Comprehensive Study Notes: Care & Delegation, Managed Care, and Interprofessional Collaboration
Time Management and SMART Goals
Purpose: Planning the time available in accordance with goals to achieve; essential for nurses to know how to prioritize client care activities according to time constraints.
Time management focus: Prioritizing tasks to maximize efficiency and patient safety; reduce risk of adverse events through organized client care.
SMART goals (to organize daily activities):
(S) Specific
(M) Measurable
(A) Attainable
(R) Realistic
(T) Timely
One effective approach: Implement SMART goals to structure the day and guide nursing actions.
Communication Tools: SBAR and SOAP
Purpose: Use organized communication tools to structure thoughts and actions in a factual manner.
SBAR Handoff Tool
S: Situation
B: Background
A: Assessment
R: Recommendation
SOAP Nursing Note
S: Subjective
O: Objective
A: Assessment
P: Plan
Benefit: Enhances clarity, reduces miscommunication, and supports continuity of care.
Acuity and Client Assignment
Acuity defined: The complexity of a client’s condition.
Acuity tools: Used to ensure client assignments are consistent and fair; may vary by facility.
Ranking: Clients are ranked from stable to high risk based on the tasks involved in their care.
Implication: Higher acuity tasks require appropriate staffing and skill mix to maintain safety and quality.
Discharge Planning
Ideal discharge planning process should:
(I) Include the client and caregivers.
(D) Discuss the 5 key areas: Medications, Home life, Warning signs, Test results, Follow-up.
(E) Educate the client: Condition, discharge process, next steps.
(A) Assess effectiveness of education.
(L) Listen to the client’s goals and preferences.
Goal: Facilitate safe transition from acute care to home or another setting while aligning with patient goals.
Delegation: Definition and Scope
Definition: One person assigning tasks to another person.
Standardization: Nursing delegation should have clear guidelines to ensure activities are within the health care personnel’s scope of practice.
Responsibility and accountability: All licensed nurses and assistive personnel have a personal responsibility to know their role and scope of practice.
Key concept: Delegation transfers responsibility for the task, but the delegator retains accountability for ensuring the task is completed safely and effectively.
Distinction: Delegation is not the same as work allocation or general assignment; it is a conscious transfer of responsibility to a competent individual.
Outcome: Delegation expands what a nurse can accomplish with others’ help and can increase overall efficiency.
Principles of Delegation
Delegation can be applied at multiple levels within nursing practice.
Follow the hierarchy of nursing practice (e.g., advanced practice nurses).
State practice acts define the scope of practice; organization policies also shape delegation.
Key accountability: The delegator remains responsible for the outcome.
Guidelines for successful delegation:
Follow State Nurse Practice Act and facility policies/procedures.
Delegate only tasks for which you have accountability and responsibility.
Follow state regulations, job descriptions, and agency policies.
Follow the delegation process and key behaviors for delegating.
Accept delegation only when you clearly understand the task, time frame, reporting requirements, and other expectations.
Confront fears about delegation; distinguish realistic concerns from unfounded fears.
Delegating to Other Nurses
RNs may delegate to other RNs.
The RN who accepts an assignment is responsible for completing care safely and completely.
RNs may delegate to LPNs/LVNs, but the RN remains responsible for ensuring correct and appropriate intervention.
Five Rights of Delegation (reiterated):
Right Task
Right Circumstances
Right Person
Right Direction and Communication
Right Supervision
Delegating to Unlicensed Assistive Personnel (UAP) – Part 1
UAP function as “nurse extenders”; diverse categories with varying levels of training/experience.
Examples of UAPs: Certified Nursing Assistants/Assistants, Home Health Aides, Medical Technicians, Orderlies, Surgical Technicians.
Nurses may delegate tasks to UAPs as employees of the health care provider.
Nurses may not delegate to patients’ family members or friends because they are not employees of the provider.
Nurses must determine whether a task can be delegated to a particular UAP for a specific patient.
UAPs may not delegate tasks to others.
Delegating to Unlicensed Assistive Personnel (Part 2) – Communication and Validation
Delegator (nurse) must communicate clear instructions to the UAP.
Confirm that the UAP understands the instructions.
Validate that the action has been completed.
Delegator must provide information about the task as it relates to the patient(s).
Include timing for task completion, potential need for additional resources, expected outcomes, and documentation of task completion.
