Ati video case study type 1 diabetes

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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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subject matter covered; however, the publisher is not responsible for errors, omissions, or for any outcomes related to

the use of the contents of this book and makes no guarantee and assumes no responsibility or liability for the use of the

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recommendations. The publisher does not recommend or endorse any specific tests, providers, products, procedures,

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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

that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by

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

and government regulations often change the accepted standard in this field. When consideration is being given to use

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on dose, precautions, and contraindications and determining the appropriate usage for the product. Any references

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

shall in any way advise personnel concerning legal authority to perform the activities or procedures discussed. Such

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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.

◯ Investigates the consequence and possible causes. ◯ Analyzes the possible causes and relationships that

can exist. ◯ Determines additional influences at each level

of relationship. ◯ Determines the root cause or causes.

● Potential solutions or corrective actions are analyzed and one is selected for implementation.

● Educational or corrective action is implemented. ● The issue is reevaluated at a preestablished

time to determine the efficacy of the solution or corrective action.

Core measures

National standardized measures are developed by the Joint Commission to improve client outcomes. It is used to measure client outcomes and provides information to support accreditation of hospitals.

Core measures developed include stroke, venous thromboembolism, heart failure, acute myocardial infarction, and substance use.

Audits

Audits can produce valuable quantitative data.

Types of audits ● Structure audits evaluate the influence of

elements that exist separate from or outside of the client-staff interaction.

● Process audits review how care was provided and assume a relationship exists between nurses and the quality of care provided.

● Outcome audits determine what results, if any, occurred as a result of the nursing care provided.

◯ Some outcomes are influenced by aspects of care (the quality of medical care, the level of commitment of managerial staff, and the characteristics of the facility’s policies and procedures).

◯ Nursing-sensitive outcomes are those that are directly affected by the quality of nursing care. Examples include client fall rates and the incidence of nosocomial infections.

Timing of audits ● Retrospective audits occur after the client receives care. ● Concurrent audits occur while the client is

receiving care. ● Prospective audits predict how future client care will be

affected by the current level of services.

NURSE’S ROLE IN QUALITY IMPROVEMENT ● Serve as unit representative on committees developing

policies and procedures. ● Use reliable resources for information (Centers for

Disease Control and Prevention, professional journals, evidenced-based research).

● Enhance knowledge and understanding of the facility’s policies and procedures.

● Provide client care consistent with these policies and procedures.

● Document client care thoroughly and according to facility guidelines.

● Participate in the collection of information/data related to staff’s adherence to selected policy or procedure.

● Assist with analysis of the information/data. ● Compare results with the established benchmark. ● Make a judgment about performance in regard to

the findings. ● Assist with provision of education or training necessary

to improve the performance of staff. ● Act as a role model by practicing in accordance with the

established standard. ● Assist with re-evaluation of staff performance by

collection of information/data at a specified time.

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Nursing strategies to promote evidence- based approach to client care ● Remain aware of current trends in research. ● Incorporate evidence into clinical practice. ● Question traditional nursing practice to promote change. ● Collaborate with other disciplines to enrich practice. ● Use the PICO model (population, intervention,

comparison, and outcome) to find current evidence to guide best practice.

Quality improvement tools for tracking outcomes

Structured care methodologies are used to track variances, measure outcomes, improve quality, and facilitate best practices.

Standards of care: Baseline of quality care a client should receive

Algorithms: Series of progressive treatment based on client response (advanced cardiac life support)

Critical or clinical pathway: Projected path of treatment based on a set time frame for clients who have comparable diagnoses

Protocols: Standard guidelines for a specific intervention (stroke protocol)

Guidelines: Evidence-based information to provide quality care and improve outcomes

Performance appraisal, peer review, and

disciplinary action A performance appraisal is the process by which a supervisor evaluates an employee’s performance in relation to the job description for that employee’s position as well as other expectations the facility can have.

● Performance appraisals are done at regular intervals and can be more frequent for new employees.

● Performance expectations should be based on the standards set forth in a job description and written in objective terms.

● Performance appraisals allow nurses the opportunity to discuss personal goals with the unit manager as well as to receive feedback regarding level of performance. Performance appraisals can also be used as a motivational tool.

● Deficiencies identified during a performance appraisal or reported by coworkers might need to be addressed in a disciplinary manner.

PERFORMANCE APPRAISAL AND PEER REVIEW

● A formal system for conducting performance appraisals should be in place and used consistently. Performance appraisal tools should reflect the staff member’s job description and can be based on various types of scales or surveys.

● Various sources of data should be collected to ensure an unbiased and thorough evaluation of an employee’s performance. ◯ Data should be collected over time and not just

represent isolated incidents. ◯ Actual observed behavior should be documented/used as

evidence of satisfactory or unsatisfactory performance. These can be called anecdotal notes and are kept in the unit manager or equivalent position’s files.

◯ Peers can be a valuable source of data. Peer review is the evaluation of a colleague’s practice by another peer. Peer review should: ■ Begin with an orientation of staff to the peer

review process, their professional responsibility in regard to promoting growth of colleagues, and the disposition of data collected.

■ Focus on the peer’s performance in relation to the job description or an appraisal tool that is based on institutional standards.

■ Be shared with the peer and usually the manager. ■ Be only part of the data used when completing a

staff member’s performance appraisal. ◯ The employee should be given the opportunity to

provide input into the evaluation. ● The unit manager should host the performance appraisal

review in a private setting at a time conducive to the staff member’s attendance. The unit manager should review the data with the staff member and provide the opportunity for feedback. Personal goals of the staff member are discussed and documented, including avenues for attainment. Staff members who do not agree with the unit manager’s evaluation of their performance should have the opportunity to make written comments on the evaluation form and appeal the rating.

DISCIPLINARY ACTION ● Deficiencies identified during a performance appraisal

or the course of employment should be presented in writing, and corrective action should be based on institutional policy regarding disciplinary actions and/ or termination of employment. Evidence regarding the deficiency must support such a claim. (1.8)

● Some offenses (mistreatment of a client or use of alcohol or other substances while working) warrant immediate dismissal. Lesser infractions should follow a stepwise manner, giving the staff member the opportunity to correct unacceptable behavior.

● Staff members who witness an inappropriate action by a coworker should report the infraction up the chain of command. At the time of the infraction, this might be the charge nurse. The unit manager should also be notified, and written documentation by the manager is placed in the staff member’s permanent file.

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Conflict resolution Conflict is the result of opposing thoughts, ideas, feelings, perceptions, behaviors, values, opinions, or actions between individuals.

● Conflict is an inevitable part of professional, social, and personal life and can have constructive or destructive results. Nurses must understand conflict and how to manage it.

● Nurses can use problem-solving and negotiation strategies to prevent a problem from evolving into a conflict.

● Lack of conflict can create organizational stasis, while too much conflict can be demoralizing, produce anxiety, and contribute to burnout.

● Conflict can disrupt working relationships and create a stressful atmosphere.

● If conflict exists to the level that productivity and quality of care are compromised, the unit manager must attempt to identify the origin of the conflict and attempt to resolve it.

Common causes of conflict ● Ineffective communication ● Unclear expectations of team members in their

various roles ● Poorly defined or actualized organizational structure ● Conflicts of interest and variance in standards ● Incompatibility of individuals ● Management or staffing changes ● Diversity related to age, gender, race, or ethnicity

CATEGORIES OF CONFLICT

INTRAPERSONAL CONFLICT Occurs within the person and can involve internal struggle related to contradictory values or wants.

Example: A nurse wants to move up on the career ladder but is finding that time with their family is subsequently compromised.

INTERPERSONAL CONFLICT Occurs between two or more people with differing values, goals, or beliefs.

● Interpersonal conflict in the health care setting involves disagreement among nurses, clients, family members, and within a health care team. Bullying and incivility in the workplace are forms of interpersonal conflict.

● This is a significant issue in nursing, especially in relation to new nurses, who bring new personalities and perspectives to various health care settings.

● Interpersonal conflict contributes to burnout and work-related stress.

Example: A new nurse is given a client assignment that is heavier than those of other nurses, and when the new nurse asks for help, it is denied.

INTERGROUP CONFLICT Occurs between two or more groups of individuals, departments, or organizations and can be caused by a new policy or procedure, a change in leadership, or a change in organizational structure.

Example: There is confusion as to whether it is the responsibility of the nursing unit or dietary department to pass meal trays to clients.

STAGES OF CONFLICT Five stages of conflict exist. If the nurse manager is familiar with the stages there is an increased chance that the conflict can be resolved effectively.

STAGE 1: LATENT CONFLICT The actual conflict has not yet developed; however, factors are present that have a high likelihood of causing conflict to occur.

Example: A new scheduling policy is implemented within the organization. The nurse manager should recognize that change is a common cause of conflict.

STAGE 2: PERCEIVED CONFLICT A party perceives that a problem is present, though an actual conflict might not actually exist.

