs when

deciding to take an action, or modify an intervention based on the client’s response.

● The nurse uses clinical judgment to: ◯ Analyze data and related evidence. ◯ Ascertain the meaning of the data and evidence. ◯ Apply knowledge to a clinical situation. ◯ Determine client outcomes desired and/or achieved as

indicated by evidence-based practices.

PRIORITIZATION AND TIME MANAGEMENT

● Nurses must continuously set and reset priorities in order to meet the needs of multiple clients and to maintain client safety.

● Priority setting requires that decisions be made regarding the order in which:

◯ Clients are seen. ◯ Assessments are completed. ◯ Interventions are provided. ◯ Steps in a client procedure are completed. ◯ Components of client care are completed.

● Establishing priorities in nursing practice requires that the nurse make these decisions based on evidence obtained:

◯ During shift reports and other communications with members of the health care team.

◯ Through careful review of documents. ◯ By continuously and accurately collecting client data.

PRIORITIZATION PRINCIPLES IN CLIENT CARE Prioritize systemic before local (“life before limb”).

Prioritizing interventions for a client in shock over interventions for a client who has a localized limb injury

Prioritize acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation).

Prioritizing the care of a client who has a new injury/ illness (mental confusion, chest pain) or an acute exacerbation of a previous illness over the care of a client who has a long-term chronic illness

Prioritize actual problems before potential future problems.

Prioritizing administration of medication to a client experiencing acute pain over ambulation of a client at risk for thrombophlebitis

Listen carefully to clients and don’t assume.

Asking a client who has a new diagnosis of diabetes mellitus what they feel is most important to learn about disease management.

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NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 MANAGING CLIENT CARE 5

Recognize and respond to trends vs. transient findings.

Recognizing a gradual deterioration in a client’s level of consciousness and/or Glasgow Coma Scale score

Recognize indications of medical emergencies and complications vs. expected findings.

Recognizing indications of increasing intracranial pressure in a client who has a new diagnosis of a stroke vs. the findings expected following a stroke

Apply clinical knowledge to procedural standards to determine the priority action.

Recognizing that the timing of administration of antidiabetic and antimicrobial medications is more important than administration of some other medications

PRIORITY-SETTING FRAMEWORKS

Maslow’s hierarchy (1.1)

The nurse should consider this hierarchy of human needs when prioritizing interventions. For example, the nurse should prioritize a client’s: ● Need for airway, oxygenation (or breathing), circulation,

and potential for disability over need for shelter. ● Need for a safe and secure environment over a need

for socialization.

Airway breathing circulation (ABC) framework ● The ABC framework identifies, in order, the three basic

needs for sustaining life. ◯ An open airway is necessary for breathing, so it is the

highest priority. ◯ Breathing is necessary for oxygenation of the

blood to occur. ◯ Circulation is necessary for oxygenated blood to reach

the body’s tissues. ● The severity of manifestations should also be

considered when determining priorities. A severe circulation problem can take priority over a minor breathing problem.

● Some frameworks also include a “D” for disability and “E” for exposure.

PRIORITY INTERVENTIONS ● First: Airway

◯ Identify an airway concern (obstruction, stridor). ◯ Establish a patent airway if indicated. ◯ Recognize that 3 to 5 min without oxygen

causes irreversible brain damage secondary to cerebral anoxia.

● Second: Breathing ◯ Assess the effectiveness of breathing (apnea,

depressed respiratory rate). ◯ Intervene as needed (reposition, administer naloxone).

● Third: Circulation ◯ Identify circulation concern (hypotension,

dysrhythmia, inadequate cardiac output, compartment syndrome).

◯ Institute actions to reverse or minimize circulatory alteration.

● Fourth: Disability ◯ Assess for current or evolving disability (neurological

deficits, stroke in evolution). ◯ Implement actions to slow down development

of disability. ● Fifth: Exposure

◯ Remove the client’s clothing to allow for a complete assessment or resuscitation.

◯ Implement measures to reduce the risk for hypothermia (provide warm blankets and IV solutions or use cooling measures for clients exposed to extreme heat).

Safety/risk reduction ● Look first for a safety risk. For example, is there a

finding that suggests a risk for airway obstruction, hypoxia, bleeding, infection, or injury?

● Next ask, “What’s the risk to the client?” and “How significant is the risk compared to other posed risks?”

● Give priority to responding to whatever finding poses the greatest (or most imminent) risk to the client’s physical well-being.

