Chapter 2: Coordinating Client Care PDF

CHAPTER 2 NURSE QUALITIES FOR CHAPTER 2 Coordinating EFFECTIVE COLLABORATION Client Care...

CHAPTER 2 NURSE QUALITIES FOR CHAPTER 2 Coordinating EFFECTIVE COLLABORATION Client Care Good communication skills Assertiveness Conflict negotiation skills Leadership skills One of the primary roles of nursing is the Professional presence Decision-making and critical thinking coordination and management of client care in collaboration with the health care team. In so THE NURSE’S ROLE doing, high‑quality health care is provided as Coordinate the interprofessional team. clients move through the health care system in a Have a holistic understanding of the client, the client’s health care needs, and the health care system. cost‑effective and time‑efficient manner. Provide the opportunity for care to be provided with continuity over time and across disciplines. To effectively coordinate client care, a nurse Provide the client with the opportunity to be a partner must have an understanding of collaboration in the development of the plan of care. Provide information during rounds and with the interprofessional team, principles interprofessional team meetings regarding the status of of case management, continuity of care the client’s health. Provide an avenue for the initiation of a consultation (including consultations, referrals, transfers, related to a specific health care issue. and discharge planning), and motivational Provide a link to postdischarge resources that might need a referral. principles to encourage and empower self, staff, colleagues, and other members of the VARIABLES THAT AFFECT interprofessional team. COLLABORATION Hierarchical influence on decision‑making COLLABORATION WITH THE Decision‑making is also influenced by the facility INTERPROFESSIONAL TEAM hierarchy. An interprofessional team is a group of health care In a centralized hierarchy, nurses at the top of the professionals from various disciplines. Collaboration organizational chart make most of the decisions. involves discussion of client care issues in making In a decentralized hierarchy, staff nurses who provide health care decisions, especially for clients who have direct client care are included in the decision‑making multiple problems. The specialized knowledge and process. Large organizations benefit from the use of skills of each discipline are used in the development decentralized decision‑making because managers at the of an interprofessional plan of care that addresses top of the hierarchy do not have firsthand knowledge multiple problems. Nurses should recognize that the of unit‑level challenges or problems. Decentralized collaborative efforts of the interprofessional team allow decision‑making promotes job satisfaction among the achievement of results that a team member would be staff nurses. incapable of accomplishing alone. Nurse‑provider collaboration should be fostered Behavioral change strategies to create a climate of mutual respect and Although bombarded with constant change, members collaborative practice. of the interprofessional team can be resistant to change. Collaboration occurs among different levels of nurses Three strategies a manager can use to promote change are and nurses with different areas of expertise. the rational‑empirical, normative‑reeducative, and the Collaboration should also occur between the power‑coercive. Often the manager uses a combination of interprofessional team, the client, and the client’s these strategies. family/significant others when an interprofessional plan of care is being developed. RATIONAL‑EMPIRICAL: The manager provides factual Collaboration is a form of conflict resolution that results information to support the change. Used when resistance in a win‑win solution for both the client and health to change is minimal. care team. NORMATIVE‑REEDUCATIVE: The manager focuses on interpersonal relationships to promote change. POWER‑COERCIVE: The manager uses rewards to promote change. Used when individuals are highly resistant to change. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 Coordinating Client Care 23  Planned change Generational differences team members Planned change is important in health care because it Generational differences influence the value system of enables the interprofessional team to replace unproven the members of an interprofessional team and can affect methods with evidence-based ones. how members function within the team. Generational Planned change might be a proactive way to improve differences can be challenging for members of a team, but care quality. Change might also be required by a working with individuals from different generations also regulatory board. can bring strength to the team. Variables that affect whether change can fully take Veterans (Silent Generation, Traditionals): Born place include individual and organizational willingness, 1925 to 1942 competing demands, and whether the change Baby Boomers: Born 1942 to early 1960s is meaningful. Generation X: Born mid-1960s to early 1980s Changes in technology are more readily accepted than Generation Y (Millennial): Born mid-1980s to 2000 social change. Generation Z (Homelanders): Born after 2001 Include people who will be affected by the change in the planning process to decrease