Example: A nurse perceives that a nurse manager is unfair with scheduling. The nurse might not be aware that, in reality, it is only because the nurse manager misunderstood the nurse’s scheduling request.

STAGE 3: FELT CONFLICT Those involved begin to feel an emotional response to the conflict.

Example: A nurse feels anger towards the nurse manager after finding out that they are scheduled to work two holidays in a row.

STAGE 4: MANIFEST CONFLICT The parties involved are aware of the conflict and action is taken. Actions at this stage can be positive and strive towards conflict resolution, or they can be negative and include debating, competing, or withdrawal of one or more parties from the situation.

Example: The nurse manager and nurses on a unit agree that the current scheduling system is causing a conflict and agree to work together to come up with a solution.

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STAGE 5: CONFLICT AFTERMATH Conflict aftermath is the completion of the conflict process and can be positive or negative.

Example: Positive conflict aftermath: the nurse manager and nurses on a unit are satisfied with the newly revised scheduling system and feel valued for being included in the conflict resolution process.

Example: Negative conflict aftermath: the nurse manager and nurses are unable to come up with a scheduling solution that meets the needs of both parties. They agree to continue with the current system; however, tensions still remain, increasing the risk of a recurrence of the conflict.

CONFLICT RESOLUTION STRATEGIES

PROBLEM-SOLVING ● Open communication among staff and between staff

and clients can help defray the need for conflict resolution.

● When potential sources of conflict exist, the use of open communication and problem-solving strategies are effective tools to de-escalate the situation.

Actions nurses can take to promote open communication and de‑escalate conflicts

● Use “I” statements, and remember to focus on the problem, not on personal differences.

● Listen carefully to what others are saying, and try to understand their perspective.

● Move a conflict that is escalating to a private location or postpone the discussion until a later time to give everyone a chance to regain control of their emotions.

● Share ground rules with participants. For example, everyone is to be treated with respect, only one person can speak at a time, and everyone should have a chance to speak.

Steps of the problem-solving process

Identify the problem. State it in objective terms, minimizing emotional overlay.

Discuss possible solutions. Brainstorming solutions as a group can stimulate new solutions to old problems. Encourage individuals to think creatively, beyond simple solutions.

Analyze identified solutions. The potential pros and cons of each possible solution should be discussed in an attempt to narrow down the number of viable solutions.

Select a solution. Based on this analysis, select a solution for implementation.

Implement the selected solution. A procedure and timeline for implementation should accompany the implementation of the selected solution.

Evaluate the solution’s ability to resolve the original problem. The outcomes surrounding the new solution should be evaluated according to the predetermined timeline. The solution should be given adequate time to become established as a new routine before it is evaluated. If the solution is deemed unsuccessful, the problem-solving process will need to be reinstituted and the problem discussed again.

1.8 Steps in progressive discipline

First infraction Informal reprimand Manager and employee meet Discuss the issue Suggestions for improvement/correction

Second infraction Written warning Manager meets with employee to distribute written warning Review of specific rules/policy violations Discussion of potential consequences if infractions continue

Third infraction Employee placed on suspension with or without pay. Time away from work gives the employee opportunity to: Examine the issues Consider alternatives

Fourth infraction Employee termination Follows after multiple warnings have been given and employee continues to violate rules and policies

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NEGOTIATION ● Negotiation is the process by which interested parties:

◯ Resolve ongoing conflicts. ◯ Agree on steps to take. ◯ Bargain to protect individual or collective interests. ◯ Pursue outcomes that benefit mutual interests.

● Most nurses use negotiation on a daily basis. ● Negotiation can involve the use of several conflict

resolution strategies. ● The focus is on a win-win solution or a win/lose-win/

lose solution in which both parties win and lose a portion of their original objectives. Each party agrees to give up something and the emphasis is on accommodating differences rather than similarities between parties.

Example

One nurse offers to care for Client A today if the other will care for Client B tomorrow.

Strategy: Avoiding/Withdrawing ● Both parties know there is a conflict, but they refuse to

face it or work toward a resolution. ● Can be appropriate for minor conflicts, when one party

holds more power than the other party, or if the issue can work itself out over time.

● Because the conflict remains, it can surface again at a later date and escalate over time.

● This is usually a lose-lose solution.

Strategy: Smoothing ● One party attempts to “smooth” another party by trying

to satisfy the other party. ● Often used to preserve or maintain a peaceful work

environment. ● The focus can be on what is agreed upon, leaving

conflict largely unresolved. ● This is usually a lose-lose solution.

Strategy: Competing/Coercing ● One party pursues a desired solution at the expense

of others. ● Managers can use this when a quick or unpopular

decision must be made. ● The party who loses something can experience anger,

aggravation, and a desire for retribution. ● This is usually a win-lose solution.

Strategy: Cooperating/Accommodating ● One party sacrifices something, allowing the other party

to get what it wants. This is the opposite of competing. ● The original problem might not actually be resolved. ● The solution can contribute to future conflict. ● This is a lose-win solution.

Strategy: Compromising/Negotiating ● Each party gives up something. ● To consider this a win/lose-win/lose solution, both

parties must give up something equally important. If one party gives up more than the other, it can become a win-lose solution.

Strategy: Collaborating ● Both parties set aside their original individual goals and

work together to achieve a new common goal. ● Requires mutual respect, positive communication, and

shared decision-making between parties. ● This is a win-win solution.

Example

An experienced nurse on a urology unit arrives to work on the night shift. The unit manager immediately asks the nurse to float to a pediatrics unit because the hospital census is high and they are understaffed. The nurse has always maintained a positive attitude when asked to work on another medical-surgical unit but states they do not feel comfortable in the pediatric setting. The manager insists the nurse is the most qualified.

Strategy: Avoiding/Withdrawing/Smoothing The nurse basically cannot use these strategies due to the immediacy of the situation. The assignment cannot be simply avoided or smoothed over; it must be accepted or rejected.

Strategy: Competing/Coercing ● If the nurse truly feels unqualified to work on the

pediatric unit, then this approach can be appropriate: the nurse must win and the manager must lose.

● Although risking termination by refusing the assignment, the nurse should take an assertive approach and inform the manager that pediatric clients would be placed at risk.

Strategy: Cooperating/Accommodating ● If the nurse decides to accommodate the manager’s

request, then the pediatric clients can be at risk for incompetent care.

● Practice liability is another issue for consideration.

Strategy: Compromising/Negotiating ● This approach generally minimizes the losses

for all involved while making certain each party gains something.

For example, the nurse might offer to work on another medical-surgical unit if someone from that unit feels comfortable in the pediatric environment.

● Although each party is giving up something (the manager gives in to a different solution and the nurse still has to work on another unit), this sort of compromise can result in a win-win resolution.

Strategy: Collaborating Both the nurse manager and nurse come to the agreement that providing safe and competent care of the children in the pediatric unit is the common goal. While they might need to compromise/negotiate to address the immediate need, they can collaborate to achieve a solution that avoids this situation in the future.

For example, the nurse might agree to orient to the pediatric unit in order to become competent for future assignments and the nurse manager can enlist the services of a staffing agency that provides pediatric nurses on an as needed basis.

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NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 MANAGING CLIENT CARE 17

ASSERTIVE COMMUNICATION ● Use of assertive communication can be necessary during

conflict negotiation. ● Assertive communication allows expression in direct,

honest, and nonthreatening ways that do not infringe upon the rights of others.

● It is a communication style that acknowledges and deals with conflict, recognizes others as equals, and provides a direct statement of feelings.

Elements of assertive communication ● Selecting an appropriate location for verbal exchange ● Maintenance of eye contact ● Establishing trust ● Being sensitive to cultural needs ● Speaking using “I” statements and including affective

elements of the situation ● Avoiding “you” statements that can indicate blame ● Stating concerns using open, honest, direct statements ● Conveying empathy ● Focusing on the behavior or issue of conflict and

avoiding personal attacks ● Concluding with a statement that describes a

fair solution

GRIEVANCES ● A grievance is a wrong perceived by an employee based

on a feeling of unfair treatment that is considered grounds for a formal complaint.

● Grievances that cannot be satisfactorily resolved between the parties involved can require management by a third party.

● Facilities have a formal grievance policy that should be followed when a conflict cannot be resolved.

● The steps of an institution’s grievance procedure should be outlined in the grievance policy.

Typical steps of the grievance process ● Started at the first level of management and continued

up the chain of command as needed ● Formal hearing if the issue is not resolved at a

lower level ● Professional mediation if a solution is not reached

during a formal hearing

Resource management Resource management includes budgeting and resource allocation. Human, financial, and material resources must be considered.

● Budgeting is usually the responsibility of the unit manager, but staff nurses can be asked to provide input.

● Resource allocation is a responsibility of the unit manager as well as every practicing nurse.

● Providing cost-effective client care should not compromise quality of care.

