Chapter 21

1. Chapter 21 Managing Patient Care

2. Entry Level Competencies • The National Council of State Boards of Nursing (NCSBN) identified competencies that registered nurses (RNs) and licensed practical/ vocational nurses need on entry to practice. Three of these are: • Demonstrate nursing knowledge and display confidence in knowledge base. • Demonstrate knowledge of roles, responsibilities, and functions of a nurse. • Recognize own limitations and see support of validation of decisions as needed.

3. Empowered Nursing Team • Includes nurse executive, nurse manager, and nursing staff • Nurse executive possesses many roles: • Ethical leader • Business leader • Quality of care promoter • Cost-effectiveness promoter

4. Empowered Nursing Team (cont’d) • Philosophy of care • Professional nursing staff’s values and concerns for the way they view and care for patients • Selection of nursing care delivery model that supports professional nursing practice • Selection of a management structure that supports professional nursing practice

5. Magnet Recognition • Magnet hospitals typically have clinical promotion systems and research and evidence-based practice. • Nurses have professional autonomy over their practice and control over the practice environment. • Magnet hospitals empower the nursing team to make changes and be innovative. • This results in a strong collaborative relationship among team members and improved patient quality of care outcomes.

6. Case Study • Jennifer is a nursing student who is assigned the following three patients: • Mrs. Sinclair, who is scheduled for surgery to repair a fractured right hip • Mr. Timmons, who has finished lunch and is ready for pain medication • Mr. Dodson, who has a postoperative wound infection and is due for antibiotic medication

7. Nursing Care Delivery Model • Assists nurses in achieving desirable outcomes for their patients • Results in success via the following factors: • Decision-making authority for nurses • Effective methods of communicating with colleagues

8. Nursing Care Delivery Models (cont’d)

9. Team Nursing • Collaborative care style that encourages each member of team to work with and help the other members • Hierarchical communication from charge nurse to charge nurse, charge nurse to team leader, and team leader to team members • Decision making occurs at clinical level

10. Total Patient Care • Registered nurse works directly with patient, family, and health care team members. • RN is responsible for patients during shift of care, although care can be delegated. • Approach may not be cost-effective owing to high number of registered nurses needed. • Patient satisfaction is high.

11. Primary Nursing • One primary registered nurse assumes responsibility for caseload. • Communication is lateral from nurse to nurse and from caregiver to caregiver. • Flexible model uses a variety of staffing levels and mixes. • RN works with a limited number of patients.

12. Case Management • Collaborative process of assessing, planning, facilitating, and advocating for options and services to meet an individual’s health needs • Clinicians oversee the management of patients with specific, complex health problems and are usually held accountable for some standard of cost management and quality. • Often the case manager is an advanced practice nurse, who helps improve patient outcomes via specific interventions.

13. Decision Making • Decentralized management means that decision making occurs at the level of the staff. • Encompasses • Responsibility: duties and activities an individual is employed to perform • Autonomy: independent decisions about patient care • Authority: legitimate power to give commands and make final decisions specific to a given position • Accountability: answerable for the actions

14. Quick Quiz! 1. A travel nurse has taken an assignment at a health care facility where nurses assume responsibility for a caseload of patients over a period of time. This type of nursing exemplifies A. Team nursing. B. Primary nursing. C. Functional nursing. D. Decentralized management.

15. Staff Involvement • Establishing nursing practice or problem-solving committees or professional shared governance councils • Nurse/physician collaborative practice • Interdisciplinary collaboration • Staff communication • Staff education

16. Leadership Qualities

17. Leadership Skills

18. Clinical Care Coordination • Clinical Decisions • Priority Setting • Organizational Skills • Use of Resources • Time Management • Evaluation

19. Priority Setting • Determine which patient’s needs should be addressed first: • High priority: immediate threat to patient survival or safety • Intermediate priority: nonemergent, non–life threatening • Low priority: actual or potential problems may or may not be directly related to patient’s illness or disease

20. Case Study (cont’d) • Mrs. Sinclair’s surgery is scheduled for 1 pm. She has never had surgery before and is very nervous and moving restlessly in bed. She is reluctant to talk, but her preoperative checklist is not yet completed, and she needs to be escorted to surgery in 30 minutes.

21. Case Study (cont’d) • Mr. Timmons had abdominal surgery 2 days ago for colon tumor removal. He has finished his lunch and is ready for pain medication. He is preparing to get out of bed to walk down the hall.

22. Case Study (cont’d) • Mr. Dodson has a postoperative wound infection. His wet-to-dry abdominal dressing needs to be changed, and he needs his next dose of antibiotic.

23. Case Study (cont’d) • Jennifer stays with Mrs. Sinclair to assess her new symptoms and complete her preoperative checklist. She sends a unit clerk to check on Mr. Timmons. • Once Mrs. Sinclair’s checklist is completed, she stops by Mr. Timmons’ room to assess his pain and administer his medication. • She then verifies Mr. Dodson’s identification and administers the antibiotic, and next completes the dressing change.

24. Organizational Skills • Perform tasks correctly. • Perform the correct tasks. • Utilize resources. • Manage time. • Evaluate outcomes. • Progress to an improved level of health.

25. Time Management • Remain goal oriented. • Identify priorities. • Establish personal goals.

26. Evaluate

27. Case Study (cont’d) • When Jennifer assesses Mr. Timmons’ pain, she discovers that his pain is still 8 out of 10 following Percodan 20 mg every 6 hours. Patient-controlled analgesia (PCA) with morphine was removed 4 hours ago. • She determines that his current pain medication is insufficient to control his pain and requests a change in his medication.

28. Team Communication

29. Delegation • Transfers responsibility while remaining accountable for outcomes • Requires knowing which skills are transferable • Results in improved quality of patient care, improved efficacy, increased productivity, and an empowered staff

30. The Five Rights of Delegation • Right Task • Right Circumstance • Right Person • Right Direction • Right Supervision

31. Steps to Effective Delegation • Assess the knowledge and skills of the delegatee. • Match tasks to the delegatee’s skills. • Communicate clearly: • Task, outcome, time • Listen attentively. • Provide feedback.

32. Quick Quiz! 2. A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to A. Assign only bed-making and feeding skills. B. Assess the knowledge of the certified nursing assistant. C. Remind the staff member that she is working under the license of the RN. D. Allow the staff member to perform only skills that the RN is able to teach certified nursing assistants to perform.

33. Knowledge Building • Remain competent. • Pursue lifelong learning. • Share the knowledge. • To become a leader, actively pursue learning opportunities, both formal and informal, and learn to share knowledge with the professional colleagues you encounter.