resistance. MAGNET RECOGNITION PROGRAM Lewin’s change theory The American Nurses Credentialing Center awards Magnet Recognition to health care facilities that provide Lewin’s change theory is a common model for promoting high‑quality client care and attract and retain planned change, which has three stages. well‑qualified nurses. The term magnet is used to Unfreezing: Need for change is identified or created. recognize the facility’s power to draw nurses to the Change/Movement: Strategies (driving forces) that facility and to retain them. overcome resistance to change (restraining forces) are Facilities must create a culture that uses 14 foundational identified and implemented. forces of magnetism and model five key components, Refreezing: The change is integrated and the system is which include the following. re-stabilized. ◯ Empirical data showing quality care results Lewin’s theory has been adapted into a stages of change ◯ Development of innovation, improvements, or model for individual change, with five stages: generation of new knowledge Precontemplation: No intent to change is present or has ◯ Exemplary nursing practice been considered. ◯ A culture of empowerment Contemplation: The individual considers ◯ Transformational leadership adopting a change. The facility must submit documentation to the Preparation: The individual intends to implement the American Nurses Credentialing Center (ANCC) change in the near future. that demonstrates adherence to ANA nurse Action: The individual implements the change. administrator standards. Maintenance: The individual continues the new behavior After documentation that the standards have been without relapse. met, an on‑site appraisal is conducted. A facility that meets the standards is awarded magnet status for a Stages of team formation 4‑year period. Teams typically work through a group formation process before reaching peak performance. PATHWAY TO EXCELLENCE RECOGNITION FORMING: Members of the team get to know each other. A program of practice standards to promote a positive The leader defines tasks for the team and offers direction. practice environment using evidence-based standards Acute- or long-term care facilities can apply for STORMING: Conflict arises, and team members begin to recognition with this program. express polarized views. The team establishes rules, and The Pathway to Excellence designation process includes members begin to take on various roles. an application process and adherence to 12 standards NORMING: The team establishes rules. Members show of practice, along with an independent survey of respect for one another and begin to accomplish some of the facility. the tasks. PERFORMING: The team focuses on accomplishment of tasks. 24 CHAPTER 2 Coordinating Client Care CONTENT MASTERY SERIES  CASE MANAGEMENT CONTINUITY OF CARE: CONSULTATIONS, Case management is the coordination of care provided by REFERRALS, TRANSFERS, AND an interprofessional team from the time a client starts DISCHARGE PLANNING receiving care until they no longer receive services. Continuity of care refers to the consistency of care provided as clients move through the health care system. It enhances the quality of client care and facilitates the PRINCIPLES OF CASE MANAGEMENT achievement of positive client outcomes. Case management focuses on managed care of the client Continuity of care is desired as clients move from one: through collaboration of the health care team in acute ◯ Level of care to another (from the ICU to a and post-acute settings. medical unit). The goal of case management is to avoid fragmentation ◯ Facility to another (from an acute care facility to a of care and control cost. skilled facility). A case manager collaborates with the interprofessional ◯ Unit/department to another (from the PACU to the health care team during the assessment of a client’s postsurgical unit). needs and subsequent care planning, and follows up by Nurses are responsible for facilitating continuity of monitoring the achievement of desired client outcomes care and coordinating care through documentation, within established time parameters. reporting, and collaboration. A case manager can be a nurse, social worker, or other A formal, written plan of care enhances coordination of designated health care professional. A case manager’s care between nurses, interprofessional team members, role and knowledge expectations are extensive. and providers. Therefore, case managers are required to have advanced practice degrees or advanced training in this area. Case manager nurses do not usually provide direct NURSING ROLE IN CONTINUITY OF CARE client care. The nurse’s role as coordinator of care includes: Case managers usually oversee a caseload of clients who Facilitating the continuity of care provided by members have similar disorders or treatment regimens. of the health care team. Case managers in the community coordinate resources Acting as a representative of the client and as a liaison and services for clients whose care is based in a when collaborating with the provider and other residential setting. members of the health care team. When acting as a liaison, the nurse serves in the role of client advocate by protecting the rights of clients and ensuring that client NURSING ROLE IN CASE MANAGEMENT needs are