Resources (supplies, equipment, personnel) are critical to accomplishing the goals and objectives of a health care facility, so it is essential for nurses to understand how to effectively manage resources.

COST-EFFECTIVE CARE

Cost-containment

Strategies that promote efficient and competent client care while also producing needed revenues for the continued productivity of the organization

Example: The use of managed care strives to provide clients with a plan designed to meet the needs of their individual medical problem while eliminating the unnecessary use of resources or extended hospital stays.

Cost‑effective

Strategies that achieve optimal results in relation to the money spent to achieve those results. In other words, cost-effective means “getting your money’s worth.”

Example: Spending increased money on staff training for transmission-based precautions, resulting in the increased and effective use of PPE for client care. These actions have the end result of a decrease in infection transmission and an overall savings in the cost of caring for clients who would have acquired these infections.

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18 CHAPTER 1 MANAGING CLIENT CARE CONTENT MASTERY SERIES

COST-EFFECTIVE CARE STRATEGIES Providing clients with needed education to decrease or eliminate future medical costs associated with future complications

Example: Teaching a client who has a new diagnosis of diabetes mellitus how to adjust the dosage of insulin depending on activity level, reducing the risk of hypoglycemia resulting in the need for medical care.

Promoting the use of evidence-based care, resulting in improved client care outcomes

Example: Implementing the use of evidence-based techniques to care for clients who have indwelling catheters, resulting in a decreased incidence of catheter-acquired urinary tract infections.

Promoting cost-effective resource management

Example: Using all levels of personnel to their fullest when making assignments. Delegating effectively to members of the nursing care team.

Example: Providing necessary equipment and properly charging clients.

Example: Returning uncontaminated, unused equipment to the appropriate department for credit.

Example: Using equipment properly to prevent wastage.

Example: Providing training to staff unfamiliar with equipment.

Example: Returning equipment (IV pumps) to the proper department (central service, central distribution) as soon as it is no longer needed. This action will prevent further cost to clients.

Active Learning Scenario

A nurse manager is discussing emotional intelligence with the charge nurses within the facility. What information should the manager include in this discussion? Use the Active Learning Template: Basic Concept to complete this item.

RELATED CONTENT: Define emotional intelligence.

UNDERLYING PRINCIPLES: Identify at least three characteristics of an emotionally intelligent leader.

Active Learning Scenario Key

Using the Active Learning Template: Basic Concept

RELATED CONTENT: Emotional intelligence is the ability of an individual to perceive and manage the emotions of self and others.

UNDERLYING PRINCIPLES ● Insight into the emotions of members of the team ● Understands the perspective of others ● Encourages constructive criticism and is open to new ideas ● Able to maintain focus while multitasking ● Manages emotions and channels them in a positive direction, which in turn helps the team accomplish its goals

● Committed to the delivery of high-quality client care ● Refrains from judgment in controversial or emotionally- charged situations until facts are gathered

NCLEX® Connection: Management of Care, Concepts of Management

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NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 MANAGING CLIENT CARE 19

Application Exercises

1. A nurse enters the room of a client and finds the client lying on the floor. Which of the following actions should the nurse take first?

A. Call the provider.

B. Ask a staff member for assistance getting the client back in bed.

C. Inspect the client for injuries.

D. Instruct the client to ask for help if they need to get out of bed.

2. An RN on a medical-surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the PN?

A. Obtain vital signs for a client who is 2 hr postprocedure following a cardiac catheterization.

B. Administer a unit of packed red blood cells (RBCs) to a client who has cancer.

C. Instruct a client who is scheduled for discharge in the performance of wound care.

D. Develop a plan of care for a newly admitted client who has pneumonia.

3. A PN ending their shift reports to the RN that a newly hired AP has not calculated the intake and output for several clients. Which of the following actions should the RN take?

A. Complete an incident report.

B. Delegate this task to the PN.

C. Ask the AP if they need assistance.

D. Notify the nurse manager.

4. A nurse manager is developing an orientation plan for newly licensed nurses. Which of the following information should the manager include in the plan? (Select all that apply.)

A. Skill proficiency

B. Assignment to a preceptor

C. Budgetary principles

D. Computerized charting

E. Socialization into unit culture

F. Facility policies and procedures

5. A nurse manager is providing information about the audit process to members of the nursing team. Which of the following information should the nurse manager include? (Select all that apply.)

A. A structure audit evaluates the setting and resources available to provide care.

B. An outcome audit evaluates the results of the nursing care provided.

C. A root cause analysis is indicated when a sentinel event occurs.

D. Retrospective audits are conducted while the client is receiving care.

E. After data collection is completed, it is compared to a benchmark.

6. A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following information will provide data regarding the efficacy of the procedure?

A. Frequency with which procedure is performed

B. Client satisfaction with performance of procedure

C. Incidence of complications related to procedure

D. Accurate documentation of how procedure was performed

7. A nurse is hired to replace a staff member who has resigned. After working on the unit for several weeks, the nurse notices that the unit manager does not intervene when there is conflict between team members, even when it escalates. Which of the following conflict resolution strategies is the unit manager demonstrating?

A. Avoidance

B. Smoothing

C. Cooperating

D. Negotiating

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20 CHAPTER 1 MANAGING CLIENT CARE CONTENT MASTERY SERIES

Application Exercises Key

1. A. Notify the provider to determine whether the client needs further examination and treatment, but there is another action to take first.

B. Seek assistance in returning the client to bed to prevent further harm to the client, but there is another action to take first.

C. CORRECT: The first action to take using the nursing process is to assess the client in order to determine which interventions the client will need.

D. Instruct the client to ask for help before getting out of bed to help prevent future falls, but there is another action to take first.

NCLEX® Connection: Management of Care, Establishing Priorities

2. A. CORRECT: It is within the scope of practice of the PN to monitor a client who is 2 hr postprocedure for a cardiac catheterization, because this client is considered stable.

B. The RN is responsible for administering blood components, including packed RBCs, because this outside of the scope of practice for the PN.

C. The RN is responsible for client education. It is within the scope of practice of the PN to reinforce but not provide initial client education.

D. The RN is responsible for developing a plan of care for a client. It is within the scope of practice for the PN to suggest additions to but not develop the plan of care.

NCLEX® Connection: Management of Care, Assignment, Delegation and Supervision

3. A. An incident report is indicated when a critical incident has occurred. It is not necessary to complete an incident report in this situation.

B. Do not redelegate this task. C. CORRECT: Find out what the AP knows about performing

the task and provide education for the AP if indicated. D. The RN is capable of handling the situation. It is

not necessary to notify the nurse manager.

NCLEX® Connection: Management of Care, Assignment, Delegation and Supervision

4. A. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. Include evaluation of skill proficiency and provide additional instruction as indicated.

B. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. Include assignment of a preceptor to ease the transition of the newly licensed nurse.

C. Budgetary principles are an administrative skill that is usually the responsibility of the unit manager.

D. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. Include computerized charting, which is an essential skill for the newly licensed nurse.

E. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. Include socialization to the unit as a way to ease the transition of the newly licensed nurse.

F. CORRECT: The purpose of orientation is to assist the newly licensed nurse to transition from the role of student to the role of employee and licensed nurse. Include information about facility policies and procedures, which is essential information for the newly licensed nurse.

NCLEX® Connection: Management of Care, Concepts of Management

5. A. CORRECT: A structure audit evaluates the setting in which care is provided and includes resources (equipment and staffing levels).

B. CORRECT: An outcome audit evaluates the effectiveness of nursing care. It should include observable data (infection rates among clients).

C. CORRECT: A root cause analysis is indicated when a sentinel event occurs. A sentinel event is a serious problem (injury to or death of a client). Immediate investigation of the problem is indicated. The health care team can use root cause analysis to study the problem and take measures to prevent recurrence.

D. Retrospective audits are conducted when the client is no longer receiving care.

E. CORRECT: The benchmark is set at the beginning of the process and then it is compared to the data after collection is completed.

NCLEX® Connection: Management of Care, Performance Improvement (Quality Improvement)

6. A. The frequency with which the procedure is performed is important. The team can take the frequency in which the procedure is performed under consideration in the planning process, but this information does not address the efficacy of the procedure.

B. The team should take client satisfaction under consideration in the planning process, but this information does not address the efficacy of the procedure.

C. CORRECT: The incidence of complications related to the procedure is an outcome measure directly related to the efficacy of the procedure.

D. The team can take accuracy of documentation under consideration in the planning process, but this information does not address the efficacy of the procedure.

NCLEX® Connection: Management of Care, Performance Improvement (Quality Improvement)

7. A. CORRECT: The goal in resolving conflict is a win-win situation. The unit manager is using an ineffective strategy, avoidance, to deal with this conflict. Although the unit manager is aware of the conflict, they are not attempting to resolve it.

B. The goal in resolving conflict is a win-win solution. When smoothing is used, one person attempts to “smooth” the other party and/or point out areas in which the parties agree. This is typically a lose-lose solution.

