Chapter 1: Managing Client Care PDF

CHAPTER 1 Democratic CHAPTER 1 Managing Includes the group when decisions are made. Client Care...

CHAPTER 1 Democratic CHAPTER 1 Managing Includes the group when decisions are made. Client Care Motivates by supporting staff achievements. Communication occurs up and down the chain of command. Work output by staff is usually of good quality when Managing client care requires leadership, cooperation and collaboration are necessary. management skills, and knowledge to effectively Laissez‑faire coordinate and carry out client care. Makes very few decisions, and does little planning. Motivation is largely the responsibility of individual To effectively manage client care, a nurse staff members. Communication occurs up and down the chain of must develop knowledge and skills in several command and between group members. areas, including leadership, management, critical Work output is low unless an informal leader evolves from the group. thinking, clinical reasoning, clinical judgment, Effective with professional employees. prioritization, time management, assigning, delegating, supervising, staff education, quality CHARACTERISTICS OF LEADERS Initiative improvement, performance appraisal, peer Inspiration review, disciplinary action, conflict resolution, Energy Positive attitude and cost‑effective care. Communication skills Respect Problem‑solving and critical‑thinking skills Leadership and management A combination of personality traits and leadership skills Leaders influence willing followers to move Management is the process of planning, organizing, toward a goal. directing, and coordinating the work within Leaders have goals that might differ from those of an organization. the organization. Leadership is the ability to inspire others to achieve a Transformational leaders empower and inspire desired outcome. followers to achieve a common, long-term vision. Effective managers usually possess good leadership Transactional leaders focus on immediate problems, skills. However, effective leaders are not always in a maintaining the status quo and using rewards to management position. motivate followers. Managers have formal positions of power and authority. Authentic leaders inspire others to follow them by Leaders might have only the informal power afforded modeling a strong internal moral code. them by their peers. One cannot be a leader without followers. Emotional intelligence Emotional intelligence is the ability of an individual to perceive and manage the emotions of self and others. LEADERSHIP 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. LEADERSHIP STYLES Emotional intelligence is also an important Most can be categorized as autocratic/authoritarian, characteristic of the successful nurse leader. democratic, or laissez‑faire. The nurse might need to use Emotional intelligence is developed through any of these leadership styles depending on the situation. understanding the concept and applying it to practice in everyday situations. Autocratic/authoritarian The emotionally intelligent leader: Makes decisions for the group. Has insight into the emotions of members of the team. Motivates by coercion. Understands the perspective of others. Communication occurs down the chain of command, or Encourages constructive criticism and is open to from the highest management level downward through new ideas. other managers to employees. Manages emotions and channels them in a positive Work output by staff is usually high: good for crisis direction, which in turn helps the team accomplish situations and bureaucratic settings. its goals. Effective for employees with little or no formal education. Is 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 CHAPTER 1 Managing Client Care 3  MANAGEMENT Clinical judgment The five major management functions are planning, Clinical judgment is the decision made regarding a organizing, staffing, directing, and controlling. course of action based on a critical analysis of data. Clinical judgment considers the client’s needs when PLANNING: The decisions regarding what needs to be deciding to take an action, or modify an intervention done, how it will be done, and who is going to do it based on the client’s response. ORGANIZING: The organizational structure that The nurse uses clinical judgment to: determines the lines of authority, channels of ◯ Analyze data and related evidence. communication, and where decisions are made ◯ Ascertain the meaning of the data and evidence. ◯ Apply knowledge to a clinical situation. STAFFING: The acquisition and management of adequate ◯ Determine client outcomes desired and/or achieved as staff and staffing mix indicated by evidence‑based practices. DIRECTING: The leadership role assumed by a manager that influences and motivates staff to perform assigned roles PRIORITIZATION AND CONTROLLING: The evaluation of staff performance and TIME MANAGEMENT evaluation of unit goals to ensure identified outcomes Nurses must continuously set and reset priorities in are being met order to meet the needs of multiple clients and to maintain client safety. Priority setting requires that decisions be made CHARACTERISTICS OF MANAGERS regarding the order in which: Hold formal positions of authority and power ◯ Clients are seen. Possess clinical expertise ◯ Assessments are completed. Network with members of the team ◯ Interventions are provided. Coach subordinates ◯ Steps in a client procedure are completed. Make decisions about the function of the organization, ◯ Components of client care are completed. including resources, budget, hiring, and firing Establishing priorities in nursing practice requires that the nurse make these decisions based on evidence obtained: Critical thinking ◯ During shift reports and other communications with members of the health care team. Critical thinking is used when analyzing client issues ◯ Through careful review of documents. and problems. Thinking skills include interpretation, ◯ By continuously and accurately collecting client data. analysis, evaluation, inference, and explanation. These skills assist the nurse to determine the most appropriate action to take. PRIORITIZATION PRINCIPLES Critical thinking reflects upon the meaning of IN CLIENT CARE statements, examines available data, and uses reason to Prioritize systemic before local (“life before limb”). make informed decisions. Prioritizing interventions for a client in Critical thinking is necessary to reflect and evaluate shock over interventions for a client from a broader scope of view. who has a localized limb injury Sometimes one must think “outside the box” to find solutions that are best for clients, staff, and Prioritize acute (less opportunity for physical the organization. adaptation) before chronic (greater opportunity for physical adaptation). Clinical reasoning Prioritizing the care of a client who has a new injury/ Clinical reasoning is the mental process used when illness (mental confusion, chest pain) or an acute analyzing the elements of a clinical situation and using exacerbation of a previous illness over the care analysis to make a decision. The nurse continues to of a client who has a long‑term chronic illness use clinical reasoning to make decisions as the client’s Prioritize actual problems before potential situation changes. future problems. Clinical reasoning supports the clinical decision‑making process by: Prioritizing administration of medication to a ◯ Guiding the nurse through the process of assessing client experiencing acute pain over ambulation and compiling data. of a client at risk for thrombophlebitis ◯ Selecting and discarding data based on relevance. Listen carefully to clients and don’t assume. ◯ Using nursing knowledge to make decisions about client care. Problem solving is a part of Asking a client who has a new diagnosis of decision‑making. diabetes mellitus what they feel is most important to learn about disease management. 