Chapter 7 – Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning

Health Care Delivery Systems

# Managed Care
# Used to describe strategies in health care delivery system that reduce the coast of health care
# Emphasizes promotion of care, client education
# Responsible self-care, early identification of disease, use of health care resources
# Case Management
# Strategy that supports managed care
# It uses an interprofessional health care delivery
# Includes assessment and development of a plan of care
# Coordination of all servicers
# Referral and follow-up
# Critical pathways are used
Case management involves consultation and collaboration with an interprofessional health care team
# Case Manager
# Professional nurse who assumes responsibility for coordination the client’s care
# To admission from discharge
# Establishes plan of care, coordinates interprofessional consultation and referrals
# Facilitates discharge
# Critical Pathways
# Clinical management care plan for providing client-centered
# Interprofessional collaboration
# Ensure shared decision
# Variation analysis is a continuous process
# Comparing specific client outcomes with the expected outcome
# The goal is the anticipated and recognize negative variances early
# Nursing Care Plan
# Written guidelines and communications tool that identifies the client’s pertinent assessment data
# Problems and nursing diagnosis, goals, interventions, and expected outcomes
# The client and family are involved
# The plan identifies short-term and long-term goals
# All the informations are documented in the care plan for evaluation
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Nursing Delivery Systems

# Functional Nursing
# Involves a task approach to client care
# Tasks are being delegated to individual members of team
# This type of system is task-oriented – results in fragmentation of care / lack of accountability
# Team Nursing
# Generally, is led by a RN
# RN is responsible for assessing clients, analyzing client data, planning and evaluating each client
# The team leader determines the work assignment, each staff member works
# Relationship Based-Practice (Primary Nurse)
# Keeping the nurse at the bed side actively involved in client care
# Is responsible for managing and coordinating the client care while in the hospital
# Client-Focused Care
# The RN assumes total responsibility for planning and delivering care to the client
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Professional Responsibilities

# Accountability
# Process in which individuals have and obligation (or duty) to act and are answerable for their actions
# Involves assuming only responsibilities that are in scope of practice
# Involves admitting mistakes rather than blaming others
The nurse is always responsible for his or her actions when providing care to the client
# Leadership and Management
# Leadership = Interpersonal process that involves influencing other (followers) to achieve goals
# Management = Is the accomplishment of tasks or goals by oneself or by directing others
# Theories of Leadership and Management
# Charismatic = based on personal beliefs and characteristics
# Quantum = based on chaos theory and promotes creativity
# Relational = based on collaboration and teamwork
# Servant = based on a desire to serve others
# Transactional = based on principles of social exchange theory
# Transformational = focus on promoting change
# Leader and Manger Approaches
# Autocratic = strong controls, make decisions, addresses all problems
# Democratic = “participative management”. All group members have input into problem solving
# Laissez-faire = passive, nondirective and inactive approach, decision is left to the group
# Situational = combination of styles based on the current circumstances
# Bureaucratic = believes that individuals are motivates by external forces
# Effective leader and Manager Behaviors
# Behaviors
# Treats employees as unique individuals
# Inspire employees and stimulates critical thinking
# Show how to think about problems in new ways to solve
# Is visible to employees, flexible and provide guidance, assistance and feedbacks
# Communicates, motivates and empowers employees
# Qualities
# Effective communicator and promotes interprofessional collaboration
# Credible, critical thinker, initiator of actions, risk taker
# Is persuasive and influences employees
# Functions of Management
# Planning, organizing, directing and controlling
# Problem-Solving Process and Decision Making
# Obtaining informations and using acceptable solution
# Identifying a problem and deciding which alternative can best achieve objectives
# Types of Managers
# Frontline Manager = coordinate the activities and supervise all team members
# Middle Manager = Supervising staff, preparing budgets, work schedules, writing policies
# Nurse executive = Top level of nurse manager, supervise numerous department
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Power

# Ability to do or act to achieve desired results

# Powerful people are able to modify behavior and influence other to change
# Effective nurse leaders are power to improve the delivery of care and to enhance the profession
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Empowerment

# Interpersonal process of enabling others to do for themselves

# Involvers open communication, mutual goal setting and decision making
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Formal Organizations

# Goals and objectives are measurable

# Mission, vision and values
# Authority relationship are defined
# Policies = guidelines that define the organization’s standpoint on course of actions
# Procedures = are based on policies and define methods for tasks
# Protocols = prescribe a specific course of action for a specific type of client or problem
# Centralization
# Decision by few individuals at the top of the organization
# Decision are communicated thereafter to the employees
# Decentralization
# Distribution of authority throughout the organization
# Try to move the decision-making as close to the client
The nurse must follow policies, procedures, and protocols of the health care agency in which is employed
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Evidence-Based Practice

