Chapter 2: Nurse Qualities for Effective Collaboration

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 in Coordinating Client Care

• Coordinate the interprofessional team
• Have a holistic understanding of the client, their 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 client's status
• Provide an avenue for the initiation of a consultation related to a specific health care issue
• Provide a link to post-discharge resources that might be needed

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

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

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
• Lewin's change theory is a common model for promoting planned change, which has three stages: unfreezing, change/movement, and refreezing

Pathway to Excellence Recognition

• 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

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
• The goal of case management is to avoid fragmentation of care and control cost
• Case managers collaborate with the interprofessional health care team during the assessment of a client's needs and subsequent care planning
• Case managers follow up by monitoring the achievement of desired client outcomes within established time parameters

Continuity of Care

• Continuity of care refers to the consistency of care provided as clients move through the health care system
• Continuity of care is desired as clients move from one level of care to another, from one facility to another, or from one unit/department to another
• 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### Discharge Planning
• Begin discharge planning upon the client's admission to ensure continuity of care.
• Evaluate client/family competencies in relation to home care prior to discharge.
• Involve the client and family in care planning to achieve optimal results.
• Collaborate with other health care professionals to ensure all health care needs are met and necessary referrals are made.

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 to protect client confidentiality.

Transfers

• Clients can be transferred from one unit, department, or one facility to another.
• Continuity of care must be maintained during transfers.
• The nurse's role regarding transfers is to provide written and verbal report of the client's status and care needs.

Consultations

• A consultant is a professional who provides expert advice in a particular area.
• Consultants provide expertise for clients who require a specific type of knowledge or service.
• The nurse's role regarding consultations is to initiate necessary consults, notify the provider of the client's needs, and provide the consultant with all pertinent information.

Report to the Provider

• Recommendations for changes in the plan of care.
• Clarification of prescriptions.
• Assessment data integral to changes in client status.

Discharge Instructions

• Step-by-step instructions for procedures to be done at home.
• 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.
• Plans for follow-up care and therapies.

Discharge Planning

• A comprehensive discharge plan includes a review of the client's current health and prognosis.
• Mobility status and goals.
• Sensory, motor, physical, or cognitive impairments.
• Support systems and caregivers.
• Potential supports and resources in the community.
• Internal and external home environment.
• Financial resources and limitations.
• Need for assistance with transportation or home maintenance.
• Need for therapy, wound care, or other services.

Leaving Against Medical Advice (AMA)

• A client who leaves a facility without a prescription from the provider is considered leaving against medical advice.
• The nurse should immediately notify the provider.
• If the client is at risk for harm, it is imperative that the nurse explains the risk involved in leaving the facility.
• The individual should sign a form relinquishing responsibility for any complications that arise from discontinuing prescribed care.

Standardized Nursing Care Plans

• 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.

Communication and Continuity of Care

• Poor communication can lead to adverse outcomes, including sentinel events.
• Communication is required anytime there is a transfer of care, whether from one unit or facility to another, or at change-of-shift.
• Guidelines on transfer reporting contain details on what to communicate when transferring client care.

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.
• 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.

Principles of Case Management

• Continuity of care refers to the consistency of care provided as clients move through the health care system.
• Continuity of care enhances the quality of client care and facilitates the achievement of positive client outcomes.
• Case management focuses on managed care of the client through collaboration of the health care team in acute and post-acute settings.

Transfers and Referrals

• 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 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.

Referrals

• A referral is a formal request for a service by another care provider.
• 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 nursing care.

Consultations

• A consultant is a professional who provides expert advice in a particular area.
• The nurse's role regarding consultations is to provide written and verbal report of the client's status and care needs.

Critical Pathways

• A critical or clinical pathway or care map is 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).
• 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.

Documentation

• Documentation to facilitate continuity of care includes 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 client care.

Collaboration

• 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.
• 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.

Variables That Affect Collaboration

• Hierarchical influence on decision-making: 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.

Promoting 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.