Assessment/data collection first

Use the nursing process to gather pertinent information prior to making a decision regarding a plan of action. For example, determine if additional information is needed prior to calling the provider to ask for pain medication for a client.

Survival potential ● Use this framework for situations in which health

resources are extremely limited (mass casualty, disaster triage).

● Give priority to clients who have a reasonable chance of survival with prompt intervention. Clients who have a limited likelihood of survival even with intense intervention are assigned the lowest priority.

1.1 Maslow’s hierarchy of needs

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Least restrictive/least invasive ● Select interventions that maintain client safety while

posing the least amount of restriction to the client. For example, if a client who has a high fall risk index is getting out of bed without assistance, move the client closer to the nurses’ work area rather than choosing to apply restraints.

● Select interventions that are the least invasive. For example, bladder training for the incontinent client is a better option than an indwelling urinary catheter.

Acute vs. chronic, urgent vs. nonurgent, stable vs. unstable ● A client who has an acute problem takes priority over a

client who has a chronic problem. ● A client who has an urgent need takes priority over a

client who has a nonurgent need. ● A client who has unstable findings takes priority over a

client who has stable findings.

Evidence-based practice ● Use current data to make informed clinical decisions to

provide the best practice. Best practice is determined by current research collected from several sources that have desirable outcomes.

● Use knowledge of evidence-based practice to guide prioritization of care and interventions (responding to clients experiencing wound dehiscence or crisis). For example, initiating CPR in the proper steps for a client experiencing cardiac arrest.

Methods to promote evidence-based practice ● Use a variety of sources of research. ● Keep current on new research by reading professional

journals and collaborating with other nurses and professionals in other disciplines.

● Change traditional nursing practice with new research-based practices.

TIME MANAGEMENT Organize care according to client care needs and priorities.

● What must be done immediately (administration of analgesic or antiemetic, assessment of unstable client)?

● What must be done by a specific time to ensure client safety, quality care, and compliance with facility policies and procedures (routine medication administration, vital signs, blood glucose monitoring)?

● What must be done by the end of the shift (ambulation of the client, discharge and/or discharge teaching, dressing change)?

● What can the nurse delegate? ◯ What tasks can only the RN perform? ◯ What client care responsibilities can the nurse

delegate to other health care team members (practical nurses [PNs] and assistive personnel [APs])?

Use time-saving strategies and avoid time wasters. (1.2) ● Good time management:

◯ Facilitates greater productivity. ◯ Decreases work-related stress. ◯ Helps ensure the provision of quality client care. ◯ Enhances satisfaction with care provided.

1.2 Time management examples

Time savers Documenting nursing interventions as soon as possible after completion to facilitate accurate and thorough documentation Grouping activities that are to be performed on the same client or are in close physical proximity to prevent unnecessary walking Estimating how long each activity will take and planning accordingly Mentally envisioning the procedure to be performed and gathering all equipment prior to entering the client’s room Taking time to plan care and taking priorities into consideration Delegating activities to other staff when client care workload is beyond what can be handled by one nurse Enlisting the aid of other staff when a team approach is more efficient than an individual approach Completing more difficult or strenuous tasks when energy level is high Avoiding interruptions and graciously but assertively saying “no” to unreasonable or poorly-timed requests for help Setting a realistic standard for completion of care and level of performance within the constraints of assignment and resources Completing one task before beginning another task Breaking large tasks into smaller tasks to make them more manageable Using an organizational sheet to plan care Using breaks to socialize with staff

Time wasters Documenting at the end of the shift all client care provided and assessments done Making repeated trips to the supply room for equipment Providing care as opportunity arises regardless of other responsibilities Missing equipment when preparing to perform a procedure Failing to plan or managing by crisis Being reluctant to delegate or under-delegating Not asking for help when needed or trying to provide all client care independently Procrastinating: delaying time-consuming, less desirable tasks until late in the shift Agreeing to help other team members with lower priority tasks when time is already compromised Setting unrealistic standards for completion of care and level of performance within constraints of assignment and resources Starting several tasks at once and not completing tasks before starting others Not addressing low level of skill competency, increasing time on task Providing care without a written plan Socializing with staff during client care time

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NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 MANAGING CLIENT CARE 7

● Poor time management: ◯ Impairs productivity. ◯ Leads to feelings of being overwhelmed and stressed. ◯ Increases omission of important tasks. ◯ Creates dissatisfaction with care provided.

