Management

of Care
Archer Review

Key Topics
▪ Prioritization + Delegation
o Establishing Priorities
o Assignment, Delegation and Supervision
▪ Legal and ethical concepts
▪ Information Technology
▪ Continuity of Care
▪ Referrals
▪ Performance (quality) Improvement
▪ Organ Donation
▪ Collaboration with Interdisciplinary Team
▪ Case Management
▪ Concepts of Management
 Legal + Ethical Concepts

Justice
● Fairness
● To distribute care evenly
● To administer care fairly
● To be just and equitable
Beneficence
● Doing good
● Doing the right thing for the client

Nonmaleficence
● Doing no harm
● No intentional harm
● No unintentional harm
Accountability
● Accepting responsibility for your actions
● Responsible for your nursing care
● Responsible for your actions
● Accept the consequences of your actions

Fidelity
● Keeping your promises
● Faithful
● True to professional responsibilities
Autonomy
● “The nurse accepts the client as a unique person who has the innate right to
have their own opinions, perspectives, values and beliefs.”
● Self-determination
● Encouraging patients to make their own decisions
● No judgement or coercion
● The patient has the right to refuse any and all treatment

Veracity
● Telling the truth
● Must be completely truthful with
your patients
● You may not withhold any part of
the truth from your client
● This includes when news may upset
or cause the client distress; it does
not give you the right not to be
truthful with them.
NCLEX Question
What ethical principle below is accurately paired with a way that ethical principle
is applied to nursing practice?

A. Beneficence: Doing no harm during the course of nursing care

B. Justice: The obligation to be fair; equally dividing time and other resources
among a group of clients.
C. Veracity: Fully answering the client’s questions without any withholding of
information
D. Fidelity: Upholding the American Nurses Association’s Code of Ethic

Answer: C
The correct answer is C. Fully answering the client’s questions without any
withholding of information is an example of the application of veracity into nursing
practice. Veracity is being completely truthful with patients; nurses must not withhold
the whole truth from clients even when it may lead to patient distress.

A is incorrect. Beneficence is doing good and right for the patient. Nonmaleficence is
doing no harm.

B is incorrect. Justice is fairness. Nurses must be fair when they distribute care and
Resources equitably, which is not always equally among a group of patients. Health
Promotion and Maintenance

D is incorrect. Fidelity is the duty to keep promises; faithfulness.

 Legal Concepts

Advanced Directives & Living Wills

● Advanced Directive: a set of instructions someone prepares in advance of ill health that determines
his healthcare wishes.
● Living Will: one type of advance directive that becomes effective when a person is terminally ill.
● Legal documents
● Prepared for when the client is not able to communicate their own wishes
● Can specify DNR, Full code, or specific interventions
Good to know...
If summoned, EMTs are legally obligated to provide emergency care to a client, regardless of
advance directive status. If the client is brought to a hospital, physicians will evaluate the client
and implement the advance directive, if necessary.

While some states do honor an advance directive from another state, others do not. For this
reason, it is essential for anyone who is moving to a new state (permanently OR temporarily) to
update their advance directive to the original state in which they will reside.

Advance directives don’t expire. If a new advance directive is created, the most recent one will be
honored when presented to medical personnel.

If there is no one available to make medical decisions for a client who appears incapable of doing
so, two physicians must evaluate the client and make a recommendation regarding the patient’s
decision-making ability.

Medical Power of Attorney

● Legal document
● Designates a specific person to make medical
decision for the client should they be unable
to make their own decisions
● If the client doesn’t have a MPOA laws vary
state by state on who the decision goes to
Federal Laws to know
● Health Insurance Portability and Accountability Act
○ HIPAA
○ Will discuss further :)
● American Disabilities Act – ADA
○ A civil rights law that prohibits discrimination against individuals with
disabilities in all areas of public life, including jobs, schools, transportation,
and all public and private places that are open to the general public.
● Emergency Medical Treatment and Active Labor Act – EMTALA
○ Requires anyone coming to an emergency department to be stabilized and
treated, regardless of their insurance status or ability to pay

