Managing Care: Prioritization and Delegation Notes

Managing Care: Prioritization and Delegation

Managing Care

  • Involves:
    • Clinical judgment/critical thinking
    • Clinical reasoning
    • Clinical decision making
    • Delegation
    • Ongoing evaluation

Clinical Judgment Action Model

  • A cyclical process involving:
    • Noticing: Recognizing cues (filtering information from various sources like signs and symptoms, pathology, health history, and environment).
    • Interpreting: Analyzing cues, linking them to the client’s clinical presentation, and establishing probable needs, concerns, and problems.
    • Responding: Generating solutions, identifying expected outcomes, and related nursing interventions/actions to meet the client’s needs.
    • Reflecting: Evaluating outcomes and the client’s response to nursing interventions/actions to make a nursing judgment about the extent to which outcomes have been met.

Six Phases of Clinical Judgment

  1. Recognize cues: Filtering information from different sources (S&S, patho, health history, environment).
  2. Analyze cues: Linking recognized cues to the client’s clinical presentation and establishing probable client needs, concerns, and problems.
  3. Prioritize hypotheses: Establishing priorities of care based on the client’s health problems (environmental factors, risk assessment, urgency, S&S, diagnostic tests, lab values).
  4. Generate solutions: Identifying expected outcomes and related nursing interventions/actions to ensure a client’s needs are met.
  5. Take action: Implementing appropriate interventions/actions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health.
  6. Evaluate outcome: Evaluating the client’s response to nursing interventions/actions and reach a nursing judgment regarding the extent to which outcomes have been met.

Priority Setting

  • What it is:
    • Organizes care
    • Allows the nurse to see the most important issue
    • Avoids delays
    • Provides a big-picture view of the client’s problem/outcome
    • A dynamic process
  • What it is NOT:
    • Ordering of a list of tasks
    • Task-oriented
    • Task-driven
    • A to-do list
    • My list

Prioritizing

  • How to prioritize:
    • Manage time.
    • Remember everything has time constraints or deadlines.
    • Establish order for:
      • Ranking clients within a group (who to assess first).
      • Client problems, needs, or risks.
      • Nursing actions for a client or a group of clients.
    • Consider safety, resources (such as NA, NA II, or PN), the size of the client load, yourself, and the unexpected (predict and manage).
  • Requires:
    • Critical thinking and clinical judgment
    • Decision-making, delegation
    • Ongoing evaluation
  • Use priority-setting frameworks to assist in prioritizing:
    • Maslow’s Hierarchy of Needs
    • ABCs + VL(D)
    • Safety & Risk Reduction
    • Nursing Process
    • Least restrictive/Least Invasive
    • Acute vs Chronic (nonacute)
    • Stable vs. Unstable
    • Emergent, Urgent, nonurgent
    • CURE

Priority Frameworks

ABCs + VL (D)
  • Always the priority for initial assessments when the client’s life is at stake.
  • All three are essential for survival.
    • Airway: Is O2O_2 getting past the upper airway?
      • Assess: Stridor, obstruction, or injury.
    • Breathing: Effective breathing pattern and oxygenation.
      • Look, listen, feel.
      • Assess: Respiratory rate, breath sounds, cyanosis, SpO2SpO_2.
    • Circulation: Circulatory system to deliver O2O_2.
      • Assess: Bleeding, heart rate, BP, capillary refill, urine output (diuresis).
    • Vital Signs
    • Lab- Life-threatening laboratory values
    • Disability: Is client alert, confused, or unresponsive? Are they responsive to verbal or painful stimulus?
      • Assess: BG, BE FAST, Neurosensory of the LE
Maslow’s Hierarchy of Needs
  • Contains five levels of prioritized needs.
  • In most circumstances, physiological needs supersede the others.
  • In theory, the highest priority needs are those necessary for survival.
  • Low, Medium, or High Priority
Safety & Risk Reduction
  • Establishes priority based on which situation poses the greatest threat to the client at that time.
  • When multiple risks are present, another priority-setting framework like the ABCs may need to be used to identify the highest priority.
Nursing Process
  • Four steps that nurses use for clinical judgment.
  • It helps determine priority nursing actions based on the steps and always starts with assessment/data collection.
Least Restrictive/Least Invasive
  • Sets priorities based on the interventions that are the least restrictive or invasive to the client to minimize the risk for harm to the client.
  • Use when caring for a client who is exhibiting behaviors that could result in harm – to themselves or others.
  • You must always ensure that the nursing action selected will not put the client at risk for harm or injury.
CURE
  • Critical
  • Urgent
  • Routine
  • Extras
Other Framework Types
  • Acute vs. Chronic (Nonacute):
    • Acute needs pose more of a threat to the client; chronic needs usually develop over time, giving the body the opportunity to adjust, making them a lower priority – nonacute interventions can be done later.
  • Unstable vs. Stable:
    • Unstable clients pose a greater threat than stable clients and need to receive care first.
    • Also, use this framework when delegating to NA I, NA II, or PN.
  • Emergent, Urgent, Nonurgent