Time management is a cyclic process. ● Time initially spent developing a plan will save time

later and help to avoid management by crisis. ● Set goals and plan care based on established priorities

and thoughtful utilization of resources. ● Complete one client care task before beginning the next,

starting with the highest priority task. ● Reprioritize remaining tasks based on continual

reassessment of client care needs. ● At the end of the day, perform a time analysis and

determine if time was used wisely.

TIME MANAGEMENT AND TEAMWORK ● Be cognizant of assistance needed by other health care

team members. ● Offer to help when unexpected crises occur. ● Assist other team members with provision of care when

experiencing a period of down time.

TIME MANAGEMENT AND SELF-CARE ● Take time for yourself. ● Schedule time for breaks and meals. ● Take physical and mental breaks from work

and the unit.

Assigning, delegating, and supervising

Assigning is the process of transferring the authority, accountability, and responsibility of client care to another member of the health care team.

Delegating is the process of transferring the authority and responsibility to another team member to complete a task, while retaining the accountability.

Supervising is the process of directing, monitoring, and evaluating the performance of tasks by another member of the health care team.

Nurses must delegate appropriately and supervise adequately to ensure that clients receive safe, quality care. (1.3) ● Delegation decisions are based on individual client

needs, facility policies and job descriptions, state nurse practice acts, and professional standards. The nurse should consider legal/ethical concerns when assigning and delegating.

● The nurse leader should recognize limitations and use available information and resources to make the best possible decisions at the time. The nurse must remember that it is their responsibility to ensure that clients receive safe, effective nursing care even in tasks delegated to others.

● Nurses must follow the ANA codes of standards in delegating and assigning tasks.

ASSIGNING Assigning is performed in a downward or lateral manner with regard to members of the health care team.

CLIENT FACTORS ● Condition of the client and level of care needed ● Specific care needs (cardiac monitoring,

mechanical ventilation) ● Need for special precautions (isolation precautions, fall

precautions, seizure precautions) ● Procedures requiring a significant time commitment

(extensive dressing changes or wound care)

HEALTH CARE TEAM FACTORS ● Knowledge and skill level of team members ● Amount of supervision necessary ● Staffing mix (RNs, PNs, APs) ● Nurse-to-client ratio ● Experience with similar clients ● Familiarity of staff member with unit

ADDITIONAL FACTORS When a nurse receives an unsafe assignment, they should take the following actions. ● Bring the unsafe assignment to the attention

of the scheduling/charge nurse and negotiate a new assignment.

● If no resolution is arrived at, take the concern up the chain of command.

● If a satisfactory resolution is still not arrived at, the nurse should file a written protest to the assignment (an assignment despite objection [ADO] or document of practice situation [DOPS]) with the appropriate administrator.

● Failure to accept the assignment without following the proper channels can be considered client abandonment.

MAKING CLIENT ROOM ASSIGNMENTS The nurse should consider client age and diagnosis, as well as client safety, comfort, privacy, and infection control needs when planning client room assignments.

Private rooms Private rooms are required for clients who have an infectious disease that requires airborne precautions, or clients who require a protective environment.

Private rooms are preferred for clients who are on droplet and contact precautions. These clients can cohort if no private rooms are available and if all of the following are true. ● The clients have the same active infection with the same

micro-organisms. ● The clients remain at least 3 feet away from each other. ● The clients have no other existing infection.

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A private room is also preferred for the following clients. ● Client who are agitated ● Client who have dementia and a history of wandering ● Clients who require a quiet environment (those at risk

for increased intracranial pressure [stroke, traumatic brain injury])

● Clients who are at risk for sensory overload (those who are having pain, are acutely ill, have invasive tubes [nasogastric, IVs, endotracheal], or have reduced cognitive function [head injury])

● Clients who require privacy (those who are near death)

Other considerations ● A client who is confused or disoriented should be

assigned a room away from noise and away from exits. ● Children who are transitioning from a critical care unit

to a lower level of care should be assigned a room near the nurses station and with a roommate of similar age.

DELEGATING AND SUPERVISING A licensed nurse is responsible for providing clear directions when a task is initially delegated and for periodic reassessment and evaluation of the outcome of the task.

● RNs delegate to other RNs, PNs, and APs. ◯ RNs must be knowledgeable about the applicable state

nurse practice act and regulations regarding the use of PNs and APs.

◯ RNs delegate tasks so that they can complete higher level tasks that only RNs can perform. This allows more efficient use of all members of the health care team.

● PNs can delegate to other PNs and APs.

