Managing Care, Clinical Decision Making, Collaboration

Practice of Medical-surgical Nursing

• Roles of the medical-surgical nurse

  • care coordinator and transition manager

  • caregiver

  • pt educator

  • leader

  • advocate for the pt and family

Quality and Safety Education for Nurses’ Core Competencies

• provide pt-centered care

• collab w/ interprofessional health care team

• implement evidence based practice

• use quality improvement in pt care

• use informatics in pt care

• maintain safety

QSEN & professional nursing concepts

• clinical judgment

• systems thinking

• health equity

• ethics

Patient-Centered Care Attributes

• respect for pts values, preferences, and expressed needs

• coordination and integration of care

• information, communication, and education

• physical comfort

• emotional support and alleviation of fear and anxiety

• involvement of family and friends

• access to care

Military & Veteran Health Care Systems

• military hospitals

• civilian managed care

• TRICARE

• veterans health admin (VHA)

• veterans access, choice, and accountability act

Military & Veterans Health

• Mental Health Issues

  • PTSD

  • substance use disorder

  • military sexual trauma

  • homelessness

• Medical-surgical health issues

  • amputations

  • environmental/chemical exposures

  • TBI (blast concussions)

  • hearing loss

NPSG: Medication Reconciliation

• obtain/update info on meds currently taken

• define med information (name, dose, route, frequency, purpose)

• compare med info brought to the agency w meds ordered

• give pt/family written med information at end of encounter

• explain importance of med management

SBAR

Situation

Background

Assessment

Recommendation/request

TeamSTEPPS

• systematic communication approach for interprofessional teams

• improves safety and quality

• Strategies and Tools to Enhance Performance and Patient Safety

• Common communication tools

  • CUS (I’m concerned; i’m uncomfortable; I don’t feel like this is safe)

  • check backs

  • call outs

  • two-challenge rule

5 rights of delegation

1. right person

2. right task

3. right supervision

4. right circumstance

5. right communication

Quality Improvement Models

• PDSA

• FOCUS-PDCA

• DMAIC

PICOT Question

• Population/Patient problem (such as falls)

• Intervention (bed alarms to reduce falls)

• Comparison (reminder signage for staff instead of or in addition to bed alarms)

• Outcome (fall reduction)

• Time Frame (during night shift, but time may not always be relevant)

Health Equity

• ability to recognize differences in the resources and/or knowledge needed for individuals to fully participate in health care and achieve optimal outcomes

• health care disparities are differences in:

  • access to and use of health care

  • health care quality

  • health outcomes

  • health insurance coverages

ethical principles

• autonomy

• beneficence

• nonmaleficence

• fidelity

• veracity

• social justice

Nursing Process (AAPIE)

• assessing

• analyzing

• planning

• implementation

• evaluation

NCBSN Clinical Judgment Measurement Model

• recognize cues

• analyze cues

• prioritize hypotheses

• generate solutions

• take action

• evaluate outcomes

Critical Thinking

• using logic and reasoning to come to a conclusion

• led by nursing standards, nursing practice, and national competencies

• considers pros and cons of a decision

• uses information and knowledge directed by nursing standards and best practice

• critical thinking is used every day in the healthcare setting

Clinical Reasoning

• Collecting cues, processing info, understanding the situation, implement interventions, evaluate, and reflect

• clinical reasoning is the basic nursing process

  • assessment

  • analysis of data

  • planning

  • intervention

  • evaluation

• process used by nurses to make informed & responsible clinical decisions & addresses problems faced by their pts

• process called ADPIE and based on the clinical judgement management model

Clinical Judgment

• the outcome of critical thinking

• nurses rely on critical thinking to come to conclusions, then using clinical judgement they can decide which is the best action to take

• Clinical Judgement:

  • assessment

  • use of prior knowledge based on previous similar situations

  • analyzation of assessment data

  • application of knowledge to

  • implementation of an intervention or solution

Clinical Judgement Model: Recognize Cues

• cues are your assessment data

  • what do you see?

  • subjective/objective data

    • subjective; what pt says, reports

    • objective; concrete info, labs, vitals, cat scan images

  • what is relevant data collected?

• the ability to distinguish between relevant and irrelevant cues guides the ability to prioritize care

Clinical Judgement Model: Analyze Cues

• once data has been collected, nurses need to recognize what the data means

• Assessment of the whole situation history

• what the nurse sees, hears, & picks up on regarding the pt, family, room, situation

• how does the data collected pertain to the hx of the pt or the current medical dx?

Clinical Judgement Model: Prioritize Hypothesis

• consider all possible problems and which one is most urgent

• what will happen if a certain decision is made?

• which intervention is most important to perform?

• what is the most urgent need of the pt?

Clinical Judgement Model: Generate Solutions

• using the hypothesis to develop expected outcomes

• which interventions should we perform?

• how will these interventions benefit the pt?

• how could the interventions potentially harm the pt?

Clinical Judgement Model: Take Action

• perform interventions based on the highest priority of care

• consider what other assessment data should be collected once intervention is performed

• what other actions or orders should we anticipate

• who do we need to collaborate w/ in order to meet the expected outcome?

Clinical Judgement Model: evaluate outcomes

• reassessment after implementation of interventions

• what has improved?

• what has declined?

• what is unchanged?

• evaluation allows nursing knowledge to evoke and adapt to new or similar situations

• allows nurses to interpret if existing knowledge is up to date

Urgency Factor Levels

• nonacute

• acute

• critical

• imminent

Urgency Factor Levels - Nonacute

• non threatening to life

• delay in doing interventions does not negatively impact pt outcome

Urgency Factor Levels - Acute

• low potential to become life threatening

• necessary interventions are scheduled, expected, typical

Urgency Factor Levels - Critical

• potential to become life threatening

• quick recognition and rapid response needed to stop threat from becoming life threatening

Urgency Factor Levels - Imminent

• life threatening interventions are needed immediately

Successful Collaboration

• effective communication

• mutual trust

• decision making

• managing conflict

• exchange of feedback

• mutual respect

Delegation barriers

• many nurses feel they can do it all

• lack of trust or respect

• lack of confidence

• conflict avoidance

• unsure if task is able to be delegated

Delegation

• transfers responsibility but NOT accountability

• relies on the 5 rights of delegation

• not a part of regularly assigned work

Assignment

• assignment is a skill or task that is part of an individual’s job

• expected to perform this task on a regular basis

• part of their job description