Nursing Chapter 1: Managing Client Care

Managing Client Care

• Managing client care requires leadership, management skills, and knowledge to effectively coordinate and carry out client care.
• Effective management involves planning, organizing, directing, and controlling the work within an organization.

Leadership

• Leadership is the ability to inspire others to achieve a desired outcome.
• Effective leaders possess good communication, problem-solving, and critical-thinking skills.
• Leaders influence willing followers to move toward a goal.
• Characteristics of leaders include:
  • Initiative
  • Inspiration
  • Energy
  • Positive attitude
  • Respect
  • Problem-solving and critical-thinking skills

Leadership Styles

• Autocratic/authoritarian:
  • Makes decisions for the group
  • Motivates by coercion
  • Communication occurs down the chain of command
  • Work output is usually high, but not suitable for all situations
• Democratic:
  • Includes the group when making decisions
  • Motivates by supporting staff achievements
  • Communication occurs up and down the chain of command
  • Work output 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

Management Functions

• Planning:
  • Decides what needs to be done, how it will be done, and who is going to do it
• Organizing:
  • Determines the organizational structure, lines of authority, and channels of communication
• Staffing:
  • Acquires and manages adequate staff and staffing mix
• Directing:
  • Influences and motivates staff to perform assigned roles
• Controlling:
  • Evaluates staff performance and 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

Critical Thinking and Clinical Reasoning

• Critical thinking:
  • Analyzes client issues and problems
  • Uses interpretation, analysis, evaluation, inference, and explanation to make informed decisions
• Clinical reasoning:
  • Analyzes the elements of a clinical situation and makes decisions based on analysis
  • Uses nursing knowledge to make decisions about client care

Prioritization

• Prioritization principles:
  • Prioritize systemic before local (life before limb)
  • Prioritize acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation)
  • Prioritize actual problems before potential problems
• Priority-setting frameworks:
  • Maslow's hierarchy of needs
  • Airway, breathing, circulation (ABC) framework
  • Disability and exposure (D and E) framework

Time Management

• Organize care according to client care needs and priorities
• Determine what must be done immediately and what can be done by a specific time to ensure client safety

Evidence-Based Practice

• Select interventions that maintain client safety while posing the least amount of restriction to the client
• Use a variety of sources of research to keep current on new practices
• Change traditional nursing practice with new research-based practices### Managing Client Care

Time Management

• Prioritize tasks based on client needs and available resources
• Use time-saving strategies to facilitate accurate and thorough documentation
• Avoid time wasters, such as documenting at the end of the shift and making repeated trips to the supply room
• Estimate time needed for each activity and plan accordingly
• Delegate tasks to other staff members when client care workload is beyond what can be handled by one nurse
• Take breaks to socialize with staff and plan care to avoid procrastination

Evidence-Based Practice

• Use current research to guide prioritization of care and interventions
• Make informed clinical decisions based on current data and best practices
• Determine best practice through current research collected from several sources with desirable outcomes

Assigning, Delegating, and Supervising

• Assigning is the process of transferring authority, accountability, and responsibility to another team member
• Delegating is the process of transferring authority and responsibility to another team member while retaining accountability
• Supervising is the process of directing, monitoring, and evaluating the performance of tasks by another team member
• Delegate tasks based on individual client needs, facility policies, and job descriptions
• Consider legal and ethical concerns when assigning and delegating tasks

Delegation Factors

• Predictability of outcome: will the task have a predictable outcome?
• Potential for harm: is there a chance that something negative can happen to the client?
• Complexity of care: are complex tasks required as part of the client's care?
• Need for problem-solving and innovation: is nursing judgment required while performing the task?
• Level of interaction with the client: is there a need to provide psychosocial support or education during the task?

Delegatee Factors

• Education, training, and experience: does the delegatee have the necessary knowledge and skills to perform the task?
• Ability to communicate with others: can the delegatee communicate effectively as part of the task?
• Demonstrated competence: has the delegatee demonstrated competence in performing the task?
• Agency policies and procedures: are the delegatee's skills and abilities in line with agency policies and procedures?

Delegation and Supervision Guidelines

• Use the five rights of delegation: right task, right circumstance, right person, right direction/communication, and right supervision/evaluation
• Use nursing judgment and knowledge related to the scope of practice and the delegatee's skill level when delegating

Licensed Personnel and Assistive Personnel

• Licensed personnel: nurses who have completed a course of study, passed the NCLEX-PN or NCLEX-RN exam, and have a nursing license
• Assistive personnel: specifically trained to function in an assistive role to licensed nurses in client care activities

Examples of Tasks That Can Be Delegated

• To Practical Nurses (PNs): monitoring findings, reinforcing client teaching, performing tracheostomy care, suctioning, and administering medication

• To Assistive Personnel (APs): activities of daily living (ADLs), bathing, grooming, dressing, toileting, ambulating, and vital signs for stable clients### Delegation and Supervision

• Delegate a task to an AP (assistant personnel) when the client has a stable condition, such as measuring vital signs of a postoperative client.