C. The goal in resolving a conflict is a win-win solution. When cooperating is used, one party allows the other party to win. This is a lose-win solution.

D. The goal in resolving a conflict is a win-win solution. When negotiating is used, each party gives up something. If one party gives up more than the other, this can become a win-lose solution.

NCLEX® Connection: Management of Care, Concepts of Management

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NURSING LEADERSHIP AND MANAGEMENT NCLEX® CONNECTIONS 21

NCLEX® Connections

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

Management of Care CASE MANAGEMENT: Explore resources available to assist the client with achieving or maintaining independence.

CLIENT RIGHTS Recognize the client's right to refuse treatment/procedures.

Advocate for client rights and needs.

COLLABORATION WITH INTERDISCIPLINARY TEAM Review plan of care to ensure continuity across disciplines.

Identify significant information to report to other disciplines.

CONCEPTS OF MANAGEMENT: Act as liaison between the client and others.

CONTINUITY OF CARE Use documents to record and communicate client information.

Provide and receive hand off care (report) on assigned clients.

REFERRALS: Identify community resources for the client.

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22 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 COORDINATING CLIENT CARE 23

CHAPTER 2 Coordinating Client Care

One of the primary roles of nursing is the coordination and management of client care in collaboration with the health care team. In so doing, high-quality health care is provided as clients move through the health care system in a cost-effective and time-efficient manner.

To effectively coordinate client care, a nurse must have an understanding of collaboration with the interprofessional team, principles of case management, continuity of care (including consultations, referrals, transfers, and discharge planning), and motivational principles to encourage and empower self, staff, colleagues, and other members of the interprofessional team.

COLLABORATION WITH THE INTERPROFESSIONAL TEAM

An interprofessional team is a group of health care professionals from various disciplines. Collaboration involves discussion of client care issues in making health care decisions, especially for clients who have multiple problems. The specialized knowledge and skills of each discipline are used in the development of an interprofessional plan of care that addresses multiple problems. Nurses should recognize that the collaborative efforts of the interprofessional team allow the achievement of results that a team member would be incapable of accomplishing alone. ● Nurse-provider collaboration should be fostered

to create a climate of mutual respect and collaborative practice.

● Collaboration occurs among different levels of nurses and nurses with different areas of expertise.

● Collaboration should also occur between the interprofessional team, the client, and the client’s family/significant others when an interprofessional plan of care is being developed.

● Collaboration is a form of conflict resolution that results in a win-win solution for both the client and health care team.

NURSE QUALITIES FOR EFFECTIVE COLLABORATION ● Good communication skills ● Assertiveness ● Conflict negotiation skills ● Leadership skills ● Professional presence ● Decision-making and critical thinking

THE NURSE’S ROLE ● Coordinate the interprofessional team. ● Have a holistic understanding of the client, the client’s

health care needs, and the health care system. ● Provide the opportunity for care to be provided with

continuity over time and across disciplines. ● Provide the client with the opportunity to be a partner

in the development of the plan of care. ● Provide information during rounds and

interprofessional team meetings regarding the status of the client’s health.

● Provide an avenue for the initiation of a consultation related to a specific health care issue.

● Provide a link to postdischarge resources that might need a referral.

VARIABLES THAT AFFECT COLLABORATION

Hierarchical influence on decision‑making

Decision-making is also influenced by the facility hierarchy. ● In a centralized hierarchy, nurses at the top of the

organizational chart make most of the decisions. ● In a decentralized hierarchy, staff nurses who provide

direct client care are included in the decision-making process. Large organizations benefit from the use of decentralized decision-making because managers at the top of the hierarchy do not have firsthand knowledge of unit-level challenges or problems. Decentralized decision-making promotes job satisfaction among staff nurses.

Behavioral change strategies

Although bombarded with constant change, members of the interprofessional team can be resistant to change. Three strategies a manager can use to promote change are the rational-empirical, normative-reeducative, and the power-coercive. Often the manager uses a combination of these strategies.

RATIONAL-EMPIRICAL: The manager provides factual information to support the change. Used when resistance to change is minimal.

NORMATIVE-REEDUCATIVE: The manager focuses on interpersonal relationships to promote change.

POWER-COERCIVE: The manager uses rewards to promote change. Used when individuals are highly resistant to change.

CHAPTER 2

24 CHAPTER 2 COORDINATING CLIENT CARE CONTENT MASTERY SERIES

Planned change

Planned change is important in health care because it enables the interprofessional team to replace unproven methods with evidence-based ones. ● Planned change might be a proactive way to improve

care quality. Change might also be required by a regulatory board.

● Variables that affect whether change can fully take place include individual and organizational willingness, competing demands, and whether the change is meaningful.

● Changes in technology are more readily accepted than social change.

● Include people who will be affected by the change in the planning process to decrease resistance.

Lewin’s change theory

Lewin’s change theory is a common model for promoting planned change, which has three stages.

● Unfreezing: Need for change is identified or created. ● Change/Movement: Strategies (driving forces) that

overcome resistance to change (restraining forces) are identified and implemented.

● Refreezing: The change is integrated and the system is re-stabilized.

Lewin’s theory has been adapted into a stages of change model for individual change, with five stages: ● Precontemplation: No intent to change is present or has

been considered. ● Contemplation: The individual considers

adopting a change. ● Preparation: The individual intends to implement the

change in the near future. ● Action: The individual implements the change. ● Maintenance: The individual continues the new behavior

without relapse.

Stages of team formation

Teams typically work through a group formation process before reaching peak performance.

FORMING: Members of the team get to know each other. The leader defines tasks for the team and offers direction.

STORMING: Conflict arises, and team members begin to express polarized views. The team establishes rules, and members begin to take on various roles.

NORMING: The team establishes rules. Members show respect for one another and begin to accomplish some of the tasks.

PERFORMING: The team focuses on accomplishment of tasks.

Generational differences team members

Generational differences influence the value system of the members of an interprofessional team and can affect how members function within the team. Generational differences can be challenging for members of a team, but working with individuals from different generations also can bring strength to the team. ● Veterans (Silent Generation, Traditionals): Born

1925 to 1942 ● Baby Boomers: Born 1942 to early 1960s ● Generation X: Born mid-1960s to early 1980s ● Generation Y (Millennial): Born mid-1980s to 2000 ● Generation Z (Homelanders): Born after 2001

MAGNET RECOGNITION PROGRAM The American Nurses Credentialing Center awards Magnet Recognition to health care facilities that provide high-quality client care and attract and retain well-qualified nurses. The term magnet is used to recognize the facility’s power to draw nurses to the facility and to retain them. ● Facilities must create a culture that uses 14 foundational

forces of magnetism and model five key components, which include the following. ◯ Empirical data showing quality care results ◯ Development of innovation, improvements, or

generation of new knowledge ◯ Exemplary nursing practice ◯ A culture of empowerment ◯ Transformational leadership

● The facility must submit documentation to the American Nurses Credentialing Center (ANCC) that demonstrates adherence to ANA nurse administrator standards.

● After documentation that the standards have been met, an on-site appraisal is conducted. A facility that meets the standards is awarded magnet status for a 4-year period.

PATHWAY TO EXCELLENCE RECOGNITION A program of practice standards to promote a positive practice environment using evidence-based standards ● Acute- or long-term care facilities can apply for

recognition with this program. ● The Pathway to Excellence designation process includes

an application process and adherence to 12 standards of practice, along with an independent survey of the facility.

NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 COORDINATING CLIENT CARE 25

CASE MANAGEMENT Case management is the coordination of care provided by an interprofessional team from the time a client starts receiving care until they no longer receive services.

PRINCIPLES OF CASE MANAGEMENT ● Case management focuses on managed care of the client

through collaboration of the health care team in acute and post-acute settings.

● The goal of case management is to avoid fragmentation of care and control cost.

● A case manager collaborates with the interprofessional health care team during the assessment of a client’s needs and subsequent care planning, and follows up by monitoring the achievement of desired client outcomes within established time parameters.

● A case manager can be a nurse, social worker, or other designated health care professional. A case manager’s role and knowledge expectations are extensive. Therefore, case managers are required to have advanced practice degrees or advanced training in this area.

● Case manager nurses do not usually provide direct client care.

● Case managers usually oversee a caseload of clients who have similar disorders or treatment regimens.

● Case managers in the community coordinate resources and services for clients whose care is based in a residential setting.

NURSING ROLE IN CASE MANAGEMENT ● Coordinating care, particularly for clients who have

complex health care needs ● Facilitating continuity of care ● Improving efficiency of care and utilization of resources ● Enhancing quality of care provided ● Limiting unnecessary costs and lengthy stays ● Advocating for the client and family

CRITICAL PATHWAYS A critical or clinical pathway or care map can be used to support the implementation of clinical guidelines and protocols. These tools are usually based on cost and length of stay parameters mandated by prospective payment systems (Medicare and insurance companies). ● Case managers often initiate critical pathways,

but they are used by many members of the interprofessional team.

