Plan-Managing Self, as the Nurse and Client Care

Class 8

November 4, 2009 Judith Anne Shaw, Ph.D., R.N.

Plan-Managing

• Delegation of Client Care– Standards for Nursing Practice– Communication Games

• Models of Care Delivery– Contemporary– Traditional

• Monitoring & Evaluating Quality of Care

• Quality Improvement• Time Management

DELEGATION

• Know person’s capabilities

• Know job description

DELEGATION

Concept

Skill

Process

Art

(Hansten & Jackson, 2004)

DELEGATION

Direct

Indirect

DIRECT DELEGATION

Verbal Direction

by

the Registered Nurse

INDIRECT DELEGATION

Approved list of activities or tasks

established in

policies and procedures within an agency

What is the Difference?

Assignment

vs.

Delegation

Five Rights of Delegation1. Right task

2. Right circumstances

3. Right person

4. Right direction/communication

5. Right supervision/evaluation

DELEGATION

NURSING PROCESS

CONCEPT

DELEGATION and theNURSING PROCESS

1. Assessment

2. Plan

3. Implementation/Intervention

4. Evaluation

Assessment Know your world

-Practice-Organization

Know yourself- Barriers- Benefits

Know your delegate- Competency- Motivation

(Hansten & Jackson, 2004)

Plan

Know what needs to be done- Professional- Technical- Amenity- Based on outcome

(Hansten & Jackson, 2004)

Implementation/Intervention

Prioritize &Match the Job to the Delegate

Know how to communicate

Know how to resolve conflict (Hansten & Jackson,

2004)

Evaluation

• Know how to give feedback

• Evaluate and problem solve

(Hansten & Jackson, 2004)

Delegation Decisions

• Level of client acuity

• Level of unlicensed assistive personnel (UAP) capability

• Level of licensed nurse capability

Delegation Decisions

• Possible injury

• Times skill performed by unlicensed assistive personnel

• Level of decision-making needed for activity

• Client’s ability for self-care

Criteria for Safe Delegation

• Potential for harm to the client

• Complexity of problem solving and innovation required

• Predictability of the outcome

• Extent of interaction

GAMES

…people may play

Organizational Game

• Karpman Triangle:

– 3 roles

1. Victim

2. Persecutor

3. Rescuer

Karpman Triangle

Persecutor Rescuer

Victim

*Participants move from one to another

Call The Game!

• Refuse to play any of the roles

• Give an adult response

Karpman Triangle

Persecutor Rescuer

Victim

*Participants move from one to another

Models of

Care

Models

…remember that a picture

(even a word picture)

is worth a thousand words

Traditional Models of Care

Total Care

Functional

Team

Modular

Primary

Total Care

Gains

1. Extremely client focused

Losses

1. Not most efficient use of staff

Functional Care Delivery

Gains

1. Efficient

2. Economical

3. Productive

Losses

1. Fragmentation of care

Team Approach

Gains

1. Holistic care2. Increased client &

employee satisfaction

Losses

1. Time consuming2. Expensive3. May increase

workload stress

Contemporary Challenge of the Team Approach

AIM- Develop a group of individuals into a

cohesive whole- Share goals, expectations, and behavioural

norms by team members- Individual differences and contributions

acknowledged- Develop and promote best practices

TEAMWORK

WORKING TOGETHER

TYPES OF TEAMS

• Multidisciplinary Team

• Interdisciplinary Team

• Transdisciplinary Team

TEAM BUILDING

CHALLENGE

How to build a

well-functioning team?

TEAM HIGH PERFORMANCE LEVELS

• Participative leadership

• Shared responsibility

• Aligned on purpose

• Strong communication

• Future-focused

• Focused on task

• Rapid Response

Modular Approach

Gains Losses

• Located nearer .Use of

the client paraprofessionals

• Efficient . Dependenton skill of coordinator

Primary Care

Gains

1. Decreases fragmented care

2. Increases accountability & clientsatisfaction

Losses

1. Limits number of clients a nurse can provide care to-

2. Client may be in jeopardy

Mini-Nurse Manager Quiz

Of the traditional models of Care Delivery, which model do you think optimizes the provision of quality client care?

Provide explanation for your choice.

Contemporary Models of Care Delivery

Case Management

Client-Focused

Product Line Management

Differentiated Practice

Case Management

Gains

1.Continuity of care

2. Efficient use of resources

3. Professional development & satisfaction

4. Holistic approach

Losses

1. May be in jeopardy

2. Possibly, limited prepared staff

Client-Focused Care

Gains

1. Possible increased client & staff satisfaction

Losses

1. Possible staff dissatisfaction & stress

2. Institutional licensure

3. Quality of care giver

Product Line Management

Gains

1. Cost effective

2. Potential for being more efficient

3. Allow nurses to provide direct care

Losses

1. Potential of not focusing on client

2.Potential of not being able to adequately access client needs

Differentiated Practice

Gains

1. Potential for nurse increased satisfaction

2. Potential for cost benefit for agency

3. Improved client care

Losses

1. Potential for limited use of nurse who has higher competency skill level vs. educational preparation

Quality Client Care

Monitoring & Evaluating

Structured Care Methodologies

• Guidelines

• Protocols

• Algorithms

• Standards of Care

• Critical (Clinical) Pathways

Critical Pathways

• Outgrowth of nursing care plan

• Multidisciplinary representatives

• Provides a communication & documentation framework

Critical PathwaysKey Elements

• Discharge planning

• Consultations

• Activities

• Nutrition

• Medications

• Diagnostic Tests

• Treatments

Quality Improvement

• What to evaluate

– Structure, process & outcomes

• Continuous quality improvement

– Quality Circle at the Unit Level

What To Evaluate

Three

different aspects

of

health care

1.Structure: setting and resources

2. Process: actual activities “carried out” by

the health care provider

3. Outcome: results of the activities

THREE MUSTS

Comprehensive Evaluation Program

Remember

Outcome Measures

-use measurable

indicators

(objective measures)

Continuous Quality Improvement

Continuously improve the capability of involving everyone in providing quality

care

Integration into All Aspects of Health Care Organization

Continuous Total

Quality Quality

Improvement Management

Total Quality Management [Unit Level]

Assign ResponsibilitiesIdentify Vital AreasDefine Scope of Care

Analyze Area in Terms of:Aspects

StandardsIndicatorsCriteria

Measure Actual PerformanceMeasure Patient Outcomes

Evaluate Performance and OutcomesRecommend and Implement Actions

Evaluate Degree of Improvement

Quality Improvement at the Unit Level

Quality CircleQuality Circle

Accreditation of Healthcare Organizations

. Cost

. Quality

the interest of consumers, healthcare payers, and healthcare providers.

Time Management

• Scheduling Time ----- To What End?

Consider...

It is not important how much activity can be packed into each day

rather

how much closer we get to achieving the desired results.

Ask yourself...

“To what end” are you as keeper of your appointment book filling in the spaces?

Catch a vision…a goal and work towards it!

Each day must

--be planned

with the

end-result in mind!

Nurse Time

35% -direct client care

20% -documentation

Remainder - “Other”

Nurses MUST Manage Time

through effective

time

management skills.