Pitfalls of Prioritization

  • Prioritize without assessments.
  • Poor time management.
  • Inappropriate delegation.
  • Completing the easiest tasks first.

Prioritize Nursing Action

  • Rank Activities
    • Must do
    • Should do
    • Nice to do
  • Time management

Delegation

  • Transfers responsibility while remaining responsible and accountable for outcomes.
  • Requires knowing which skills are transferable.
  • See NA I and NA II task list.
  • NCBON 7 components by the LPN.
  • Results in improved quality of patient care, improved efficacy, increased productivity, and an empowered staff.
Key Definitions
  • UAP (Unlicensed Assistive Personnel): Individuals not licensed but trained to carry out delegated nursing care tasks. Examples: Nurse Aide I/II, Medication Aide, Medical Assistant, Personal Care Assistant, etc.
  • Supervision: Ongoing oversight, guidance, and evaluation of assigned/delegated tasks by the nurse.
  • Accountability/Responsibility:
    • The nurse is accountable for the decision to delegate, ensuring it aligns with practice standards and policy.
    • The delegatee (UAP) is accountable for correct task performance.
Delegation Scope: Role and Legal Authority
  • Role
    • Registered Nurse (RN): May assign, teach, delegate, and supervise both licensed and unlicensed personnel. Has the broadest authority in delegation.
    • Licensed Practical Nurse (LPN): May assign/delegate tasks to other LPNs and UAP under RN supervision.
  • Legal Authority
    • The Nursing Practice Act (NPA) gives the BON the power to regulate nursing practice, including:
      • Defining what tasks can be delegated.
      • Creating task lists for NAI and NAII.
      • Providing a Decision Tree for Delegation, available on www.ncbon.com.
Principles of Delegation
  • UPA’s knowledge and skills
  • Verification of UAP’s clinical competence by RN
  • Variables in the practice setting:
    • Complexity and frequency of nursing care needed
    • Proximity of clients to staff
    • Accessible resources
    • Qualification and number of staff
    • Facility policies and procedures and channels of communication
  • Stability- the predictability of the client’s condition
Planning Before Delegating
  • Consider:
    • Scope of practice
    • Require nursing assessment/judgment
    • Whose available - RN/PN/UAP
    • Ability to supervise
How to Delegate
  • Describe the task using “I” statements
  • Describe the importance of the task
  • Describe the expected outcome (clearly)
  • Identify any constraints on completing the tasks
  • Have the delegate repeat back the tasks with details
The 5 Rights of Delegation
  1. Right Task – ones you delegate for a specific patient such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have minimal potential risk.
  2. Right Circumstances – Consider the appropriate patient setting, available resources, and other relevant factors. In acute care setting patients’ conditions often change quickly. Use good clinical decision making to determine what to delegate.
  3. Right Person – The right person is delegating the right tasks to the right person to be performed on the right person.
  4. Right Direction/Communication- You give clear, concise description of the task, including it objective, limits, and expectations. Communication needs to be ongoing between the registered nurse and UAP during a shift of care.
  5. Right Supervision/Evaluation – Provide appropriate monitoring, evaluation, intervention as needed, and feedback. UAP need to feel comfortable asking questions and seeking assistance.