met. Coordinating care, particularly for clients who have As the coordinator of care, the nurse is responsible for: complex health care needs Admission, transfer, discharge, and Facilitating continuity of care postdischarge prescriptions. Improving efficiency of care and utilization of resources Initiation, revision, and evaluation of the plan of care. Enhancing quality of care provided Reporting the client’s status to other nurses and Limiting unnecessary costs and lengthy stays the provider. Advocating for the client and family Coordinating the discharge plan. Facilitating referrals and the use of CRITICAL PATHWAYS community resources. A critical or clinical pathway or care map can be used to support the implementation of clinical guidelines and DOCUMENTATION protocols. These tools are usually based on cost and length Documentation to facilitate continuity of care includes of stay parameters mandated by prospective payment the following. systems (Medicare and insurance companies). Graphic records that illustrate trending of assessment Case managers often initiate critical pathways, data (vital signs) but they are used by many members of the Flow sheets that reflect routine care completed and interprofessional team. other care‑related data Critical pathways are often specific to a diagnosis type Nurses’ notes that describe changes in client status or and outline the typical length of stay and treatments. unusual circumstances When a client requires treatment other than what Client care summaries that serve as quick references for is typical or requires a longer length of stay, it is client care information documented as a variance, along with information Nursing care plans that set the standard for describing why the variance occurred. care provided ◯ Standardized nursing care plans provide a starting point for the nurse responsible for care plan development. ◯ Standardized plans must be individualized to each client. ◯ All documentation should reflect the plan of care. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 Coordinating Client Care 25  COMMUNICATION AND REFERRALS CONTINUITY OF CARE A referral is a formal request for a service by another care Poor communication can lead to adverse outcomes, provider. It is made so that the client can access the care including sentinel events (unexpected death or serious identified by the provider or the consultant. injury of a client). The care can be provided in the acute setting or outside Communication regarding the client status and needs the facility. is required anytime there is a transfer of care, whether Clients being discharged from health care facilities to from one unit or facility to another, or at change-of- their home can still require nursing care. shift, as the nurse hands off the care of the client to Discharge referrals are based on client needs in relation another health care professional. to actual and potential problems and can be facilitated The guidelines on transfer reporting contain details on with the assistance of social services, especially if there what to communicate when transferring client care. is a need for: ◯ Specialized equipment (cane, walker, wheelchair, grab Communication tools bars in bathroom) A number of communication hand‑off tools are ◯ Specialized therapists (physical, occupational, speech) available to improve communication and promote client ◯ Care providers (home health nurse, hospice nurse, safety (I‑SBAR, PACE, I PASS the BATON, Five P’s). home health aide) Nurses might also communicate interprofessionally Knowledge of community and online resources through electronic means (through electronic medical is necessary to appropriately link the client with record systems and e-mail). needed services. ◯ E-mail communication can be informal, but should maintain a professional tone. Don’t use text The nurse’s role regarding referrals abbreviations. Make the message concise yet thorough Begin discharge planning upon the client’s admission. so the reader has clear understanding of the intent. Evaluate client/family competencies in relation to home ◯ Read messages before sending to ensure there is not a care prior to discharge. negative or rude tone. Involve the client and family in care planning. Some facilities permit text messaging. Check the facility Collaborate with other health care professionals to policy regarding this type of communication, and never ensure all health care needs are met and necessary send confidential information through text. referrals are made. Complete referral forms to ensure proper Hand-off or change-of-shift report reimbursement for prescribed services. Performed with the nurse who is assuming responsibility for the client’s care. Describes the current health status of the client. TRANSFERS Informs the next shift of pertinent client Clients can be transferred from one unit, department, care information. or one facility to another. Continuity of care must Provides the oncoming nurse the opportunity to ask be maintained as the client moves from one setting questions and clarify the plan of care. to another. Should be given in a private area (a conference room or The use of communication hand‑off tools (I PASS the at the bedside) to protect client confidentiality. BATON, PACE) promotes continuity of care and Report to the