4 CHAPTER 1 Managing Client Care CONTENT MASTERY SERIES  Recognize and respond to trends vs. transient findings. Fourth: Disability ◯ Assess for current or evolving disability (neurological Recognizing a gradual deterioration in a client’s level deficits, stroke in evolution). of consciousness and/or Glasgow Coma Scale score ◯ Implement actions to slow down development Recognize indications of medical emergencies and of disability. complications vs. expected findings. Fifth: Exposure ◯ Remove the client’s clothing to allow for a complete Recognizing indications of increasing intracranial assessment or resuscitation. pressure in a client who has a new diagnosis of a ◯ Implement measures to reduce the risk for stroke vs. the findings expected following a stroke hypothermia (provide warm blankets and IV solutions Apply clinical knowledge to procedural standards to or use cooling measures for clients exposed to determine the priority action. extreme heat). Recognizing that the timing of administration Safety/risk reduction of antidiabetic and antimicrobial medications is more important than administration Look first for a safety risk. For example, is there a of some other medications finding that suggests a risk for airway obstruction, hypoxia, bleeding, infection, or injury? Next ask, “What’s the risk to the client?” and “How PRIORITY-SETTING FRAMEWORKS significant is the risk compared to other posed risks?” Give priority to responding to whatever finding poses Maslow’s hierarchy (1.1) the greatest (or most imminent) risk to the client’s The nurse should consider this hierarchy of human needs physical well‑being. when prioritizing interventions. For example, the nurse should prioritize a client’s: Assessment/data collection first Need for airway, oxygenation (or breathing), circulation, Use the nursing process to gather pertinent information and potential for disability over need for shelter. prior to making a decision regarding a plan of action. For Need for a safe and secure environment over a need example, determine if additional information is needed for socialization. prior to calling the provider to ask for pain medication for a client. Airway breathing circulation (ABC) framework The ABC framework identifies, in order, the three basic Survival potential needs for sustaining life. Use this framework for situations in which health ◯ An open airway is necessary for breathing, so it is the resources are extremely limited (mass casualty, highest priority. disaster triage). ◯ Breathing is necessary for oxygenation of the Give priority to clients who have a reasonable chance blood to occur. of survival with prompt intervention. Clients who ◯ Circulation is necessary for oxygenated blood to reach have a limited likelihood of survival even with intense the body’s tissues. intervention are assigned the lowest priority. 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. 1.1 Maslow’s hierarchy of needs 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. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 Managing Client Care 5  Least restrictive/least invasive Methods to promote evidence-based practice Use a variety of sources of research. Select interventions that maintain client safety while Keep current on new research by reading professional posing the least amount of restriction to the client. For journals and collaborating with other nurses and example, if a client who has a high fall risk index is professionals in other disciplines. getting out of bed without assistance, move the client Change traditional nursing practice with new closer to the nurses’ work area rather than choosing to research-based practices. 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. TIME MANAGEMENT Organize care according to client care needs Acute vs. chronic, urgent vs. nonurgent, and priorities. stable vs. unstable What must be done immediately (administration of analgesic or antiemetic, assessment of unstable client)? A client who has an acute problem takes priority over a What must be done by a specific time to ensure client client who has a chronic problem. safety, quality care, and compliance with facility policies A client who has an urgent need takes priority over a and procedures (routine medication administration, client who has a nonurgent need. vital signs, blood glucose monitoring)? A client who has unstable findings takes priority over a What must be done by the end of the shift (ambulation client who has stable findings. of the client, discharge and/or discharge teaching, dressing change)? Evidence-based practice What can the nurse delegate? Use current data to make informed clinical decisions to ◯ What tasks can only the RN perform? provide the best practice. Best practice is determined ◯ What client care responsibilities can the nurse by current research collected from several sources that delegate to other health care team members (practical have desirable outcomes. nurses [PNs] and assistive personnel [APs])? Use knowledge of evidence-based practice to guide Use time‑saving strategies and avoid time wasters. (1.2) prioritization of care and interventions (responding to Good time management: clients experiencing wound dehiscence or crisis). For ◯ Facilitates greater productivity. example, initiating CPR in the proper steps for a client ◯ Decreases work‑related stress. experiencing cardiac arrest. ◯ Helps ensure the provision of quality client care. ◯ Enhances satisfaction with care provided. 