DELEGATION FACTORS ● Nurses can only delegate tasks appropriate for the skill

and education level of the health care team member who is receiving the assignment.

● RNs cannot delegate the nursing process, client education, or tasks that require clinical judgment to PNs or APs.

TASK FACTORS Prior to delegating client care, consider the following.

Predictability of outcome ● Will the completion of the task have a

predictable outcome? ● Is it a routine treatment? ● Is it a new treatment?

Potential for harm ● Is there a chance that something negative can happen to

the client (risk for bleeding, risk for aspiration)? ● Is the client unstable?

Complexity of care ● Are complex tasks required as a part of the client’s care? ● Is the delegatee legally able to perform the task and do

they have the skills necessary?

Need for problem solving and innovation ● Is nursing judgment required while performing the task? ● Does it require nursing assessment skills?

Level of interaction with the client ● Is there a need to provide psychosocial support or

education during the performance of the task?

DELEGATEE FACTORS Considerations for selection of an appropriate delegatee include the following.

● Education, training, and experience ● Knowledge and skill to perform the task ● Level of critical thinking required to complete the task ● Ability to communicate with others as it pertains

to the task ● Demonstrated competence ● The delegatee’s culture ● Agency policies and procedures and licensing legislation

(state nurse practice acts)

DELEGATION AND SUPERVISION GUIDELINES

● Use nursing judgment and knowledge related to the scope of practice and the delegatee’s skill level when delegating.

● Use the five rights of delegation. (1.4) ◯ What tasks the nurse delegates (right task) ◯ Under what circumstances (right circumstance) ◯ To whom (right person) ◯ What information should be communicated (right

direction/communication) ◯ How to supervise/evaluate (right

supervision/evaluation)

Online Video: Delegation

1.4 The five rights of delegation

RIGHT task RIGHT circumstance RIGHT person RIGHT direction and communication RIGHT supervision and evaluation

1.3 The health care team

LICENSED PERSONNEL: Nurses who have completed a course of study, successfully passed either the NCLEX-PN® or NCLEX-RN® exam, and have a nursing license issued by a board of nursing.

ASSISTIVE PERSONNEL: Specifically trained to function in an assistive role to licensed nurses in client care activities. These individuals can be nursing personnel (certified nursing assistants [CNAs] or certified medical assistants [CMAs]), or they can be non-nursing personnel to whom nursing activities can be delegated (dialysis technicians, monitor technicians, and phlebotomists). Some health care entities can differentiate between nurse and non-nurse assistive personnel by using the acronym NAP for nursing assistive personnel.

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Right task ● Identify what tasks are appropriate to delegate for each

specific client. ● A right task is repetitive, requires little supervision, and

is relatively noninvasive for the client. ● Delegate tasks to appropriate levels of team members

(PN, AP) based on standards of practice, legal and facility guidelines, and available resources.

RIGHT TASK: Delegate an AP to assist a client who has pneumonia to use a bedpan.

WRONG TASK: Delegate an AP to administer a nebulizer treatment to a client who has pneumonia.

Right circumstance ● Assess the health status and complexity of care required

by the client. ● Match the complexity of care demands to the skill level

of the health care team member. ● Consider the workload of the team member.

RIGHT CIRCUMSTANCE: Delegate an AP to measure the vital signs of a client who is postoperative and stable.

WRONG CIRCUMSTANCE: Delegate an AP to measure the vital signs of a client who is postoperative and received naloxone to reverse respiratory depression.

Right person ● Assess and verify the competency of the health care

team member. ◯ The task must be within the team member’s scope

of practice. ◯ The team member must have the necessary

competence/training. ● Continually review the performance of the team

member and determine care competency. ● Assess team member performance based on standards

and, when necessary, take steps to remediate a failure to meet standards.

RIGHT PERSON: Delegate a PN to administer enteral feedings to a client who has a head injury.

WRONG PERSON: Delegate an AP to administer enteral feedings to a client who has a head injury.

Right direction/communication

Communicate either in writing or orally. ● Data that needs to be collected ● Method and timeline for reporting, including when to

report concerns/findings ● Specific task(s) to be performed; client-specific

instructions ● Expected results, timelines, and expectations for

follow-up communication

RIGHT DIRECTION AND COMMUNICATION: Delegate an AP to assist the client in room 312 with a shower before 0900 and to notify the nurse when complete.

WRONG DIRECTION AND COMMUNICATION:

Delegate an AP to assist the client in room 312 with morning hygiene.