# Research is an important role of the professional nurse

# Determining the client’s personal, social, cultural, and religious preferences
# The nurse needs to follow evidence-based practice protocols developed by the institutional
The nurse must should be alert to clinical issues that warrant investigation and develop a researchable
problem about issue
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Quality Improvement

# Focus on process or systems that significantly contribute to client safety and effective client care outcomes
# Is important that quality improvement be part of the philosophy of a health care agency
# Retrospective audit = inspect medical record after the client ‘s discharge
# Concurrent audit = used to inspect compliance of nurse while the nurse are providing care
# Is similar to the nursing process and involves an interprofessional approach
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Change Process

# Dynamic process that leads to an alternation in behavior.

# Leadership style influences the approach to initiating the change process
# Lewis based concepts are 3 elements:
# Unfreezing = when problem is identified, individuals are involved, facts and evidence
# Moving and Changing = change is planning and implemented
# Refreezing = change becomes stabilized
# Type of change
# Planned Change = deliberated
 # Unplanned Change = unpredictable but is beneficial and may go unnoticed
# Resistance to Change
# Occurs when an individual reject
# Requires energy
# Does not guarantee positive outcomes
# Reasons to resistance = Conformity, dissimilar beliefs, habit, secondary gains, fear
# Overcoming Barriers
# Create a flexible and adaptable environment
# Encourage people involved to plan and set goals for change
# Included all involved
# Focus on the benefits
# Delineate drawbacks and evaluate the change process
# Provide positive feedback to all involved
# Commit to the time it takes to change
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Conflict

# Arises from a perception of incompatibility or differences in beliefs, attitudes, values, goals…

# Types of conflicts:
# Intrapersonal, Interpersonal and/or Organizational
# Modes of Conflict Resolution
# Avoidance = Avoiders are unassertive and uncooperative. Postpone dealing with the issue
# Accommodation = Accommodators neglect their own needs. Obey and serve others
# Competition = Competitor pursue their own needs and goals at the expense of others
# Compromise = Compromisers are assertive and cooperative. Work to find a solution for all
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Roles of Health Care Team Members

# Nurse Roles
# Promote health and prevent disease
# Provide comfort and care to clients
# Make decisions and act as a client advocate
# Lead and manager the nursing team
# Serve as a case manager
# Function as a rehabilitator
# Communicate effectively
# Educate clients, families, communities, and health care team members
# Act as a resource person
# Allocate resource in a cost-effective manner
# Health Care Provider (HCP)
# Diagnoses and treat diseases
# HCP Assistant
# Act to a limited extent in the role of the HCP during HCP absence
# Conducts physical examinations, performs diagnostic procedures, assists in the OR and ER and
perform treatments
# Nurse Practitioner (Advanced Practice Registered Nurse – APRN)
# As APRN who is educated to diagnose and treat acute illness and chronic conditions
# Physical Therapist
# Assist in examining, testing and threating physical disable clients
# Occupational Therapist
 # Develops adaptive devices that helps chronically ill or handcapped clients
# Respiratory Therapist
# Delivers treatment designed to improve the client’s ventilation and oxygenation status
# Speech Therapist
# Evaluates a client’s ability to swallow safely
# Nutritionist
# Assist in planning dietary
# Continuing Care Nurse
# Coordinates discharge plans for the client
# Assistive Personal, Unlicensed Assistive Personal, Client Care Technicians
# Help the RN with specific tasks and functions
# Pharmacist
# Formulates and dispense medications
# Social Worker
# Counsels clients and families about home care services and assists the continuing care nurse
# Chaplain
# Offers spiritual support and guidance to clients and families
# Administrative Staff
# Support staff members
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Interprofessional Collaboration

# Collaboration with others HCP can ensure continuity of care

# Reports
# Should be factual, accurate, current, complete, and organized
# Should include essential background information, subjective data, objective data, and change in the
client status, client problems or nursing diagnosis as appropriate treatments and procedures, medication
administration, client teaching, discharge planning, family information, the client response to the treatment
and procedures, and the client priority needs
# Telephone Reports
# Should be documented and should include when the call was made, who made the call, who was
called, to whom information was given, and what information was received
# Transfer Report
# Receiving nurse should repeat transfer information to ensure client safe
# Need to make questions to clarify information about the client’s status
# Situation, Background, Assessment, Recommendation (SBAR)
# Improve communication among team members on sharing information on a client
# Includes:
# Information about client situation
# Associated background information
# Assessment data and recommendation of care
# Treatments, medications and service needs
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Interprofessional Consultation