1.2 Time management examples Time savers Time wasters Documenting nursing interventions as soon as possible after Documenting at the end of the shift all client completion to facilitate accurate and thorough documentation care provided and assessments done Grouping activities that are to be performed on the same client Making repeated trips to the supply room for equipment or are in close physical proximity to prevent unnecessary walking Providing care as opportunity arises Estimating how long each activity will take and planning accordingly regardless of other responsibilities Mentally envisioning the procedure to be performed and Missing equipment when preparing to perform a procedure gathering all equipment prior to entering the client’s room Failing to plan or managing by crisis Taking time to plan care and taking priorities into consideration Being reluctant to delegate or under-delegating Delegating activities to other staff when client care Not asking for help when needed or trying to workload is beyond what can be handled by one nurse provide all client care independently Enlisting the aid of other staff when a team approach Procrastinating: delaying time‑consuming, less is more efficient than an individual approach desirable tasks until late in the shift Completing more difficult or strenuous Agreeing to help other team members with lower tasks when energy level is high priority tasks when time is already compromised Avoiding interruptions and graciously but assertively saying Setting unrealistic standards for completion of care and level of “no” to unreasonable or poorly-timed requests for help performance within constraints of assignment and resources Setting a realistic standard for completion of care and level of Starting several tasks at once and not performance within the constraints of assignment and resources completing tasks before starting others Completing one task before beginning another task Not addressing low level of skill competency, Breaking large tasks into smaller tasks to increasing time on task make them more manageable Providing care without a written plan Using an organizational sheet to plan care Socializing with staff during client care time Using breaks to socialize with staff 6 CHAPTER 1 Managing Client Care CONTENT MASTERY SERIES  Poor time management: ASSIGNING ◯ Impairs productivity. Assigning is performed in a downward or lateral manner ◯ Leads to feelings of being overwhelmed and stressed. with regard to members of the health care team. ◯ Increases omission of important tasks. ◯ Creates dissatisfaction with care provided. Time management is a cyclic process. CLIENT FACTORS Time initially spent developing a plan will save time Condition of the client and level of care needed later and help to avoid management by crisis. Specific care needs (cardiac monitoring, Set goals and plan care based on established priorities mechanical ventilation) and thoughtful utilization of resources. Need for special precautions (isolation precautions, fall Complete one client care task before beginning the next, precautions, seizure precautions) starting with the highest priority task. Procedures requiring a significant time commitment Reprioritize remaining tasks based on continual (extensive dressing changes or wound care) reassessment of client care needs. At the end of the day, perform a time analysis and HEALTH CARE TEAM FACTORS determine if time was used wisely. Knowledge and skill level of team members Amount of supervision necessary TIME MANAGEMENT AND TEAMWORK Staffing mix (RNs, PNs, APs) Be cognizant of assistance needed by other health care Nurse‑to‑client ratio team members. Experience with similar clients Offer to help when unexpected crises occur. Familiarity of staff member with unit Assist other team members with provision of care when experiencing a period of down time. ADDITIONAL FACTORS When a nurse receives an unsafe assignment, they should TIME MANAGEMENT AND SELF‑CARE take the following actions. Take time for yourself. Bring the unsafe assignment to the attention Schedule time for breaks and meals. of the scheduling/charge nurse and negotiate a Take physical and mental breaks from work new assignment. and the unit. If no resolution is arrived at, take the concern up the chain of command. If a satisfactory resolution is still not arrived Assigning, delegating, at, the nurse should file a written protest to the and supervising assignment (an assignment despite objection [ADO] or document of practice situation [DOPS]) with the appropriate administrator. Assigningis the process of transferring the authority, Failure to accept the assignment without following the accountability, and responsibility of client care to another proper channels can be considered client abandonment. member of the health care team. Delegatingis the process of transferring the authority and responsibility to another team member to complete a task, MAKING CLIENT ROOM ASSIGNMENTS while retaining the accountability. The nurse should consider client age and diagnosis, as well as client safety, comfort, privacy, and infection Supervisingis the process of directing, monitoring, and control needs when planning client room evaluating the performance of tasks by another member of assignments. the health care team. Private rooms Nurses must delegate appropriately and supervise adequately Private rooms are required for clients who have an to ensure that clients receive safe, quality care. (1.3) infectious disease that requires airborne precautions, or Delegation decisions are based on individual client clients who require a protective environment. needs, facility policies and job descriptions, state nurse practice acts, and professional standards. The nurse Private rooms are preferred for clients who are on should consider legal/ethical concerns when assigning droplet and contact precautions. These clients can and delegating. cohort if no private rooms are available and if all of the The nurse leader should recognize limitations and following are true. use available information and resources to make the The clients have the same active infection with the same best possible decisions at the time. The nurse must micro-organisms. remember that it is their responsibility to ensure that The clients remain at least 3 feet away from each other. clients receive safe, effective nursing care even in tasks The clients have no other existing infection. delegated to others. Nurses must follow the ANA codes of standards in delegating and assigning tasks. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 Managing Client Care 7  Online Video: Delegation A private room is also preferred for the following clients. TASK FACTORS Client who are agitated Prior to delegating client care, consider the following. Client who have dementia and a history of wandering Clients who require a quiet environment (those at risk Predictability of outcome for increased intracranial pressure [stroke, traumatic Will the completion of the task have a brain injury]) predictable outcome? Clients who are at risk for sensory overload (those Is it a routine treatment? who are having pain, are acutely ill, have invasive Is it a new treatment? tubes [nasogastric, IVs, endotracheal], or have reduced Potential for harm cognitive function [head injury]) Is there a chance that something negative can happen to Clients who require privacy (those who are near death) the client (risk for bleeding, risk for aspiration)? Other considerations Is the client unstable? A client who is confused or disoriented should be Complexity of care assigned a room away from noise and away from exits. Are complex tasks required as a part of the client’s care? Children who are transitioning from a critical care unit Is the delegatee legally able to perform the task