provider client safety. Assessment data integral to changes in client status The nurse’s role regarding transfers is to provide Recommendations for changes in the plan of care written and verbal report of the client’s status and Clarification of prescriptions care needs. ◯ Client medical diagnosis and care providers Client demographic information CONSULTATIONS ◯ ◯ Overview of health status, plan of care, and A consultant is a professional who provides expert advice recent progress in a particular area. A consultation is requested to help ◯ Alterations that can precipitate an immediate concern determine what treatment/services the client requires. ◯ Most recent vital signs and medications, including Consultants provide expertise for clients who require a when a PRN was given specific type of knowledge or service (a cardiologist for ◯ Notification of assessments or client care needed a client who had a myocardial infarction, a psychiatrist within the next few hours for a client whose risk for suicide must be assessed). ◯ Allergies ◯ Diet and activity prescriptions The nurse’s role regarding consultations ◯ Presence of or need for specific equipment or adaptive Initiate necessary consults or notify the provider of the devices (oxygen, suction, wheelchair) client’s needs so the consult can be initiated. ◯ Advance directives and whether a client is to be Provide the consultant with all pertinent information resuscitated in the event of cardiac or respiratory arrest about the problem (information from the client/family, ◯ Family involvement in care and health care proxy, the client’s medical records). if applicable Incorporate the consultant’s recommendations into the client’s plan of care. 26 CHAPTER 2 Coordinating Client Care CONTENT MASTERY SERIES  DISCHARGE PLANNING Discharge instructions Step‑by‑step instructions for procedures to be done Discharge planning is an interprofessional process that is at home. Clients should be given the opportunity to started by the nurse at the time of the provide a return demonstration of these procedures to client’s admission. validate learning. The nurse conducts discharge planning with both the Medication regimen instructions for home, including client and client’s family for optimal results. adverse effects and actions to take to minimize them. Discharge planning serves as a starting point for Precautions to take when performing procedures or continuity of care. As client care needs are identified, administering medications. measures can be taken to prepare for the provision of Indications of medication adverse effects or medical needed support. complications that the client should report to A comprehensive discharge plan includes a review of the the provider. following client information. Names and numbers of providers and community ◯ Current health and prognosis services the client or family can contact. ◯ Religious or cultural beliefs Plans for follow‑up care and therapies. ◯ Ability to perform ADLs ◯ Mobility status and goals The nurse’s role with regard to discharge is to provide a ◯ Sensory, motor, physical, or cognitive impairments written summary including: ◯ Support systems and caregivers Type of discharge (prescribed by provider, AMA). ◯ Financial resources and limitations Date and time of discharge, who accompanied the client, ◯ Potential supports and resources in the community and how the client was transported (wheelchair to a ◯ Internal and external home environment private car, stretcher to an ambulance). ◯ Need for assistance with transportation or home Discharge destination (home, long‑term care facility). maintenance A summary of the client’s condition at discharge (gait, ◯ Need for therapy, wound care, or other services dietary intake, use of assistive devices, blood glucose). ◯ Need for medical equipment A description of any unresolved problems and plans for The need for additional services (home health, physical follow‑up. therapy, and respite care) can be addressed before the Disposition of valuables, medications brought from client is discharged so the service is in place when the home, and prescriptions. client arrives home. A copy of the client’s discharge instructions. A client who leaves a facility without a prescription for discharge from the provider is considered leaving against medical advice (AMA). A client who is legally competent has the legal right to leave the facility at any time. The nurse should immediately notify the provider. If the client is at risk for harm, it is imperative that the nurse explain the risk involved in leaving the facility. The individual should sign a form relinquishing responsibility for any complications that arise from discontinuing prescribed care. The nurse should document all communication, as well as the specific advice that was provided for the client. A nurse who tries to prevent the client from leaving the facility can face legal charges of assault, battery, and false imprisonment. NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 Coordinating Client Care 27  2.1 Interfacility transfer form 28 CHAPTER 2 Coordinating Client Care CONTENT MASTERY SERIES  2.2 Transfer report NURSING LEADERSHIP AND MANAGEMENT CHAPTER 2 Coordinating Client Care 29  2.3 Discharge summary 30 CHAPTER 2 Coordinating Client Care CONTENT MASTERY SERIES