Terminology
● Tort: A wrongful act or an infringement of a right
● Negligence: Failure to take proper care in doing something.
● Malpractice: Improper, illegal, or negligent professional activity or treatment,.
● Assault: An act, criminal or tortious, that threatens physical harm to a
person, whether or not actual harm is done.
● Battery: Unconsented physical contact with another person, even where the
contact is not violent but merely menacing or offensive.
● False Imprisonment: The state of being imprisoned without legal authority.
 HIPAA

Health Insurance Portability and

Accountability Act
● Protecting patient health information
● Specific rules about sharing this information
● If someone doesn’t NEED the information to do their job, DON’T share it with
them.
○ Can share with other health care providers that need it to take care of the client
○ Can share with their family WITH the client’s permission.
● Directory information
○ Includes the client’s name and facility location
○ CAN be shared, UNLESS the client ops out of being included in the directory
○ No specifics should be shared - that’s not included in the directory!
How you can protect your patient’s
information
● Turn off your computer screen when not using
● Do not speak about patients in a public place
● Shred personal health information
● NEVER post information about clients on social media
● Don’t use computers that are not secure for PHI
● Don’t send PHI to your personal email
● Don’t open the chart of patients you’re not taking care of.

Documentation
If it wasn’t documented, it wasn’t done!
● Your charting is a part of the client’s medical record
● Other healthcare providers as well as the patient can see it
● It can be used in a lawsuit
● It’s subject to review by different agencies:
○ The Joint commission
○ Medicare/Medicaid
○ Quality assurance committees

DO
● Chart in real time
● Chart under your name
● Chart events accurately, without
any subjective opinions:.
● Ex: Pt stated ‘get out of my room
you ugly cow’
DON’T
● Delay charting
● Chart early
● Char under someone else
● Chart for someone else
● Allow someone else to chart
under your name
● Chart your opinion of a patient:
● Ex: Pt was rude to nurse
● Change another persons
documentation
Informed Consent
● When you, as a nurse, witness an informed consent with your signature and title, this
signature signifies and means that you can validate the client’s name and identity.
● It does not say that you taught the client about the procedure or treatment or confirm their
understanding of the process or treatment.
● Does NOT signify or mean that you have taught the client about the procedure or treatment.
● Does NOT signify or mean that you can confirm and validate that the client is fully informed
about the procedure or treatment.
● Does NOT signify or mean that you have taught the client and you can confirm their
knowledge about the procedure or treatment.

NCLEX Question
A client who completes an informed consent is asserting and using their basic
right to:

A. Beneficence
B. Nonmaleficence
C. Self-determination
D. Have choices
Answer: C
Choice C is correct. A client who completes an informed consent is asserting and using their
fundamental right to self-determination. Self-determination is defined as the intrinsic right of all
people, including healthcare consumers, to make their own autonomous decisions about
accepting or rejecting care or treatments, as is done with informed consent.

Choice A is incorrect. Beneficence is an ethical principle that states that we should “do good” for
the client. It is not the basis of informed consent.

Choice B is incorrect. Nonmaleficence is an ethical principle that states that we should do “no
harm” to the client. It is not the basis of informed consent.

Choice D is incorrect. Although the client makes choices with informed consent, making choices
is not the basis of informed consent; making choices among alternatives of treatments is
supported.

Information Technology
Examples of IT in nursing
● Electronic Medical Record (EMR)
● Medication Administration Record (MAR)
● Barcode medication administration
● Barcode client identification
● Automated orders from health care providers
● Intranet
○ Policies
○ Procedures
○ Scheduling
○ IV compatibilities
○ Medication look up
○ Continuing education

Receiving/transcribing orders
● Ultimately the nurses responsibility to ensure the order is appropriate
○ Review an order when received
○ Ensure it is complete
○ Question and clarify when needed
● Illegible? Clarify.
● Seems off? Clarify.
● Doesn’t make sense for your client? Clarify.
● Telephone + Verbal orders
○ Discouraged - can lead to errors!
○ You are allowed to refused to take them.
○ If you take one - document the order, and why it was necessary to ‘take a verbal’
○ Read the order back the the healthcare provider to ensure it is correct.
Accessing data
● Only access information you absolutely need to do your job.
● Do not share information with others that do not need it
○ See HIPPA!
● Log off from your workstation when leaving
● Don’t leave your computer screen up with sensitive information