● Critical pathways are often specific to a diagnosis type and outline the typical length of stay and treatments.

● When a client requires treatment other than what is typical or requires a longer length of stay, it is documented as a variance, along with information describing why the variance occurred.

CONTINUITY OF CARE: CONSULTATIONS, REFERRALS, TRANSFERS, AND

DISCHARGE PLANNING Continuity of care refers to the consistency of care provided as clients move through the health care system. It enhances the quality of client care and facilitates the achievement of positive client outcomes. ● Continuity of care is desired as clients move from one:

◯ Level of care to another (from the ICU to a medical unit).

◯ Facility to another (from an acute care facility to a skilled facility).

◯ Unit/department to another (from the PACU to the postsurgical unit).

● Nurses are responsible for facilitating continuity of care and coordinating care through documentation, reporting, and collaboration.

● A formal, written plan of care enhances coordination of care between nurses, interprofessional team members, and providers.

NURSING ROLE IN CONTINUITY OF CARE The nurse’s role as coordinator of care includes: ● Facilitating the continuity of care provided by members

of the health care team. ● Acting as a representative of the client and as a liaison

when collaborating with the provider and other members of the health care team. When acting as a liaison, the nurse serves in the role of client advocate by protecting the rights of clients and ensuring that client needs are met.

As the coordinator of care, the nurse is responsible for: ● Admission, transfer, discharge, and

postdischarge prescriptions. ● Initiation, revision, and evaluation of the plan of care. ● Reporting the client’s status to other nurses and

the provider. ● Coordinating the discharge plan. ● Facilitating referrals and the use of

community resources.

DOCUMENTATION Documentation to facilitate continuity of care includes the following. ● Graphic records that illustrate trending of assessment

data (vital signs) ● Flow sheets that reflect routine care completed and

other care-related data ● Nurses’ notes that describe changes in client status or

unusual circumstances ● Client care summaries that serve as quick references for

client care information ● Nursing care plans that set the standard for

care provided ◯ Standardized nursing care plans provide a

starting point for the nurse responsible for care plan development.

◯ Standardized plans must be individualized to each client.

◯ All documentation should reflect the plan of care.

26 CHAPTER 2 COORDINATING CLIENT CARE CONTENT MASTERY SERIES

COMMUNICATION AND CONTINUITY OF CARE ● Poor communication can lead to adverse outcomes,

including sentinel events (unexpected death or serious injury of a client).

● Communication regarding the client status and needs is required anytime there is a transfer of care, whether from one unit or facility to another, or at change-of- shift, as the nurse hands off the care of the client to another health care professional.

● The guidelines on transfer reporting contain details on what to communicate when transferring client care.

Communication tools ● A number of communication hand-off tools are

available to improve communication and promote client safety (I-SBAR, PACE, I PASS the BATON, Five P’s).

● Nurses might also communicate interprofessionally through electronic means (through electronic medical record systems and e-mail).

◯ E-mail communication can be informal, but should maintain a professional tone. Don’t use text abbreviations. Make the message concise yet thorough so the reader has clear understanding of the intent.

◯ Read messages before sending to ensure there is not a negative or rude tone.

● Some facilities permit text messaging. Check the facility policy regarding this type of communication, and never send confidential information through text.

Hand-off or change-of-shift report ● Performed with the nurse who is assuming

responsibility for the client’s care. ● Describes the current health status of the client. ● Informs the next shift of pertinent client

care information. ● Provides the oncoming nurse the opportunity to ask

questions and clarify the plan of care. ● Should be given in a private area (a conference room or

at the bedside) to protect client confidentiality.

Report to the provider ● Assessment data integral to changes in client status ● Recommendations for changes in the plan of care ● Clarification of prescriptions

CONSULTATIONS ● A consultant is a professional who provides expert advice

in a particular area. A consultation is requested to help determine what treatment/services the client requires.

● Consultants provide expertise for clients who require a specific type of knowledge or service (a cardiologist for a client who had a myocardial infarction, a psychiatrist for a client whose risk for suicide must be assessed).

The nurse’s role regarding consultations ● Initiate necessary consults or notify the provider of the

client’s needs so the consult can be initiated. ● Provide the consultant with all pertinent information

about the problem (information from the client/family, the client’s medical records).

● Incorporate the consultant’s recommendations into the client’s plan of care.

REFERRALS A referral is a formal request for a service by another care provider. It is made so that the client can access the care identified by the provider or the consultant. ● The care can be provided in the acute setting or outside

the facility. ● Clients being discharged from health care facilities to

their home can still require nursing care. ● Discharge referrals are based on client needs in relation

to actual and potential problems and can be facilitated with the assistance of social services, especially if there is a need for: ◯ Specialized equipment (cane, walker, wheelchair, grab

bars in bathroom) ◯ Specialized therapists (physical, occupational, speech) ◯ Care providers (home health nurse, hospice nurse,

home health aide) ● Knowledge of community and online resources

is necessary to appropriately link the client with needed services.

The nurse’s role regarding referrals ● Begin discharge planning upon the client’s admission. ● Evaluate client/family competencies in relation to home

care prior to discharge. ● Involve the client and family in care planning. ● Collaborate with other health care professionals to

ensure all health care needs are met and necessary referrals are made.

● Complete referral forms to ensure proper reimbursement for prescribed services.

TRANSFERS Clients can be transferred from one unit, department, or one facility to another. Continuity of care must be maintained as the client moves from one setting to another.

● The use of communication hand-off tools (I PASS the BATON, PACE) promotes continuity of care and client safety.

● The nurse’s role regarding transfers is to provide written and verbal report of the client’s status and care needs.

◯ Client medical diagnosis and care providers ◯ Client demographic information ◯ Overview of health status, plan of care, and recent progress

◯ Alterations that can precipitate an immediate concern ◯ Most recent vital signs and medications, including when a PRN was given

◯ Notification of assessments or client care needed within the next few hours

◯ Allergies ◯ Diet and activity prescriptions ◯ Presence of or need for specific equipment or adaptive devices (oxygen, suction, wheelchair)

◯ Advance directives and whether a client is to be resuscitated in the event of cardiac or respiratory arrest

◯ Family involvement in care and health care proxy, if applicable

Online Images: Transfer Report, Interfacility Transfer Form

NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 COORDINATING CLIENT CARE 27

DISCHARGE PLANNING Discharge planning is an interprofessional process that is started by the nurse at the time of the client’s admission. ● The nurse conducts discharge planning with both the

client and client’s family for optimal results. ● Discharge planning serves as a starting point for

continuity of care. As client care needs are identified, measures can be taken to prepare for the provision of needed support.

● A comprehensive discharge plan includes a review of the following client information. ◯ Current health and prognosis ◯ Religious or cultural beliefs ◯ Ability to perform ADLs ◯ Mobility status and goals ◯ Sensory, motor, physical, or cognitive impairments ◯ Support systems and caregivers ◯ Financial resources and limitations ◯ Potential supports and resources in the community ◯ Internal and external home environment ◯ Need for assistance with transportation or home

maintenance ◯ Need for therapy, wound care, or other services ◯ Need for medical equipment

● The need for additional services (home health, physical therapy, and respite care) can be addressed before the client is discharged so the service is in place when the client arrives home.

● A client who leaves a facility without a prescription for discharge from the provider is considered leaving against medical advice (AMA). A client who is legally competent has the legal right to leave the facility at any time. The nurse should immediately notify the provider. If the client is at risk for harm, it is imperative that the nurse explain the risk involved in leaving the facility. The individual should sign a form relinquishing responsibility for any complications that arise from discontinuing prescribed care. The nurse should document all communication, as well as the specific advice that was provided for the client. A nurse who tries to prevent the client from leaving the facility can face legal charges of assault, battery, and false imprisonment.

Discharge instructions ● Step-by-step instructions for procedures to be done

at home. Clients should be given the opportunity to provide a return demonstration of these procedures to validate learning.

● Medication regimen instructions for home, including adverse effects and actions to take to minimize them.

● Precautions to take when performing procedures or administering medications.

● Indications of medication adverse effects or medical complications that the client should report to the provider.

● Names and numbers of providers and community services the client or family can contact.

● Plans for follow-up care and therapies.

The nurse’s role with regard to discharge is to provide a written summary including: ● Type of discharge (prescribed by provider, AMA). ● Date and time of discharge, who accompanied the client,

and how the client was transported (wheelchair to a private car, stretcher to an ambulance).

● Discharge destination (home, long-term care facility). ● A summary of the client’s condition at discharge (gait,

dietary intake, use of assistive devices, blood glucose). ● A description of any unresolved problems and plans for

follow-up. ● Disposition of valuables, medications brought from

home, and prescriptions. ● A copy of the client’s discharge instructions.