Right supervision/evaluation

The delegating nurse must: ● Provide supervision, either directly or indirectly

(assigning supervision to another licensed nurse). ● Provide clear directions and expectations of the task to

be performed (time frames, what to report). ● Monitor performance. ● Provide feedback. ● Intervene if necessary (unsafe clinical practice). ● Evaluate the client and determine if client

outcomes were met. ● Evaluate client care tasks and identify needs for quality

improvement activities and/or additional resources.

RIGHT SUPERVISION: Delegate the ambulation of a client to an AP. Observe the AP to ensure safe ambulation of the client, and provide positive feedback to the AP after completion of the task.

WRONG SUPERVISION: Delegate the ambulation of a client to an AP without supervision to determine the need for intervention and failing to provide feedback to the AP.

1.5 Examples of tasks nurses can delegate to practical nurses and assistive personnel (provided the facility’s policy and state’s practice guidelines permit)

TO PN Monitoring findings (as input to the RN’s ongoing assessment) Reinforcing client teaching from a standard care plan Performing tracheostomy care Suctioning Checking NG tube patency Administering enteral feedings Inserting a urinary catheter Administering medication (excluding IV medication in some states)

TO AP Activities of daily living (ADLs) Bathing Grooming Dressing Toileting Ambulating Feeding (without swallowing precautions)

Positioning Routine tasks Bed making Specimen collection Intake and output Vital signs (for stable clients)

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SUPERVISION Supervision occurs after delegation. A supervisor oversees a staff member’s performance of delegated activities and determines if: ● Completion of tasks is on schedule. ● Performance was at a satisfactory level. ● Unexpected findings were documented and reported

or addressed. ● Assistance was required to complete assigned tasks in a

timely manner. ● Assignment should be re-evaluated and

possibly changed.

Sta† education Staff education refers to the nurse’s involvement in the orientation, socialization, education, and training of fellow health care workers to ensure the competence of all staff and to help them meet standards set forth by the facility and accrediting bodies. The process of staff education is also referred to as staff development. ● The quality of client care provided is directly related to

the education and level of competency of health care providers.

● The nurse leader has a responsibility in maintaining competent staff.

● Nurse leaders work with a unique, diverse workforce. The nurse should respect and recognize the health care team’s diversity.

ORIENTATION Orientation helps newly licensed nurses translate the knowledge, skills, and attitudes learned in nursing school into practice.

ORIENTATION TO THE INSTITUTION ● The newly licensed nurse is introduced to the

philosophy, mission, and goals of the institution and department.

● Policies and procedures that are based on institutional standards are reviewed.

● Use of and access to the institution’s computer system is a significant focus.

● Safety and security protocols are emphasized in relation to the nurse’s role.

ORIENTATION TO THE UNIT ● Classroom orientation is usually followed by orientation

to the unit by an experienced nurse. ● Preceptors assist in orienting newly licensed nurses to a

unit and supervising their performance and acquisition of skills.

● Preceptors are usually assigned to newly licensed nurses for a limited amount of time.

● Mentors can also serve as a newly licensed nurse’s preceptor, but their relationship usually lasts longer and focuses more on assumption of the professional role and relationships, as well as socialization to practice.

● Coaches establish a collaborative relationship to help a nurse establish specific individual goals. The relationship is often task-related and typically time limited.

SOCIALIZATION Socialization is the process by which a person learns a new role and the values and culture of the group within which that role is implemented.

● Successful socialization helps new staff members fit in with already established staff on a client care unit.

● Staff development educators and unit managers can begin this process during interviewing and orientation.

● Nurse preceptors/mentors are frequently used to assist newly licensed nurses with this process on the clinical unit.

1.6 Staff education

CHARACTERISTICS IDENTIFIED/ PROVIDED BY

Involves methods appropriate to learning domain and learning styles of staff.

Peers, unit managers, staff development educators

Initiated in specific situations ● New policies or procedures implemented

● New equipment becomes available

● Educational need identified

Unit managers, staff development educators

Can focus on one-on-one approach

Unit manager, charge nurse, preceptor

Can use “just in time” training to meet immediate needs for client care

Staff members, supervisors

Higher education degree or certification Staff

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EDUCATION AND TRAINING Staff education, or staff development, is the process by which a staff member gains knowledge and skills. The goal of staff education is to ensure that staff members have and maintain the most current knowledge and skills necessary to meet the needs of clients. (1.6)

Steps in providing educational programs

1. Identify and respond: Determine the need for knowledge or skill proficiency

2. Analyze: Look for deficiencies, and develop learning objectives to meet the need

3. Research: Resources available to address learning objectives based on evidence-based practice

4. Plan: Program to address objectives using available resources

5. Implement: Program(s) at a time conducive to staff availability; consider online learning modules

6. Evaluate: Use materials and observations to measure behavior changes secondary to learning objectives

Improved nursing ability

An increase in knowledge and competence is the goal of staff education.