# Is needed when the nurse encounters a problem that cannot be solved using nursing knowledge and skills
# Process in which a specialist is sought to identify methods of care or treatment plans to meet the needs of
a client
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Discharge Planning

# Begins when the client is admitted to the hospital or health care facility
# Is an interprofessional process for continuing care after leaving the health care
# All caregivers need to be involved
# The nurse needs to educate the client and family regarding care at home with:
# How to administer medications
# Site and adverse effects of medications that need to be reported
# Dietary and measures
# Complications of the medical conditions
# How to perform prescribed treatments
# How to use special equipment
# Schedule for home care services
# How to access available community resources
# When to obtain follow-up care
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Delegation and Assignments

# Delegation
# Process of transferring performance of a selected nursing task for individual who is competent
# Involves achieving outcomes and sharing activities who have the authority to accomplish
# The nurse practical act and policies and procedures define aspects of care can be delegated
# Even delegated, the nurse who delegates maintains accountability for the task
# Only the task, not the ultimate accountability may be delegated to another
# The 5 rights of delegation include:
# Right task
# Right circumstances
# Right person
# Right direction/communication
# Right Supervision/evaluation
The nurse delegates only tasks for which he or she is responsible. The nurse who delegates is accountable
for the task. The person who assumes responsibility for the task is also accountable.
# Principles and Guidelines for Delegating
# Delegate the right task for the right delegatee
# Be familiar with the experience, their scopes of practice, job description, policies and procedures
# Provide clear direction and expectations
# Determine the degree of supervision
# Provide the delegatee with the authority to complete the task and provide deadline
# Evaluate and provide feedback
# Unlicensed Assistive Personal (UAP) = noninvasive interventions such as skin care, range-of-motion
exercises, ambulation, grooming, hygiene measure
# Licensed Practical Nurse (LPN) = UAP perform plus also certain invasive tasks such as dressing changes,
suctioning, urinary catheterization, and medical administration (oral, subcutaneous, intramuscular, and
selected piggyback medications. Can also review with the client teaching plans that were initiated by the
registered nurse
# Registered Nurse (RN) = UAP + LPN and is responsible for assessment and planning care, initialing teaching,
and administering medication intravenously

# Assignments
# Is the transfer of activities to specific staff members
# Principles and Guidelines for Assignments
 # Always ensure client safety
# Be aware of individual variations in work abilities
# Determine which task can be delegated and to whom
# Match the task to the delegatee on the basis of the nurse practice act and limitations
# Provide directions clear, concise, accurate and complete
# Validate the delegatee’s understanding
# Communicate feeling of confidence and provide feedback
# Maintain continuity of care
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Time Management

# Description
# Technique to completing tasks within a definite time period
# Learning how, when, and where
# Requires an ability to anticipate the day’s activities
# Combine activities when possible and do not be interrupted by nonessential activities
# Efficiency in completing tasks as quickly as possible
# Effectiveness in deciding the most important task to do and doing it correctly
# Principle and Guidelines
# Identify tasks, obligations, and activities and write them down
# Organize the work day
# Prioritize client needs
# Anticipate the needs of the day
# Focus on beginning working on the most important first while keeping goals in mind
# Begin client rounds at the beginning of the shift, collecting data on each assigned client
# Delegate tasks when appropriate
# Anticipate resource needs, and gather the necessary supplies before beginning the task
# Organize paperwork and continuously document task completion
# At eh end of the day, evaluate the effectiveness of time management
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Prioritizing Care

# Prioritizing is deciding which needs or problems require immediate action and which ones could tolerate
a delay in response until a later time because they are not urgent
# Guidelines for Prioritizing
# The nurse and the client mutually rank the client’s need in order of importance based on the client’s
preferences and expectations, safety, and physical and psychological needs
# Priorities are classified as High, Intermediate or Low
# High = Life-threatening or that could result in harm to the client
# Intermediate = Nonemergency and non-life-threatening
# Low = Not related directly to the client’s illness or prognosis
# Consider problems that involve actual or life-threatening concerns before potential threatening
# When prioritizing, consider time constrains and available resources
# Problems identified as important by the client must be given high priority
# The nurse can be use A-B-C as a guide when determining priorities
# Client needs related to maintaining a patent airway are always the priority
# If CPR is necessary, the order of priority is C-A-B
# The nurse can use Marlow’s Hierarchy of Needs Theory as guide to determine priorities and to
identify the levels of physiological needs, safety, love and belonging, self-esteem, and self-actualization
# The nurse can use steps of nursing process as a guide to determine priorities
# Setting Priorities for Client Teaching
# Determine immediate learning needs
# Review the learning objectives
# Determine what the client perceives
# Assess the client’s anxiety level and time to teach
# Prioritizing when Caring for a Group of Clients
# Identify the problems for each client
# Review the problems and any nursing diagnoses
# Determine are which are most urgent based on basic needs, the client’s changing or unstable status
# Anticipate the time and combine activities when possible
# Involve the client as much as possible
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Disaster and Emergency Response Planning