Online Image: Discharge Summary

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2.1 Interfacility transfer form

NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 COORDINATING CLIENT CARE 29

2.2 Transfer report

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2.3 Discharge summary

NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 COORDINATING CLIENT CARE 31

Application Exercises

1. A nurse is preparing to transfer a client who is 72 hr postoperative to a long-term care facility. Which of the following information should the nurse include in the transfer report? (Select all that apply).

A. Type of anesthesia used

B. Advance directives status

C. Vital signs on day of admission

D. Medical diagnosis

E. Need for specific equipment

2. A nurse is assisting with the discharge planning for a client. Which of the following actions should the nurse take? (Select all that apply.)

A. Determine the client’s need for home medical equipment.

B. Provide a list of all the medications the client received in the facility.

C. Obtain printed instructions for medication self-administration.

D. Provide the family with a list of community agencies that can provide assistance.

E. Discuss the importance of attending follow-up appointments.

3. A case manager is discussing critical pathways with a group of newly hired nurses. Which of the following statements indicates understanding?

A. “The time to fill out the pathways often increases the cost of care.”

B. “The pathway shows an estimate of the number of days the client will be hospitalized.”

C. “Deviance from the pathway is a sign of improved care quality.”

D. “The pathway includes information about the client’s history.”

4. A nurse who has just assumed the role of unit manager is examining the skills necessary for interprofessional collaboration. Which of the following actions support the nurse’s interprofessional collaboration? (Select all that apply.)

A. Use aggressive communication when addressing the team.

B. Recognize the knowledge and skills of each member of the team.

C. Ensure that a nurse is assigned to serve as the group facilitator for all interprofessional meetings.

D. Encourage the client and family to participate in the team meeting.

E. Support team member requests for referral.

5. A nurse is caring for a client who has chest pain. The client says, “I am going home immediately.” Which of the following actions should the nurse take? (Select all that apply.)

A. Notify the client’s family of their intent to leave the facility.

B. Document the client’s intent to leave the facility against medical advice (AMA).

C. Explain to the client the risks involved if they choose to leave.

D. Ask the client to sign a form relinquishing responsibility of the facility.

E. Prevent the client from leaving the facility until the provider arrives.

Active Learning Scenario

A nurse is explaining the role of a case manager to a newly licensed nurse. What should the case manager include in the discussion? Use the ATI Active Learning Template: Basic Concept to complete this item.

UNDERLYING PRINCIPLES: Identify three roles of a case manager.

32 CHAPTER 2 COORDINATING CLIENT CARE CONTENT MASTERY SERIES

Application Exercises Key

1. A. The receiving nurse and facility do not need to know the type of anesthesia used in order to provide care or address the client’s current needs.

B. CORRECT: Communicate the client’s advance directive status as part of client advocacy.

C. The receiving nurse and facility do not need to know admission vital signs in order to provide care or address the client’s current needs. However, provide the most recent set of vital signs in the report.

D. CORRECT: Communicate the client’s medical diagnosis in order to provide care and address the client’s current needs.

E. CORRECT: Communicate the client’s need for specific equipment so the facility can provide appropriate care.

NCLEX® Connection: Management of Care, Continuity of Care

2. A. CORRECT: Determine whether the client will need home medical equipment so that the process of acquiring the equipment can begin.

B. Provide the client a list of currently prescribed medications so that the client can continue to take the correct medications at home.

C. CORRECT: Provide instructions about medications and procedures to perform at home.

D. CORRECT: Inform the client and family about community agencies that can help provide resources or assist with client care.

E. CORRECT: Ensure the client has follow-up appointments scheduled and knows when to contact the provider otherwise to prevent or minimize health complications.

NCLEX® Connection: Management of Care, Collaboration with Interdisciplinary Team

3. A. Critical pathways often reduce the cost of care by streamlining care services.

B. CORRECT: Critical pathways are specific to a client diagnosis and show the average length of stay a client with the diagnosis type will have.

C. Deviances from the pathway require documentation of explanation, because it usually indicates the client is not progressing at the expected rate.

D. Critical pathways include a projection of treatments the client will receive.

NCLEX® Connection: Management of Care, Concepts of Management

4. A. The nurse should use assertive skills when communicating with the interprofessional team.

B. CORRECT: The nurse should recognize that each member of the team has specific skills to contribute to the collaboration process.

C. A nurse can serve as the facilitator. However, this role can be assumed by any member of the team.

D. CORRECT: Collaboration should occur among the client, family, and interprofessional team.

E. CORRECT: The nurse should support suggestions for referrals to link clients to appropriate resources.

NCLEX® Connection: Management of Care, Collaboration with Interdisciplinary Team

5. A. Notifying the client’s family without the client’s permission violates the client’s right to confidentiality. Notify the client’s provider.

B. CORRECT: When documenting a discharge, document the type of discharge, including an AMA discharge.

C. CORRECT: The nurse is legally responsible to warn the client of the risks involved in leaving the hospital against medical advice.

D. CORRECT: Clients who leave the hospital prior to a prescribed discharge are asked to sign a form to provide legal protection for the hospital.

E. A nurse who tries to prevent a client from leaving the hospital by any action (threatening them or refusing to give them their clothes) can be charged with assault, battery, and false imprisonment.

NCLEX® Connection: Management of Care, Client Rights

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES: Roles of a case manager ● Coordinating care of clients who have complex health care needs ● Facilitating continuity of care ● Improving efficiency of care ● Enhancing quality of care provided ● Limiting cost and lengthy stays ● Advocating for the client and family

NCLEX® Connection: Management of Care, Concepts of Management

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NURSING LEADERSHIP AND MANAGEMENT NCLEX® CONNECTIONS 33

NCLEX® Connections

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

Management of Care ADVANCE DIRECTIVES/SELF-DETERMINATION/LIFE PLANNING: Integrate advance directives into client plan of care.

ADVOCACY: Discuss identified treatment options with client and respect their decisions.

CLIENT RIGHTS: Provide education to clients and staff about client rights and responsibilities.

CONFIDENTIALITY/INFORMATION SECURITY: Assess staff member and client understanding of confidentiality requirements.

ETHICAL PRACTICE: Recognize ethical dilemmas and take appropriate action.

INFORMED CONSENT: Verify the client receives appropriate education and consents to care and procedures.

INFORMATION TECHNOLOGY: Apply knowledge of facility regulations when accessing client records.

LEGAL RIGHTS AND RESPONSIBILITIES: Educate the client/staff on legal issues.

Safety and Infection Control REPORTING OF INCIDENT/EVENT/IRREGULAR OCCURRENCE/VARIANCE: Report unsafe practice of health care personnel and intervene as appropriate (e.g., substance abuse, improper care, staffing practices).

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34 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

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NURSING LEADERSHIP AND MANAGEMENT CHAPTER 3 PROFESSIONAL RESPONSIBILITIES 35

CHAPTER 3 Professional Responsibilities

Professional responsibilities are the obligations that nurses have to their clients. To meet their professional responsibilities, nurses must be knowledgeable in the following areas: client rights, advocacy, informed consent, advance directives, confidentiality and information security, information technology, legal practice, disruptive behavior, and ethical practice.

Client rights ● Client rights are the legal guarantees that clients have

with regard to their health care. ◯ Clients using the services of a health care institution

retain their rights as individuals and citizens of the United States. The American Hospital Association (AHA) identifies client rights in health care settings in the Patient Care Partnership (www.aha.org).

◯ Residents in nursing facilities that participate in Medicare programs similarly retain resident rights under statutes that govern the operation of these facilities.

● Nurses are accountable for protecting the rights of clients. Situations that require particular attention include informed consent, refusal of treatment, advance directives, confidentiality, and information security.

NURSING ROLE IN CLIENT RIGHTS ● Nurses must ensure that clients understand their rights.

Nurses also must protect clients’ rights during nursing care.

● Regardless of the client’s age, nursing needs, or the setting in which care is provided, the basic tenants are the same. Each client has the right to the following.

◯ Be informed about all aspects of care and take an active role in the decision-making process.

◯ Accept, refuse, or request modification to the plan of care.

◯ Receive care that is delivered by competent individuals who treat the client with respect.

REFUSAL OF TREATMENT The Patient Self-Determination Act (PSDA) stipulates that on admission to a health care facility, all clients must be informed of their right to accept or refuse care. Competent adults have the right to refuse treatment, including the right to leave a health care facility without a prescription for discharge from the provider. ● If the client refuses a treatment or procedure, the

client is asked to sign a document indicating that they understand the risk involved with refusing the treatment or procedure, and that they have chosen to refuse it.

● When a client decides to leave the facility without a prescription for discharge, the nurse notifies the provider and discusses with the client the potential risks associated with leaving the facility prior to discharge.

● The nurse carefully documents the information that was provided to the client and that notification of the provider occurred. The client should be informed of the following. ◯ Possible complications that could occur

without treatment ◯ Possibility of permanent physical or mental

impairment or disability ◯ Possibility of other complications that could

lead to death ● The client is asked to sign an Against Medical

Advice form. ● If the client refuses to sign the form, this is also

documented by the nurse.