and do to a lower level of care should be assigned a room near they have the skills necessary? the nurses station and with a roommate of similar age. Need for problem solving and innovation Is nursing judgment required while performing the task? DELEGATING AND SUPERVISING Does it require nursing assessment skills? A licensed nurse is responsible for providing clear Level of interaction with the client directions when a task is initially delegated and for Is there a need to provide psychosocial support or periodic reassessment and evaluation of the outcome education during the performance of the task? of the task. RNs delegate to other RNs, PNs, and APs. DELEGATEE FACTORS ◯ RNs must be knowledgeable about the applicable state nurse practice act and regulations regarding the use Considerations for selection of an appropriate delegatee of PNs and APs. include the following. ◯ RNs delegate tasks so that they can complete higher Education, training, and experience level tasks that only RNs can perform. This allows Knowledge and skill to perform the task more efficient use of all members of the health Level of critical thinking required to complete the task care team. Ability to communicate with others as it pertains PNs can delegate to other PNs and APs. to the task Demonstrated competence The delegatee’s culture DELEGATION FACTORS Agency policies and procedures and licensing legislation Nurses can only delegate tasks appropriate for the skill (state nurse practice acts) and education level of the health care team member who is receiving the assignment. RNs cannot delegate the nursing process, client DELEGATION AND SUPERVISION GUIDELINES education, or tasks that require clinical judgment to PNs or APs. 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) The health care team ◯ 1.3 ◯ What information should be communicated (right LICENSED PERSONNEL: Nurses who have completed direction/communication) a course of study, successfully passed either the ◯ How to supervise/evaluate (right NCLEX‑PN® or NCLEX‑RN® exam, and have a supervision/evaluation) 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 1.4 The five rights of delegation nursing assistants [CNAs] or certified medical assistants [CMAs]), or they can be non-nursing personnel to RIGHT task whom nursing activities can be delegated (dialysis RIGHT circumstance technicians, monitor technicians, and phlebotomists). RIGHT person Some health care entities can differentiate between nurse and non-nurse assistive personnel by using the RIGHT direction and communication acronym NAP for nursing assistive personnel. RIGHT supervision and evaluation 8 CHAPTER 1 Managing Client Care CONTENT MASTERY SERIES  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 TO AP Monitoring findings (as input to the RN’s ongoing assessment) Activities of daily living (ADLs) Positioning Reinforcing client teaching from a standard care plan Bathing Routine tasks Performing tracheostomy care Grooming Bed making Suctioning Dressing Specimen collection Checking NG tube patency Toileting Intake and output Administering enteral feedings Ambulating Vital signs (for stable clients) Inserting a urinary catheter Feeding (without Administering medication (excluding IV medication in some states) swallowing precautions) Right task Right direction/communication Identify what tasks are appropriate to delegate for each Communicate either in writing or orally. specific client. Data that needs to be collected A right task is repetitive, requires little supervision, and Method and timeline for reporting, including when to is relatively noninvasive for the client. report concerns/findings Delegate tasks to appropriate levels of team members Specific task(s) to be performed; client‑specific (PN, AP) based on standards of practice, legal and instructions facility guidelines, and available resources. Expected results, timelines, and expectations for follow‑up communication Delegate an AP to assist a client RIGHT TASK: who has pneumonia to use a bedpan. RIGHT DIRECTION AND COMMUNICATION: Delegate an AP to assist the client in room 312 with a shower WRONG TASK: Delegate an AP to administer a before 0900 and to notify the nurse when complete. nebulizer treatment to a client who has pneumonia. WRONG DIRECTION AND COMMUNICATION: Right circumstance Delegate an AP to assist the client in room 312 with morning hygiene. Assess the health status and complexity of care required by the client. Right supervision/evaluation Match the complexity of care demands to the skill level of the health care team member. The delegating nurse must: Consider the workload of the team member. Provide supervision, either directly or indirectly (assigning supervision to another licensed nurse). RIGHT CIRCUMSTANCE: Delegate an AP Provide clear directions and expectations of the task to to measure the vital signs of a client be performed (time frames, what to report). who is postoperative and stable. Monitor performance. WRONG CIRCUMSTANCE: Delegate an AP to measure Provide feedback. the vital signs of a client who is postoperative and Intervene if necessary (unsafe clinical practice). received naloxone to reverse respiratory depression. Evaluate the client and determine if client outcomes were met. Right person Evaluate client care tasks and identify needs for quality improvement activities and/or additional resources. Assess and verify the competency of the health care team member. RIGHT SUPERVISION: Delegate the ambulation of ◯ The task must be within the team member’s scope a client to an AP. Observe the AP to ensure safe of practice. ambulation of the client, and provide positive ◯ The team member must have the necessary feedback to the AP after completion of the task. competence/training. WRONG SUPERVISION: Delegate the ambulation Continually review the performance of the team of a client to an AP without supervision to member and determine care competency. determine the need for intervention and Assess team member performance based on standards failing to provide feedback to the AP. 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. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 Managing Client Care 9  SUPERVISION ORIENTATION Supervision occurs after delegation. A supervisor oversees Orientation helps newly licensed nurses translate the a staff member’s performance of delegated activities and knowledge, skills, and attitudes learned in nursing school determines if: into practice. Completion of tasks is on schedule. Performance was at a satisfactory level. ORIENTATION TO THE INSTITUTION Unexpected findings were documented and reported or addressed. The newly licensed nurse is introduced to the Assistance was required to complete assigned tasks in a philosophy, mission, and goals of the institution timely manner. and department. Assignment should be re‑evaluated and Policies and procedures that are based on institutional possibly changed. standards are reviewed. Use of and access to the institution’s computer system is a significant focus. Staff education Safety and security protocols are emphasized in relation to the nurse’s role. 