Performance Improvement
Performance appraisals/evaluations
Performance appraisals/evaluations serve a variety of functions, including:
● Appraisals help the nurse manager in updating personnel records and making
decisions on staffing, including hiring, scheduling, promotions, or termination
● Sets expectations for what the employer will provide, such as fair treatment,
acceptable working conditions, and feedback on their job performance.
● Develops the nurse-manager relationship leading to increased employee retention
and morale.
● Ensures legal compliance if consequential decisions such as termination should
occur.

NCLEX Question
The nurse manager is completing an annual performance appraisal/evaluation on a
staff nurse. Which elements should the nurse manager include when completing the
evaluation? Select all that apply.

A. The nurses' bar-code medication administration scan rate

B. The number of times the nurse has been absent or tardy
C. The nurse achieving a national certification
D. The nurses' performance compared to other staff nurses
E. The number of medication errors the nurse has self-reported.
Answer: A, B, + C
Choices A, B, and C are correct. The performance appraisal/evaluation goal is to provide a broad review
of the employee's performance with minimal evaluator bias. The more objective the evaluation, the less
the bias. Objective metrics such as bar-code medication administration rate, attendance, and national
certifications are logical elements to include in the appraisal.

Choices D and E are incorrect. The nurses' performance should not be compared/contrasted with other
nurses. The annual performance review should be focused solely on the nurses' performance.
Self-reporting is valued by the nursing profession and promotes a culture of safety. Using self-reports of
a medication error against the nurses' performance would likely discourage future reporting. If the nurse
manager observes unsafe practices by the nurse, they should be corrected. However, self-reporting
should be encouraged and not weaponized against the nurse.

Organ Donation
Nursing Considerations
● Process
○ If brain death will likely be declared, the hospital will notify the local organ procurement
organization - the specific organization varies for each state.
○ The organ procurement organization discusses organ donation with the family.
■ Not the nurse.
■ Not the health care provider.
● Caring for a donor
○ Have been declared brain dead
○ Your nursing care focuses on maining organ function
■ Appropriate lab values
■ Perfusion

Referrals
Purpose
The primary purpose of referrals is to ensure the completeness and
appropriateness of the clients' care.

There are many clients' needs that the nursing team can address, there are also
clients' needs that can be met by others in the multidisciplinary healthcare team.

The client is the center of care. Should participate in the referral process.

Providers
● Therapists
○ Physical therapists
○ Occupational therapists
○ Speech language pathologists
○ Respiratory therapists
● Social work
● Case manager
● Chaplain/spiritual care
● Registered Dietician/nutrition
● Outpatient services
● Specialists
 Collaboration with the
Interdisciplinary Team

Collaboration includes…
● Interdisciplinary team conferences/meetings
● Reporting information
○ SBAR
○ Handoff
○ Transfer
○ To other disciplines
● Care plan
SBAR Example
Situation: The client presented to the ED with URI s/s including dyspnea, tachypnea to the
low 30s, and a productive cough.

Background: The client is a 57 year old male with a history of congestive heart failure and
chronic obstructive pulmonary disease.

Assessment: The client's respiratory status is worsening. Retractions have increased from
mild subcostal retractions to moderate intra and supracostal retractions. Nasal flaring and
grunting are present. Respiratory rate is tachypnic and increasing. Nebulized albuterol and
oxygen have not improved symptoms.

Recommendation: Notify HCP and consider intubation.

Nursing Chain of Command
● UAP
● LPN
● RN
● Charge Nurse
● Nurse Manager
● Nursing supervisor
● Director of Nursing

Incident Reporting
● The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel
events is to prevent client injuries.
● Also helps to
○ Determine the cause
○ Correct mistakes
○ Identify faulty processes
NCLEX Question
The nurse notices a unlicensed assistive personnel (UAP) passing by several call
lights during the shift. What is the nurse’s best initial action?