Advocacy Advocacy refers to nurses’ role in supporting clients by ensuring that they are properly informed, that their rights are respected, and that they are receiving the proper level of care. ● Advocacy is one of the most important roles of the

nurse, especially when clients are unable to speak or act for themselves.

● As an advocate, the nurse ensures that the client has the information they need to make decisions about health care.

● Nurses must act as advocates even when they disagree with clients’ decisions.

● The complex health care system puts clients in a vulnerable position. Nurses are clients’ voice when the system is not acting in their best interest.

● The nursing profession also has a responsibility to support and advocate for legislation that promotes public policies that protect clients as consumers and create a safe environment for their care.

CHAPTER 3 Online Video: Client Rights

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NURSING ROLE IN ADVOCACY ● As advocates, nurses must ensure that clients are

informed of their rights and have adequate information on which to base health care decisions.

● Nurses must be careful to assist clients with making health care decisions and not direct or control their decisions.

● Nurses mediate on the client’s behalf when the actions of others are not in the client’s best interest or changes need to be made in the plan of care.

● Situations in which nurses might need to advocate for clients or assist them to advocate for themselves include the following. ◯ End-of-life decisions ◯ Access to health care ◯ Protection of client privacy ◯ Informed consent ◯ Substandard practice

● Nurses are accountable for their actions even if they are carrying out a provider’s prescription. It is the nurse’s responsibility to question a prescription if it could harm a client (incorrect medication dosage, potential adverse interaction with another prescribed medication, contraindication due to an allergy or medical history).

ESSENTIAL COMPONENTS OF ADVOCACY SKILLS ● Risk-taking ● Vision ● Self-confidence ● Articulate communication ● Assertiveness

VALUES ● Caring ● Autonomy ● Respect ● Empowerment

Informed consent ● Informed consent is a legal process by which a client

has given written permission for a procedure or treatment to be performed. Consent is considered to be informed when the client has been provided with and understands the following.

◯ Reason the treatment or procedure is needed ◯ How the treatment or procedure will benefit the client ◯ Risks involved if the client chooses to receive the treatment or procedure

◯ Other options to treat the problem, including the option of not treating the problem

◯ Risk involved if the client chooses no treatment ● The nurse’s role in the informed consent process is to

witness the client’s signature on the informed consent form and to ensure that informed consent has been appropriately obtained.

● The nurse should seek the assistance of an interpreter if the client does not speak and understand the language used by the provider.

INFORMED CONSENT GUIDELINES Consent is required for all care given in a health care facility. For most aspects of nursing care, implied consent is adequate. The client provides implied consent when they comply with the instructions provided by the nurse. For example, the nurse is preparing to administer a TB skin test, and the client holds out their arm for the nurse. ● For an invasive procedure or surgery, the client is

required to provide written consent. ● State laws regulate who is able to give informed consent.

Laws vary regarding age limitations and emergencies. Nurses are responsible for knowing the laws in the state of practice.

● The nurse must verify that consent is informed and witness the client sign the consent form.

Signing an informed consent form ● The form for informed consent must be signed by a

competent adult. ◯ Emancipated minors (minors who are independent from their parents [a married minor]) can provide informed consent for themselves.

● The person who signs the form must be capable of understanding the information provided by the health care professional who will be providing the service. The person must be able to fully communicate in return with the health care professional.

● When the person giving the informed consent is unable to communicate due to a language barrier or hearing impairment, a trained medical interpreter must be provided. Many health care agencies contract with professional interpreters who have additional skills in medical terminology to assist with providing information.

Online Video: Client Advocacy

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NURSING LEADERSHIP AND MANAGEMENT CHAPTER 3 PROFESSIONAL RESPONSIBILITIES 37

Individuals authorized to grant consent for another person ● Parent of a minor ● Legal guardian ● Court-specified representative ● Client’s health care surrogate (individual who has the

client’s durable power of attorney for health care/health care proxy)

● Spouse or closest available relative (state laws vary)

INFORMED CONSENT RESPONSIBILITIES PROVIDER: Obtains informed consent. To do so, the provider must give the client the following. ● Complete description of the treatment/procedure ● Description of the professionals who will be performing

and participating in the treatment ● Description of the potential harm, pain, and/or

discomfort that might occur ● Options for other treatments and the possible

consequences of taking other actions ● The right to refuse treatment ● Risk involved if the client chooses no treatment

CLIENT: Gives informed consent. To give informed consent, the client must do the following.

● Give it voluntarily (no coercion involved). ● Be competent and of legal age, or be an emancipated

minor. (If the client is unable to provide consent, an authorized person must give consent.)

● Receive sufficient information to make a decision based on an informed understanding of what is expected.

NURSE ● Witnesses informed consent. The nurse is responsible

for the following. ◯ Ensuring that the provider gave the client the

necessary information ◯ Ensuring that the client understood the information

and is competent to give informed consent ◯ Having the client sign the informed

consent document ◯ Notifying the provider if the client has more questions

or does not understand any of the information provided (The provider is then responsible for giving clarification.)

● The nurse documents the following. ◯ Reinforcement of information originally given by

the provider ◯ That questions the client had were forwarded to

the provider ◯ Use of an interpreter

Advance directives ● The purpose of advance directives is to communicate

a client’s wishes regarding end-of-life care should the client become unable to do so.

● The PSDA requires that all clients admitted to a health care facility be asked if they have advance directives.

◯ A client who does not have advance directives must be given written information that outlines their rights related to health care decisions and how to formulate advance directives.

◯ A health care representative should be available to help with this process.

COMPONENTS OF ADVANCE DIRECTIVES Two components of an advance directive are the living will and the durable power of attorney for health care.

Living will ● A living will is a legal document that expresses the

client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. Types of treatments that are often addressed in a living will are those that have the capacity to prolong life. Examples of treatments that are addressed are cardiopulmonary resuscitation, mechanical ventilation, and feeding by artificial means.

● Living wills are legal in all states. However, state statutes and individual health care facility policies can vary. Nurses need to be familiar with their state statute and facility policies.

● Most state laws include provisions that health care providers who follow the health care directive in a living will are protected from liability.

Durable power of attorney for health care

A durable power of attorney for health care/health care proxy is a legal document that designates a health care surrogate, who is an individual authorized to make health care decisions for a client who is unable. ● The person who serves in the role of health care

surrogate to make decisions for the client should be very familiar with the client’s wishes.

● Living wills can be difficult to interpret, especially in the face of unexpected circumstances. A durable power of attorney for health care, as an adjunct to a living will, can be a more effective way of ensuring that the client’s decisions about health care are honored.

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38 CHAPTER 3 PROFESSIONAL RESPONSIBILITIES CONTENT MASTERY SERIES

Provider’s prescriptions ● Unless a do not resuscitate (DNR) or allow natural death

(AND) prescription is written, the nurse should initiate CPR when a client has no pulse or respirations. The written prescription for a DNR or AND must be placed in the client’s medical record. The provider consults the client and the family prior to administering a DNR or AND.

● Additional prescriptions by the provider are based on the client’s individual needs and decisions and provide for comfort measures. The client’s decision is respected in regard to the use of antibiotics, initiation of diagnostic tests, and provision of nutrition by artificial means.

NURSING ROLE IN ADVANCE DIRECTIVES ● Providing written information regarding advance

directives ● Documenting the client’s advance directives status ● Ensuring that advance directives are current and

reflective of the client’s current decisions ● Recognizing that the client’s choice takes priority when

there is a conflict between the client and family, or between the client and the provider

● Informing all members of the health care team of the client’s advance directives

Confidentiality and information security

Clients have the right to privacy and confidentiality in relation to their health care information and medical recommendations. ● Nurses who disclose client information to an

unauthorized person can be liable for invasion of privacy, defamation, or slander.

● The security and privacy rules of the Health Insurance Portability and Accountability Act (HIPAA) were enacted to protect the confidentiality of health care information and to give the client the right to control the release of information. Specific rights provided by the legislation include the following: ◯ The rights of clients to obtain a copy of their medical

record and to submit requests to amend erroneous or incomplete information

◯ A requirement for health care and insurance providers to provide written information about how medical information is used and how it is shared with other entities (permission must be obtained before information is shared)

◯ The rights of clients to privacy and confidentiality

NURSING ROLE IN CONFIDENTIALITY It is essential for nurses to be aware of the rights of clients in regard to privacy and confidentiality. Facility policies and procedures are established in order to ensure compliance with HIPAA regulations. It is essential that nurses know and adhere to the policies and procedures. HIPAA regulations also provide for penalties in the event of noncompliance with the regulations.

PRIVACY RULE The Privacy Rule of HIPAA requires that nurses protect all written and verbal communication about clients.