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 ORIENTATION TO THE UNIT all staff and to help them meet standards set forth by Classroom orientation is usually followed by orientation the facility and accrediting bodies. The process of staff to the unit by an experienced nurse. education is also referred to as staff development. Preceptors assist in orienting newly licensed nurses to a The quality of client care provided is directly related to unit and supervising their performance and acquisition the education and level of competency of health care of skills. providers. Preceptors are usually assigned to newly licensed nurses The nurse leader has a responsibility in maintaining for a limited amount of time. competent staff. Mentors can also serve as a newly licensed nurse’s Nurse leaders work with a unique, diverse workforce. preceptor, but their relationship usually lasts longer and The nurse should respect and recognize the health care focuses more on assumption of the professional role and team’s diversity. 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 1.6 Staff education time limited. IDENTIFIED/ CHARACTERISTICS PROVIDED BY SOCIALIZATION Involves methods appropriate Peers, unit managers, to learning domain and staff development Socialization is the process by which a person learns a learning styles of staff. educators new role and the values and culture of the group within Initiated in specific situations which that role is implemented. New policies or procedures Successful socialization helps new staff members fit in implemented Unit managers, with already established staff on a client care unit. staff development New equipment educators Staff development educators and unit managers can becomes available begin this process during interviewing and orientation. Educational need identified Nurse preceptors/mentors are frequently used to Can focus on one‑on‑one Unit manager, charge assist newly licensed nurses with this process on the approach nurse, preceptor clinical unit. Can use “just in time” Staff members, training to meet immediate supervisors needs for client care Higher education degree Staff or certification 10 CHAPTER 1 Managing Client Care CONTENT MASTERY SERIES  EDUCATION AND TRAINING 1.7 Five stages of nursing ability 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 Novice nurse have and maintain the most current knowledge and skills Novice nurses can be students or newly licensed nurses who have minimal clinical experience. necessary to meet the needs of clients. (1.6) They approach situations from theoretical perspective relying on context‑free facts and Steps in providing educational programs established guidelines. Rules govern practice. 1. Identify and respond:Determine the need for Advanced beginner knowledge or skill proficiency Most new nurses function at the level of the advanced beginner. They practice independently 2. Analyze:Look for deficiencies, and develop learning in the performance of many tasks and can make some clinical judgments. They begin to rely on objectives to meet the need prior experience to make practice decisions. 3. Research:Resources available to address learning Competent nurse objectives based on evidence‑based practice These are usually nurses who have been in practice 4. Plan:Program to address objectives using for 2 to 3 years. They demonstrate increasing levels of skill and proficiency and clinical judgment. They available resources exhibit the ability to organize and plan care using abstract and analytical thinking. They can anticipate 5. Implement:Program(s) at a time conducive to staff the long‑term outcomes of personal actions. availability; consider online learning modules Proficient nurse 6. Evaluate:Use materials and observations to measure These are nurses who have a significant amount of behavior changes secondary to learning objectives experience upon which to base their practice. Enhanced observational abilities allow nurses to be able to Improved nursing ability conceptualize situations more holistically. Well‑developed critical thinking and decision‑making skills allow nurses An increase in knowledge and competence is the goal of to recognize and respond to unexpected changes. staff education. Expert nurse Competenceis the ability of an employee to meet the Expert nurses have garnered a wealth of experience so they can view situations holistically and process information requirements of a particular role at an established efficiently. They make decisions using an advanced level level of performance. Nurses usually progress through of intuition and analytical ability. They do not need to several stages of proficiency as they gain experience in a rely on rules to comprehend a situation and take action. particular area. Source: http://www.scribd.com/doc/27103958/Benner‑Theory‑Novice‑to‑Expert The five stages of nursing abilitywere identified by Patricia Benner (1984), and are based on level of QUALITY IMPROVEMENT PROCESS competence. Level of competence is directly related The quality improvement process begins with identification to length of time in practice and exposure to clinical of standards and outcome indicators based on evidence. situations. When nurses move to a new clinical setting that requires acquisition of new skills and knowledge, Outcome (clinical) indicatorsreflect desired client their level of competence will return to a lower stage. (1.7) outcomes related to the standard under review. Structure indicatorsreflect the setting in which care is Quality improvement provided and the available human and material resources. Process indicatorsreflect how client care is provided and Quality improvement (performance improvement, are established by policies and procedures (clinical practice quality control) is the process used to identify and guidelines). resolve performance deficiencies. Quality improvement Benchmarksare goals that are set to determine at what includes measuring performance against a set of level the outcome indicators should be met. predetermined standards. In health care, these standards are set by the facility and consider accrediting While process indicators provide important information and professional standards. about how a procedure is being carried out, an outcome Standards of care should reflect optimal goals and be indicator measures whether that procedure is effective based on evidence. in meeting the desired benchmark. For example, the use The quality improvement process focuses on assessment of incentive spirometers in postoperative clients can be of outcomes and determines ways to improve the determined to be 92% (process indicator), but the rate delivery of quality care. All levels of employees are of postoperative pneumonia can be determined to be involved in the quality improvement process. 8% (outcome indicator). If the benchmark is set at 5%, The Joint Commission’s accreditation standards require the benchmark for that outcome indicator is not being institutions to show evidence of quality improvement in met and the structure and process variables need to be order to attain accreditation status. analyzed to identify potential areas for improvement. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 Managing Client Care 11  STEPS IN THE QUALITY Audits IMPROVEMENT PROCESS Audits can produce valuable quantitative data. A standard is developed and approved by a Types of audits facility committee. Structure audits evaluate the influence of Standards are made available to employees by way of elements that exist separate from or outside of the policies and procedures. client‑staff interaction. Quality issues are identified by the staff, management, Process audits review how care was provided and or risk management department. assume a relationship exists between nurses and the An interprofessional team is developed to review quality of care provided. the issue. Outcome audits determine what results, if any, occurred The current state of structure and process related to the as a result of the nursing care provided. issue is analyzed. ◯ Some outcomes are influenced by aspects of care Data collection methods are determined. (the quality of medical care, the level of commitment ◯ Quantitative methods are primarily used in the data of managerial staff, and the characteristics of the collection process, although client interview is also facility’s policies and procedures). an option. ◯ Nursing‑sensitive outcomes are those that are Data is collected, analyzed, and compared with the directly affected by the quality of nursing care. established benchmark. Examples include client fall rates and the incidence of If the benchmark is not met, possible influencing factors nosocomial infections. are determined. A root cause analysis can be done to critically assess all factors that influence the issue. A Timing of audits root cause analysis: Retrospective audits occur after the client receives care. ◯ Focuses on variables that surround the consequence Concurrent audits occur while the client is of an action or occurrence. receiving care. ◯ Is commonly done for sentinel events (client Prospective audits predict how future client care will be death, client care resulting in serious physical affected by the current level of services. injury) but can also be done as part of the quality improvement process. ◯ Investigates the consequence and possible causes. NURSE’S ROLE IN QUALITY IMPROVEMENT ◯ Analyzes the possible causes and relationships that Serve as unit representative on committees developing can exist. policies and procedures. ◯ Determines additional influences at each level Use reliable resources for information (Centers for of relationship. Disease Control and Prevention, professional journals, ◯ Determines the root cause or causes. evidenced‑based research). Potential solutions or corrective actions are analyzed Enhance knowledge and understanding of the facility’s and one is selected for implementation. policies and procedures. Educational or corrective action is implemented. Provide client care consistent with these policies The issue is reevaluated at a preestablished and procedures. time to determine the efficacy of the solution or Document client care thoroughly and according to corrective action. facility guidelines. Participate in the collection of information/data related Core measures to staff’s adherence to selected policy or procedure. Assist with analysis of the information/data. National standardized measures are developed by the Compare results with the established benchmark. Joint Commission to improve client outcomes. It is used Make a judgment about performance in regard to to measure client outcomes and provides information to the findings. support accreditation of hospitals. Assist with provision of education or training necessary Core measures developed include stroke, venous to improve the performance of staff. thromboembolism, heart failure, acute myocardial Act as a role model by practicing in accordance with the infarction, and substance use. established standard. Assist with re‑evaluation of staff performance by collection of information/data at a specified time. 12 CHAPTER 1 Managing Client Care CONTENT MASTERY SERIES  Nursing strategies to promote evidence- PERFORMANCE APPRAISAL based approach to client care AND PEER REVIEW Remain aware of current trends in research. A formal system for conducting performance appraisals Incorporate evidence into clinical practice. should be in place and used consistently. Performance Question traditional nursing practice to promote change. appraisal tools should reflect the staff member’s job Collaborate with other disciplines to enrich practice. description and can be based on various types of scales Use the PICO model (population, intervention, or surveys. comparison, and outcome) to find current evidence to Various sources of data should be collected to guide best practice. ensure an unbiased and thorough evaluation of an employee’s performance. Quality improvement tools for tracking outcomes ◯ Data should be collected over time and not just represent isolated incidents. Structured care methodologies are used to track variances, ◯ Actual observed behavior should be documented/used as measure outcomes, improve quality, and facilitate best evidence of satisfactory or unsatisfactory performance. practices. These can be called anecdotal notes and are kept in the Standards of care: Baseline of quality care a client should unit manager or equivalent position’s files. receive ◯ Peers can be a valuable source of data. Peer review is the evaluation of a colleague’s practice by another Algorithms: Series of progressive treatment based on peer. Peer review should: client response (advanced cardiac life support) Begin with an orientation of staff to the peer Critical or clinical pathway: Projected path of treatment review process, their professional responsibility in based on a set time frame for clients who have comparable regard to promoting growth of colleagues, and the diagnoses disposition of data collected. Focus on the peer’s performance in relation to the Protocols: Standard guidelines for a specific intervention job description or an appraisal tool that is based on (stroke protocol) institutional standards. Guidelines: Evidence-based information to provide quality Be shared with the peer and usually the manager. care and improve outcomes Be only part of the data used when completing a staff member’s performance appraisal. ◯ The employee should be given the opportunity to Performance appraisal, provide input into the evaluation. peer review, and The unit manager should host the performance appraisal review in a private setting at a time conducive to the disciplinary action staff member’s attendance. The unit manager should review the data with the staff member and provide the A performance appraisal is the process by which a opportunity for feedback. Personal goals of the staff supervisor evaluates an employee’s performance in member are discussed and documented, including relation to the job description for that employee’s position avenues for attainment. Staff members who do not agree as well as other expectations the facility can have. with the unit manager’s evaluation of their performance Performance appraisals are done at regular intervals should have the opportunity to make written comments and can be more frequent for new employees. on the evaluation form and appeal the rating. 