# Description
# Is any human-made or natural event that causes destruction and devastation that cannot be
alleviated without assistance
# An emergency response plan is need and this is a formal plan of action for coordinating the response
of the health care agency staff in the event of a disaster in the health care agency or surrounding community
# American Red Cross (ARC)
# The ARC has been given authority by the federal government to provide disaster relief
# HAZMAT Team
# Are typically composed of emergency department health care providers and nursing staff
# They are the first individuals to encounter the potential exposure
# Members have been educated on how to recognize patterns of illness that may be indicative of
nuclear, biological and chemical exposure, protocols for pharmacological treatments, availability of
decontamination facilities and personal protective gear, safety measures, and methods of responding to an
exposure
# Phases of Disaster Management
# Mitigation = Actions that can prevent or reduce the damaging effects
# Preparedness = Plans for rescue, evacuation, and caring for disaster victims. Training personnel,
gathering resources, equipment, identification responsibilities, development of an emergency medical
system, creation of a location for providing food, water, clothing, shelter, other supplies and medicine
# Response = Putting disaster planning into action
# Recovery = Action take to return to a normal situation after the disaster
# Level of Disaster
# When a federal emergency has been declared, the federal response plan may take effect and
activate emergency support functions
# Level I = Massive disaster that involve significant damage, presidential declaration of disaster,
federal, regional and national resources and engagement
# Level II = Moderate disaster, presidential declaration of emergency, moderate federal assistance
# Level III = Minor disaster, minimal level of damage, could result in a presidential declaration of
emergency
# Nurse’s Role in a Disaster Plan
# Personal and Professional Preparedness
# Make personal and family preparations
# Be aware of the disaster plan at the place of employment and in the community
# Maintain certification in disaster training and in CPR
# Participate in mock disaster drills, including a bomb threat drill
 # Prepare professional emergency response items, such as copy of nursing license, personal
health care equipment such as stethoscope, cash, warm clothing, record-keeping materials, and other
nursing care supplies
# Disaster Response
# The nurse needs to follow the directions identified in the plan of the disaster
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Triage

# In a disaster or war, triage consists of a brief assessment of victims that allows the nurse to classify victims
according to the severity of the injury, urgency of treatment, and place of treatment
# Emergent = Life requiring immediate treatment
# Urgent = Injures that are not life-threatening – 30 minutes to 2 hours
# Nonurgent = Local injures who do nor immediate complications – at least 2 hours
# In an emergency department, the nurse to classify clients according to their need for care and stablish
priorities of care, the type of illness or injuries, the severity of the problem, and the resources available
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Emergency Department Triage System

# The nurse needs to be familiar with emergent, urgent and nonurgent categories
# When caring for a client who has died, recognize the importance for providing support for family
# Emergent (RED) – Priority 1 (Highest)
# Life-threatening injuries and need immediate attention and continuous evaluation
# High probability for survive when stabilized
# Trauma victims, chest pain, severe respiratory distress or cardiac arrest, limb amputation,
neurological deficits, chemical splashes to the eyes
# Urgent (YELLOW) – Priority 2
# Client who requite treatment and whose injuries have complications not life-threatening
# Can wait 30 minutes to 2 hours
# Require continuous evaluation every 30 minutes to 60 minutes thereafter
# Open fractures with a distal pulse and large wounds
# Nonurgent (GREEN) – Priority 3
# Clients with local injuries who do not have immediate complications
# Can wait at least 2 hours
# Require evaluations every 1 to 2 hours thereafter
# Closed fractures, minor lacerations, sprains, strains, contusions
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Client Assessment in the Emergency Department

# Primary Assessment
# Identify any client problems that poses an immediate or potential threat of life
# Gather information primarily through objective data
# Use de A-B-C as a guide of assesses a client who has sustained a traumatic or cervical injury
# Secondary Assessment
# After the primary assessment and after treatment for any primary problems
# Identify any other life-threatening problems
# Obtains objective and subjective data, include a history, general overview, vital signs, neurological
assessment, pain assessment, and complete or focused physical assessment