COMPONENTS OF THE PRIVACY RULE ● Only health care team members directly responsible

for the client’s care are allowed access to the client’s records. Nurses cannot share information with other clients or staff not involved in the care of the client.

● Clients have a right to read and obtain a copy of their medical record, and agency policy should be followed when the client requests to read or have a copy of the record.

● No part of the client record can be copied except for authorized exchange of documents between health care institutions. For example:

◯ Transfer from a hospital to an extended care facility ◯ Exchange of documents between a general

practitioner and a specialist during a consult ● Client medical records must be kept in a secure area to

prevent inappropriate access to the information. Using public display boards to list client names and diagnoses is restricted.

● Electronic records should be password-protected, and care must be taken to prevent public viewing of the information. Health care workers should use only their own passwords to access information.

● Client information cannot be disclosed to unauthorized individuals, including family members who request it and individuals who call on the phone.

◯ Many hospitals use a code system in which information is only disclosed to individuals who can provide the code.

◯ Nurses should ask any individual inquiring about a client’s status for the code and disclose information only when an individual can give the code.

● Communication about a client should only take place in a private setting where it cannot be overheard by unauthorized individuals. The practice of “walking rounds,” where other clients and visitors can hear what is being said, is no longer sanctioned. Taped rounds also are discouraged because nurses should not receive information about clients for whom they are not responsible. Change-of-shift reports can be done at the bedside as long as the client does not have a roommate and no unsolicited visitors are present.

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3.1 Advance directives

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40 CHAPTER 3 PROFESSIONAL RESPONSIBILITIES CONTENT MASTERY SERIES

INFORMATION SECURITY ● Health information systems (HIS) are used to manage

administrative functions and clinical functions. The clinical portion of the system is often referred to as the clinical information systems (CIS). The CIS can be used to coordinate essential aspects of client care.

● In order to comply with HIPAA regulations, each health care facility has specific policies and procedures designed to monitor staff adherence, technical protocols, computer privacy, and data safety.

INFORMATION SECURITY PROTOCOLS ● Log off from the computer before leaving the

workstation to ensure that others cannot view protected health information (PHI) on the monitor.

● Never share a user ID or password with anyone. ● Never leave a client’s chart or other printed or written

PHI where others can access it. ● Shred any printed or written client information used for

reporting or client care after it is no longer needed.

USE OF SOCIAL MEDIA ● The use of social media by members of the nursing

profession is common practice. The benefits to using social media are numerous. It provides a mechanism for nurses to access current information about health care and enhances communication among nurses, colleagues, and clients and families. It also provides an opportunity for nurses to express concerns and seek support from others. However, nurses must be cautious about the risk of intentional or inadvertent breaches of confidentiality via social media.

● The right to privacy is a fundamental component of client care. Invasion of privacy as it relates to health care is the release of client health information to others without the client’s consent. Confidentiality is the duty of the nurse to protect a client’s private information.

● The inappropriate use of social media can result in a breach of client confidentiality. Depending on the circumstances, the consequences can include termination of employment by the employer, discipline by the board of nursing, charges of defamation or invasion of privacy, and in the most serious of circumstances, federal charges for violation of HIPAA.

Protecting yourself and others ● Become familiar with facility policies about the use of

social media, and adhere to them. ● Avoid disclosing any client health information online.

Be sure no one can overhear conversations about a client when speaking on the telephone.

● Do not take or share photos or videos of a client. ● Remember to maintain professional boundaries when

interacting with clients online. ● Never post a belittling or offensive remark about a

client, employer, or coworker. ● Report any violations of facility social media policies to

the nurse manager.

Information technology ● Informatics is the use of computers to systematically

resolve issues in nursing. The use of technology in health care is increasing and most forms of communication are in electronic format.

● Examples of how a nurse can use the electronic format while providing client care include laptops for documentation and the use of an automated medication dispensing system to dispense medications.

● Databases on diseases and medications are available for the nurse to review. These databases can also be used as a teaching tool when nurses are educating clients.

● The nurse can review medications, diseases, procedures, and treatments using an electronic format.

● Computers can be beneficial for use with clients who have visual impairments.

● The Internet is a valuable tool for clients to review current medications and health questions. This is especially true for clients who have chronic illnesses.

● Nurses should instruct clients to only review valid and credible websites by verifying the author, institution, credentials, and how current the article is. A disclaimer will be presented if information is not medical advice.

● Clients can access their electronic health record (EHR) which is part of e-health. E-health enables the client to make appointments online, review laboratory results, refill an electronic prescription, and review billing information. The goal of e-health is improved health care outcomes due to 24 hr access by the client and provider to the client’s health care information.

Legal practice In order to be safe practitioners, nurses must understand the legal aspects of the nursing profession.

● Understanding the laws governing nursing practice allows nurses to protect client rights and reduce the risk of nursing liability.

● Nurses are accountable for practicing nursing in accordance with the various sources of law affecting nursing practice. It is important that nurses know and comply with these laws. By practicing nursing within the confines of the law, nurses are able to do the following.

◯ Provide safe, competent care ◯ Advocate for clients’ rights ◯ Provide care that is within the nurse’s scope of practice

◯ Discern the responsibilities of nursing in relation to the responsibilities of other members of the health care team

◯ Provide care that is consistent with established standards of care

◯ Shield oneself from liability

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SOURCES OF LAW

Federal regulations Federal regulations have a great impact on nursing practice. Some of the federal laws affecting nursing practice include the following.

● HIPAA ● Americans with Disabilities Act (ADA) ● Mental Health Parity Act (MHPA) ● Patient Self-Determination Act (PSDA) ● Uniform Anatomical Gift Act (UAGA) ● National Organ Transplant Act (NOTA) ● Emergency Medical Treatment and Active Labor Act (EMTALA)

Criminal and civil laws Criminal law is a subsection of public law and relates to the relationship of an individual with the government. Violations of criminal law can be categorized as either a felony (a serious crime [homicide]) or misdemeanor (a less serious crime [petty theft]). A nurse who falsifies a record to cover up a serious mistake can be found guilty of breaking a criminal law.

Civil laws protect the individual rights of people. One type of civil law that relates to the provision of nursing care is tort law. Torts can be classified as unintentional, quasi-intentional, or intentional.

Unintentional torts ● Negligence: Practice or misconduct that does not meet

expected standards of care and places the client at risk for injury (a nurse fails to implement safety measures for a client who has been identified as at risk for falls).

● Malpractice: Professional negligence (a nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies).

Quasi-intentional torts ● Invasion of privacy: Intrusion into a client’s private

affairs or a breach of confidentiality (a nurse releases the medical diagnosis of a client to a member of the press).

● Defamation: False communication or communication with careless disregard for the truth with the intent to injure an individual’s reputation. ◯ Libel: Defamation with the written word or

photographs (a nurse documents in a client’s health record that a provider is incompetent).

◯ Slander: Defamation with the spoken word (a nurse tells a coworker that she believes a client has been unfaithful to the spouse).

Intentional torts ● Assault: The conduct of one person makes another

person fearful and apprehensive (threatening to place a nasogastric tube in a client who is refusing to eat).

● Battery: Intentional and wrongful physical contact with a person that involves an injury or offensive contact (restraining a client and administering an injection against their wishes).

● False imprisonment: A competent person not at risk for injury to self or others is confined or restrained against their will (using restraints on a competent client to prevent their leaving the health care facility).

State laws ● The core of nursing practice is regulated by state law. ● Each state has enacted statutes that define the

parameters of nursing practice and give the authority to regulate the practice of nursing to its state board of nursing. ◯ Boards of nursing have the authority to adopt

rules and regulations that further regulate nursing practice. Although the practice of nursing is similar among states, it is critical that nurses know the laws and rules governing nursing in the state in which they practice.

◯ The laws and rules governing nursing practice in a specific state can be accessed at the state board’s website.

◯ Boards of nursing have the authority to both issue and revoke a nursing license. Boards can revoke or suspend a nurse’s license for a number of offenses, including practicing without a valid license, substance use disorders, conviction of a felony, professional negligence, and providing care beyond the scope of practice. Nurses should review the practice act in their states.

◯ Boards also set standards for nursing programs and further delineate the scope of practice for registered nurses, licensed practical nurses, and advanced practice nurses.

● State laws vary as to when an individual can begin practicing nursing. Some states allow graduates of nursing programs to practice under a limited license, whereas some states require licensure by passing the NCLEX® before working.

Good Samaritan laws

Good Samaritan laws, which vary from state to state, protect nurses who provide emergency assistance outside of the employment location. The nurse must provide a standard of care that is reasonable and prudent.

Licensure ● Until the year 2000, nurses were required to hold a

current license in every state in which they practiced. This became problematic with the increase in the electronic practice of nursing. For example, a nurse in one state interprets the reading of a cardiac monitor and provides intervention for a client who is physically located in another state. Additionally, many nurses cross state lines to provide direct care. For example, a nurse who is located near a state border makes home visits on both sides of the state line.