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 DISCIPLINARY ACTION to discuss personal goals with the unit manager as well Deficiencies identified during a performance appraisal as to receive feedback regarding level of performance. or the course of employment should be presented in Performance appraisals can also be used as a writing, and corrective action should be based on motivational tool. institutional policy regarding disciplinary actions and/ Deficiencies identified during a performance appraisal or termination of employment. Evidence regarding the or reported by coworkers might need to be addressed in deficiency must support such a claim. (1.8) a disciplinary manner. 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. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 Managing Client Care 13  Conflict resolution INTERGROUP CONFLICT Occurs between two or more groups of individuals, Conflict is the result of opposing thoughts, ideas, feelings, departments, or organizations and can be caused by a new perceptions, behaviors, values, opinions, or actions policy or procedure, a change in leadership, or a change in between individuals. organizational structure. Conflict is an inevitable part of professional, social, and personal life and can have constructive or destructive Example: There is confusion as to whether it is results. Nurses must understand conflict and how to the responsibility of the nursing unit or dietary manage it. department to pass meal trays to clients. Nurses can use problem‑solving and negotiation strategies to prevent a problem from evolving into a conflict. STAGES OF CONFLICT Lack of conflict can create organizational stasis, while Five stages of conflict exist. If the nurse manager is too much conflict can be demoralizing, produce anxiety, familiar with the stages there is an increased chance that and contribute to burnout. the conflict can be resolved effectively. Conflict can disrupt working relationships and create a stressful atmosphere. If conflict exists to the level that productivity and STAGE 1: LATENT CONFLICT quality of care are compromised, the unit manager must The actual conflict has not yet developed; however, attempt to identify the origin of the conflict and attempt factors are present that have a high likelihood of causing to resolve it. conflict to occur. Common causes of conflict Example: A new scheduling policy is implemented within the organization. The nurse manager should Ineffective communication recognize that change is a common cause of conflict. Unclear expectations of team members in their various roles Poorly defined or actualized organizational structure STAGE 2: PERCEIVED CONFLICT Conflicts of interest and variance in standards A party perceives that a problem is present, though an Incompatibility of individuals actual conflict might not actually exist. Management or staffing changes Diversity related to age, gender, race, or ethnicity 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 CATEGORIES OF CONFLICT misunderstood the nurse’s scheduling request. INTRAPERSONAL CONFLICT STAGE 3: FELT CONFLICT Occurs within the person and can involve internal struggle Those involved begin to feel an emotional response to related to contradictory values or wants. the conflict. Example: A nurse wants to move up on the Example: A nurse feels anger towards the career ladder but is finding that time with nurse manager after finding out that they are their family is subsequently compromised. scheduled to work two holidays in a row. INTERPERSONAL CONFLICT STAGE 4: MANIFEST CONFLICT Occurs between two or more people with differing values, The parties involved are aware of the conflict and action goals, or beliefs. is taken. Actions at this stage can be positive and strive Interpersonal conflict in the health care setting involves towards conflict resolution, or they can be negative and disagreement among nurses, clients, family members, include debating, competing, or withdrawal of one or more and within a health care team. Bullying and incivility in parties from the situation. the workplace are forms of interpersonal conflict. Example: The nurse manager and nurses This is a significant issue in nursing, especially in on a unit agree that the current scheduling relation to new nurses, who bring new personalities and system is causing a conflict and agree to perspectives to various health care settings. work together to come up with a solution. 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. 14 CHAPTER 1 Managing Client Care CONTENT MASTERY SERIES  STAGE 5: CONFLICT AFTERMATH Steps of the problem‑solving process Conflict aftermath is the completion of the conflict Identify the problem.State it in objective terms, process and can be positive or negative. minimizing emotional overlay. Example: Positive conflict aftermath: the nurse Discuss possible solutions.Brainstorming solutions as manager and nurses on a unit are satisfied with the a group can stimulate new solutions to old problems. newly revised scheduling system and feel valued for Encourage individuals to think creatively, beyond being included in the conflict resolution process. simple solutions. Example: Negative conflict aftermath: the nurse Analyze identified solutions.The potential pros and cons manager and nurses are unable to come up with of each possible solution should be discussed in an attempt a scheduling solution that meets the needs of to narrow down the number of viable solutions. both parties. They agree to continue with the Select a solution.Based on this analysis, select a solution current system; however, tensions still remain, for implementation. increasing the risk of a recurrence of the conflict. Implement the selected solution.A procedure and timeline for implementation should accompany the CONFLICT RESOLUTION STRATEGIES implementation of the selected solution. Evaluate the solution’s ability to resolve the original PROBLEM-SOLVING problem.The outcomes surrounding the new solution should be evaluated according to the predetermined Open communication among staff and between staff timeline. The solution should be given adequate time and clients can help defray the need for conflict to become established as a new routine before it is resolution. evaluated. If the solution is deemed unsuccessful, the When potential sources of conflict exist, the use of open problem‑solving process will need to be reinstituted and communication and problem‑solving strategies are the problem discussed again. effective tools to de‑escalate the situation. Actions nurses can take to promote open communication and de‑escalate conflicts 1.8 Steps in progressive discipline Use “I” statements, and remember to focus on the First infraction problem, not on personal differences. Informal reprimand Listen carefully to what others are saying, and try to Manager and employee meet understand their perspective. Discuss the issue Move a conflict that is escalating to a private location Suggestions for improvement/correction or postpone the discussion until a later time to give everyone a chance to regain control of their emotions. Second infraction Share ground rules with participants. For example, Written warning everyone is to be treated with respect, only one person Manager meets with employee to distribute written warning can speak at a time, and everyone should have a Review of specific rules/policy violations chance to speak. 