A. Confront the UAP about the behavior.

B. Report unsafe behavior to the charge nurse.
C. File an incident report due to safety risk.
D. Ask another UAP to help cover this UAP’s patient load.

Answer: A
Choice A is correct. Ignoring call lights (or not responding in a timely manner) puts patients at increased risk of
falls and injury. The chain of command says the nurse should address issues/conflicts with the peer (if another
nurse) or subordinate (UAP), as long as the situation is not illegal or dangerous. This nurse should first address
issues with the UAP to determine the reason for this behavior (i.e. negligence versus work overload) and
collaborate to find a solution. If the interaction is not effective, the nurse would then bring the issue up the chain
of command (charge nurse) to determine the next steps.

Choice B is incorrect. The nurse should address the UAP first before reporting. If the behavior continues, the
issue should be brought up the chain of command to determine if it is due to factors such as negligent behavior,
alarm fatigue, or improper staffing.

Choice C is incorrect. Filing an incident report would not be appropriate. Although patient safety is at risk,
according to the given information, no incident/accident has occurred.

Choice D is incorrect. Asking another UAP to cover additional clients does not address the problem and
increasing the number of patients for the second UAP would put the safety of additional patients at risk.
Assignments should be set by the unit charge nurse and based on patient acuity.
 Case Management

Case management includes…

● Knowledge of resources available to your client
○ What assistance do they need outpatient?
○ How can we help them maintain independence?
● Equipment needs in the home - durable medical equipment
○ Oxygen
○ Wound care
○ Feeding supplies
○ Suction
● Plan of care
● Discharge information and coordination
Nursing Care Delivery Models
● Total patient care model
○ The RN being responsible for all aspects of care during a shift of care, care can be
delegated, and the RN works directly with the patient, family, and health care
team members.
● Primary nursing model
○ The RN has responsibility for a caseload of patients and provides care for the
same patients during their hospital stay
● Team nursing
○ Team members provide patient care under the supervision of the RN team leader.

NCLEX Question
The nurse is providing patient care working in a unit that uses the total patient
care model for delivering nursing care. The nurse recognizes which of the
following as an aspect of this nursing care delivery model?

A. The RN assumes responsibility for a caseload of patients.

B. The RN supervises team members providing direct patient care.
C. The RN provides care for the same patients during their hospital stay.
D. The RN is responsible for all aspects of care during a shift of care.
Answer: D
Choice D is correct. Characteristics of the total patient care model include: the RN being
responsible for all aspects of care during a shift of care, care can be delegated, and the RN
works directly with the patient, family, and health care team members.

Choices A and C are incorrect. The RN having responsibility for a caseload of patients and
providing care for the same patients during their hospital stay are characteristics related to
the primary nursing model.

Choice B is incorrect. In team nursing, team members provide patient care under the
supervision of the RN team leader.

Disaster Planning Triage

Red Tag:
● See patient first, needs IMMEDIATE attention
● Examples: Shock/Pneumothorax
Yellow Tag
● See patient second, needs DELAYED attention
● Example: Open fractures
Green Tag
● See patient last, “walking wounded”
● Examples: minimal lacerations/anxiety
Black Tag
● Allow to die respectfully
● Examples: Agonal breathing/grey matter exposed
Sentinel events
● An event that has reached the patient and caused harm (death, permanent harm, or
severe, temporary harm).
● Unrelated to the patient's illness or underlying condition.
● Called "sentinel" because they signal a need for immediate investigation and response. All
sentinel events must be reviewed by the hospital and are subject to review by the Joint
Commission. A sentinel event may occur due to medical errors like wrong-site,
wrong-procedure, wrong-patient surgery. Please note that the terms "sentinel event" and
"medical error" are not synonymous; not all sentinel events occur because of an error, and
not all errors result in sentinel events.