Delegating to Unlicensed Assistive Personnel (Part 3) – Tasks Commonly Delegated
Taking vital signs
Measuring and recording intake and output (I&O)
Patient transfers and ambulation
Postmortem care
Bathing
Feeding
Gastrostomy feedings in established systems
Attending to safety
Weighing
Suctioning chronic tracheostomies
The Five Rights of Delegation (Overview)
Right Task
Right Circumstance
Right Person
Right Directions and Communication
Right Supervision and Evaluation
Tasks That Should Never Be Delegated by the RN
Highly technical tasks
Complex patient care tasks that require specific licensure, certification, or expertise
Any situation involving confidentiality or controversy
Legal Aspects of Delegation
Nurse Practice Acts define the scope of practice based on professional licensure.
National Council of State Boards of Nursing (NCSBN) responsibilities and the Clinical Triad underpin delegation practice.
Adherence to these rules helps protect nurses from liability.
Useful guidelines: The Five Rights of Delegation; consider a decision tree based on NCBSN and ANA guidelines.
Managed Care and Care Delivery Models
Managed care definition: A health care delivery system focused on decreasing costs and improving outcomes for groups of patients.
Care management aims to plan care from initial contact to conclusion of the health problem; models differ, but goals remain constant.
Trends in health care: Increased focus on preventive care; potential negative consequence: higher hospital readmissions after early discharge.
Models: Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).
Role of nurses: Coordinate direct patient care, care coordination, and cost containment; understand patients’ rights and advance directives; commit to quality improvement.
Managed care has been embraced as a model for health care reform; some debate the fit of business approaches in health care.
Case Management
Definition: Coordination of patient care over time using a combination of health and social services to meet patient needs.
Central to many managed care systems; often most effective for patients with multiple or chronic health problems.
Involves interprofessional teams that collectively plan, assess needs, coordinate, implement, and evaluate care.
From preadmission through discharge or transfer and recovery; each team led by a case manager, who may be a nurse, social worker, or other professional.
May work in clinics, hospitals, long-term care facilities, insurers, or employers; sometimes called discharge planners.
Patient-Focused Care
Organization centered on the patient.
Ensures patients are integral to planning and decision-making; incorporates patient- and family-centered care principles.
Nurses take time to learn about patient lifestyle, habits, and family; sensitivity to diverse religious, cultural, and personal preferences.
Plan of care developed with patient, addressing health and personal needs; helps patients acquire knowledge and skills to manage their condition.
Emphasizes patient autonomy and dignity during decision-making; aims to improve health outcomes by aligning care with patient goals.
Differentiated Practice
System that uses credentialing and clinical training to differentiate roles.
Organizes roles and job descriptions to facilitate improved patient outcomes.
Identifies skill sets by nursing level; enables delegation based on organizational competencies.
Ensures delivery of high-quality, top-of-license care while avoiding time spent on tasks that can be handled by less-qualified staff.
Helps maximize quality and affordability of care.
Shared Governance
Model focused on sharing the driving framework for clinical decision making between bedside nurses and nursing leadership.
Aims to influence allocation of resources and improve patient outcomes.
Encourages shared decision making, leading to higher nursing satisfaction and improved patient outcomes.
Case Method, Functional Method, Team Nursing, Primary Nursing
Case Method: One nurse provides all aspects of patient care for a designated shift; care coordination uses the nursing process; primary nursing derived from this approach; used in high acuity settings (e.g., EDs, ICUs).
Functional Method: Focuses on tasks as the primary factor; higher efficiency with less highly educated staff; risk of fragmented care.
Team Nursing: Two or more nurses pair to care for a group of clients; leverages varied experience and skills; enhances teamwork and safety.
Primary Nursing: One nurse responsible for total care of a number of patients 24/7; oversees the plan of care; may have associates providing some care; first-line manager of patient care; accountability remains with the primary nurse.
Noncompliance (Nonadherence)
Defined as failure to act in accordance with a plan.
Client nonadherence can be a serious barrier to positive health outcomes.
Some noncompliance arises from factors outside the client’s control.
Nurses should document resources used, communication attempts, and follow-ups with nonadherent clients.
Interprofessional Collaboration
Growing need due to increasing complexity of client health conditions and treatments.
Barriers include miscommunication, distrust, lack of respect among provider types, differing levels of perceived importance, and misunderstandings of roles.
Interprofessional Education Collaborative (IPEC) Core Competencies
Established in 2011 to provide structure for teamwork toward client-centered care.
Four core competency areas:
Values and ethics for interprofessional practice
Roles and responsibilities
Interprofessional communication
Teams and teamwork
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