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 NURSING LEADERSHIP AND MANAGEMENT CHAPTER 1 Managing Client Care 15  NEGOTIATION Strategy: Collaborating Both parties set aside their original individual goals and Negotiation is the process by which interested parties: work together to achieve a new common goal. ◯ Resolve ongoing conflicts. Requires mutual respect, positive communication, and ◯ Agree on steps to take. shared decision‑making between parties. ◯ Bargain to protect individual or collective interests. This is a win‑win solution. ◯ Pursue outcomes that benefit mutual interests. Most nurses use negotiation on a daily basis. Example Negotiation can involve the use of several conflict resolution strategies. An experienced nurse on a urology unit arrives The focus is on a win‑win solution or a win/lose‑win/ to work on the night shift. The unit manager lose solution in which both parties win and lose immediately asks the nurse to float to a pediatrics a portion of their original objectives. Each party unit because the hospital census is high and they agrees to give up something and the emphasis is on are understaffed. The nurse has always maintained accommodating differences rather than similarities a positive attitude when asked to work on another between parties. medical‑surgical unit but states they do not feel comfortable in the pediatric setting. The Example manager insists the nurse is the most qualified. One nurse offers to care for Client A today if Strategy: Avoiding/Withdrawing/Smoothing the other will care for Client B tomorrow. The nurse basically cannot use these strategies due to the immediacy of the situation. The assignment cannot Strategy: Avoiding/Withdrawing be simply avoided or smoothed over; it must be accepted Both parties know there is a conflict, but they refuse to or rejected. face it or work toward a resolution. Can be appropriate for minor conflicts, when one party Strategy: Competing/Coercing holds more power than the other party, or if the issue If the nurse truly feels unqualified to work on the can work itself out over time. pediatric unit, then this approach can be appropriate: Because the conflict remains, it can surface again at a the nurse must win and the manager must lose. later date and escalate over time. Although risking termination by refusing the This is usually a lose‑lose solution. assignment, the nurse should take an assertive approach and inform the manager that pediatric clients would be Strategy: Smoothing placed at risk. One party attempts to “smooth” another party by trying to satisfy the other party. Strategy: Cooperating/Accommodating Often used to preserve or maintain a peaceful work If the nurse decides to accommodate the manager’s environment. request, then the pediatric clients can be at risk for The focus can be on what is agreed upon, leaving incompetent care. conflict largely unresolved. Practice liability is another issue for consideration. This is usually a lose‑lose solution. Strategy: Compromising/Negotiating Strategy: Competing/Coercing This approach generally minimizes the losses One party pursues a desired solution at the expense for all involved while making certain each party of others. gains something. Managers can use this when a quick or unpopular For example, the nurse might offer to work on decision must be made. another medical‑surgical unit if someone from that The party who loses something can experience anger, unit feels comfortable in the pediatric environment. aggravation, and a desire for retribution. This is usually a win‑lose solution. Although each party is giving up something (the manager gives in to a different solution and the Strategy: Cooperating/Accommodating nurse still has to work on another unit), this sort of One party sacrifices something, allowing the other party compromise can result in a win‑win resolution. to get what it wants. This is the opposite of competing. The original problem might not actually be resolved. Strategy: Collaborating The solution can contribute to future conflict. Both the nurse manager and nurse come to the agreement This is a lose‑win solution. that providing safe and competent care of the children in the pediatric unit is the common goal. While they might Strategy: Compromising/Negotiating need to compromise/negotiate to address the immediate Each party gives up something. need, they can collaborate to achieve a solution that avoids To consider this a win/lose‑win/lose solution, both this situation in the future. parties must give up something equally important. If one party gives up more than the other, it can become a For example, the nurse might agree to orient to win‑lose solution. 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. 16 CHAPTER 1 Managing Client Care CONTENT MASTERY SERIES  ASSERTIVE COMMUNICATION Resource management Use of assertive communication can be necessary during Resource management includes budgeting and resource conflict negotiation. allocation. Human, financial, and material resources must Assertive communication allows expression in direct, be considered. honest, and nonthreatening ways that do not infringe Budgeting is usually the responsibility of the unit upon the rights of others. manager, but staff nurses can be asked to provide input. It is a communication style that acknowledges and deals Resource allocation is a responsibility of the unit with conflict, recognizes others as equals, and provides manager as well as every practicing nurse. a direct statement of feelings. Providing cost‑effective client care should not compromise quality of care. Elements of assertive communication Resources (supplies, equipment, personnel) are critical to Selecting an appropriate location for verbal exchange accomplishing the goals and objectives of a health care Maintenance of eye contact facility, so it is essential for nurses to understand how to Establishing trust effectively manage resources. Being sensitive to cultural needs Speaking using “I” statements and including affective elements of the situation Avoiding “you” statements that can indicate blame COST‑EFFECTIVE CARE Stating concerns using open, honest, direct statements Cost‑containment Conveying empathy Focusing on the behavior or issue of conflict and Strategies that promote efficient and competent client care avoiding personal attacks while also p