• Right direction and communication: delegate an AP to assist a client in a specific room with a specific task, such as a shower or morning hygiene.

• Wrong task: delegate an AP to administer a nebulizer treatment to a client who has pneumonia, which requires a licensed nurse.

• Right circumstance: delegate an AP to assist a client who is postoperative and stable, providing clear directions and expectations.

• Wrong circumstance: delegate an AP to measure vital signs of a client who is postoperative and received naloxone to reverse respiratory depression, requiring close supervision.

Supervision

• Observe the AP to ensure safe ambulation of a client, providing positive feedback after completion.
• Continually review the performance of the AP and determine care competency.
• Assess team member performance based on standards, and when necessary, take steps to remediate a failure to meet standards.

Nursing Leadership and Management

• The nurse leader has a responsibility to maintain competent staff and respect the diversity of the health care team.
• Staff education, or staff development, is the process by which a staff member gains knowledge and skills to ensure they meet the needs of clients.
• The quality improvement process focuses on assessment of outcomes and determines ways to improve the delivery of quality care.

Quality Improvement Process

• The quality improvement process begins with identification of standards and outcome indicators based on evidence.
• 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).
• Outcome indicators reflect desired client outcomes related to the standard under review.
• Benchmarks are goals that are set to determine at what level the outcome indicators should be met.

Audits

• Audits can produce valuable quantitative data.
• Types of audits: structure audits, process audits, and outcome audits.
• Nursing-sensitive outcomes are those that are directly affected by the quality of nursing care.
• Examples of nursing-sensitive outcomes include client fall rates and the incidence of nosocomial infections.

Nurse's Role in Quality Improvement

• Serve as a 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.

Management Functions

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

Staffing

• Acquisition and management of adequate staff and staffing mix.
• Determine client outcomes desired and/or achieved as indicated by evidence-based practices.

Directing

• Leadership role assumed by a manager that influences and motivates staff to perform assigned roles.

Controlling

• Evaluation of staff performance and evaluation of unit goals to ensure identified outcomes are being met.
• Priority setting requires decisions about the order in which tasks are completed, maintaining client safety.

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.
• Manage emotions and channel them in a positive direction.

Effective Management

• Work output by staff is usually high in crisis situations and bureaucratic settings.
• Effective for employees with little or no formal education.
• Committed to the delivery of high-quality client care.
• Refrains from judgment in controversial or emotionally-charged situations until facts are gathered.

Nursing Leadership and Management

• 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.

Planning

• Decisions regarding what needs to be done, how it will be done, and who is going to do it.

Organizing

• Organizational structure that determines the lines of authority, channels of communication, and where decisions are made.
• Assigning is performed in a downward or lateral manner with regard to members of the health care team.

Time Management

• Time management is a cyclic process.
• 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.

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.

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 in Healthcare

• Assigning tasks in a downward or lateral manner can lead to feelings of being overwhelmed and stressed, omission of important tasks, and dissatisfaction with care provided.
• Effective time management involves developing a plan, setting goals, and prioritizing tasks based on established priorities and thoughtful utilization of resources.
• It is essential to complete one client care task before beginning the next, starting with the highest priority task, and continually reassessing client care needs.

Client Factors Affecting Time Management

• Client's condition and level of care needed
• Specific care needs (e.g., cardiac monitoring, mechanical ventilation)
• Need for special precautions (e.g., isolation precautions, fall precautions, seizure precautions)
• Procedures requiring a significant time commitment (e.g., extensive dressing changes or wound care)

Health Care Team Factors Affecting Time Management

• 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

Time Management and Teamwork

• Be aware of assistance needed by other healthcare team members
• Offer to help when unexpected crises occur
• Assist other team members with provision of care when experiencing downtime

Staffing and Management

• Staffing involves the acquisition and management of adequate staff and staffing mix
• Directing involves leadership and motivation of staff to perform assigned roles
• Controlling involves evaluating staff performance and unit goals to ensure identified outcomes are being met

Characteristics of Effective Managers

• Hold formal positions of authority and power
• Possess clinical expertise
• Network with team members
• Coach subordinates
• Make decisions about the function of the organization

Prioritization and Time Management

• Nurses must continuously set and reset priorities to meet client needs and maintain client safety
• Priority setting involves deciding on the order of tasks, including:
  • Seeing clients
  • Completing assessments
  • Providing interventions
  • Completing steps in client procedures
  • Completing components of client care

Additional Factors Affecting Time Management

• Self-care: schedule time for breaks and meals, take physical and mental breaks from work
• Addressing unsafe assignments: bring concerns to the attention of the scheduling/charge nurse, negotiate a new assignment, and file a written protest if necessary