Competence is the ability of an employee to meet the requirements of a particular role at an established level of performance. Nurses usually progress through several stages of proficiency as they gain experience in a particular area.

The five stages of nursing ability were identified by Patricia Benner (1984), and are based on level of competence. Level of competence is directly related to length of time in practice and exposure to clinical situations. When nurses move to a new clinical setting that requires acquisition of new skills and knowledge, their level of competence will return to a lower stage. (1.7)

Quality improvement ● Quality improvement (performance improvement,

quality control) is the process used to identify and resolve performance deficiencies. Quality improvement includes measuring performance against a set of predetermined standards. In health care, these standards are set by the facility and consider accrediting and professional standards.

● Standards of care should reflect optimal goals and be based on evidence.

● The quality improvement process focuses on assessment of outcomes and determines ways to improve the delivery of quality care. All levels of employees are involved in the quality improvement process.

● The Joint Commission’s accreditation standards require institutions to show evidence of quality improvement in order to attain accreditation status.

QUALITY IMPROVEMENT PROCESS The quality improvement process begins with identification of standards and outcome indicators based on evidence.

Outcome (clinical) indicators reflect desired client outcomes related to the standard under review.

Structure indicators reflect the setting in which care is provided and the available human and material resources.

Process indicators reflect how client care is provided and are established by policies and procedures (clinical practice guidelines).

Benchmarks are goals that are set to determine at what level the outcome indicators should be met.

While process indicators provide important information about how a procedure is being carried out, an outcome indicator measures whether that procedure is effective in meeting the desired benchmark. For example, the use of incentive spirometers in postoperative clients can be determined to be 92% (process indicator), but the rate of postoperative pneumonia can be determined to be 8% (outcome indicator). If the benchmark is set at 5%, the benchmark for that outcome indicator is not being met and the structure and process variables need to be analyzed to identify potential areas for improvement.

1.7 Five stages of nursing ability

Novice nurse Novice nurses can be students or newly licensed nurses who have minimal clinical experience. They approach situations from theoretical perspective relying on context-free facts and established guidelines. Rules govern practice.

Advanced beginner Most new nurses function at the level of the advanced beginner. They practice independently in the performance of many tasks and can make some clinical judgments. They begin to rely on prior experience to make practice decisions.

Competent nurse These are usually nurses who have been in practice for 2 to 3 years. They demonstrate increasing levels of skill and proficiency and clinical judgment. They exhibit the ability to organize and plan care using abstract and analytical thinking. They can anticipate the long-term outcomes of personal actions.

Proficient nurse These are nurses who have a significant amount of experience upon which to base their practice. Enhanced observational abilities allow nurses to be able to conceptualize situations more holistically. Well-developed critical thinking and decision-making skills allow nurses to recognize and respond to unexpected changes.

Expert nurse Expert nurses have garnered a wealth of experience so they can view situations holistically and process information efficiently. They make decisions using an advanced level of intuition and analytical ability. They do not need to rely on rules to comprehend a situation and take action. Source: http://www.scribd.com/doc/27103958/Benner-Theory-Novice-to-Expert

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STEPS IN THE QUALITY IMPROVEMENT PROCESS A standard is developed and approved by a facility committee. ● Standards are made available to employees by way of

policies and procedures. ● Quality issues are identified by the staff, management,

or risk management department. ● An interprofessional team is developed to review

the issue. ● The current state of structure and process related to the

issue is analyzed. ● Data collection methods are determined.

◯ Quantitative methods are primarily used in the data collection process, although client interview is also an option.

● Data is collected, analyzed, and compared with the established benchmark.

● If the benchmark is not met, possible influencing factors are determined. A root cause analysis can be done to critically assess all factors that influence the issue. A root cause analysis: ◯ Focuses on variables that surround the consequence

of an action or occurrence. ◯ Is commonly done for sentinel events (client

death, client care resulting in serious physical injury) but can also be done as part of the quality improvement process.