Patient safety events occur commonly in health systems worldwide. A patient safety event is an
event, incident, or condition that could have resulted or did result in harm to a patient. Safety
events can be categorized into sentinel events, adverse events, near misses, and no harm events.
Sentinel events are just one category of patient safety events

Other events
● An adverse event: a patient safety event that resulted in harm to a patient. (e.g. an
adverse event could include side effects to medications/vaccines, medical procedures.
They may or may not be from negligence. For example, a patient sustaining an embolic
stroke after coronary angiography is an adverse event, but not due to medical
negligence.)
● A no-harm event is a patient safety event that reaches the patient but does not cause
harm.
● A close call (or a "near-miss" or a "good catch") is a patient safety event that did not
reach the patient.
● A hazardous (or unsafe) condition(s) is a circumstance (other than a patient's own
disease process or condition) that increases the probability of an adverse event.
NCLEX Question
You are educating a new nurse regarding sentinel events. Which of the following are
examples of sentinel events?

Select all that apply.

A. An untimely assessment of the client.

B. An incomplete assessment of the client.
C. A client falls from the chair to the floor and sustains a humerus fracture.
D. The wrong client is almost sent to the operating room.
E. A client undergoes colectomy instead of appendectomy.

Answer: C + E
Choices C and E are correct. A sentinel event is defined as an event that has reached the patient
and caused harm (death, permanent harm, or severe, temporary harm). A sentinel event is
unrelated to the patient's illness or underlying condition. Such events are called "sentinel"
because they signal a need for immediate investigation and response. All sentinel events must
be reviewed by the hospital and are subject to review by the Joint Commission. A sentinel event
may occur due to medical errors like wrong-site, wrong-procedure, wrong-patient surgery. Please
note that the terms "sentinel event" and "medical error" are not synonymous; not all sentinel
events occur because of an error, and not all errors result in sentinel events.

Choices A and B are incorrect. Although an untimely assessment of the client and an incomplete
assessment of the client can be contributory factors that led to a sentinel event, these are
considered deviations from a standard of care and not sentinel events.
 Concepts of Management

Management includes…
● Knowing the roles of your team members
○ UAP, LPN, and other professions
● Care planning
○ What is the overall strategy for your client? How are you addressing their needs?
● Acting as a liaison
○ The nurse is usually the point of contact between members of the interdisciplinary team
○ Coordination of care
● Management of conflict
○ Between the client and nurse
○ Between the staff
Management Styles
Autocratic

● Manager makes all decisions

Democratic

● Most decisions are made by the group with support from the manager

Participative

● Staff provides input final say is made by the manager

Laissez-faire

● Little structure or support from manager

Question
A medication error has occurred in the medical ward. After a thorough investigation was
performed, the nurse manager posts a memorandum regarding changes in medication
administration to be implemented immediately. The nurses on the unit recognized this
management style as:
A. Autocratic

B. Democratic

C. Participative

D. Laissez-faire
Answer: A
Choice A is correct. In autocratic leadership, decisions are made with little or no staff input. The manager makes all
the decisions in the unit.

Choice B is incorrect. In a democratic style of management, staff members are encouraged to participate in the
decision-making process whenever possible. The majority of the decisions are made by the group, not the manager in
this management style.

Choice C is incorrect. In a participative style of management, problems are identified by the manager and presented
to the staff with several solutions. Staff members are encouraged to provide input however, the manager makes the
final decision.

Choice D is incorrect. Little direction, structure, or support is provided by the manager in a Laissez-faire type of
management. The manager abdicates responsibility and decision-making whenever possible in this type of
management.

Management Initiatives
● Benchmarking
○ Compares best practices from top hospitals with her unit and adapts the unit’s
methods to improve unit performance.
● Continuous quality improvement
○ Continually assesses and evaluates the effectiveness of client care.
● Performance improvement
○ Establishes a system of formal evaluation for job performance and recommends
ways to improve performance as well as promote professional growth.
● Quality management
○ The act of overseeing all activities and tasks needed to maintain a desired level of
excellence. This includes the determination of a quality policy, creating then
implementing quality planning and assurance, as well as quality
control/improvement.
NCLEX Question
The nurse manager regularly performs chart audits and room inspections in the
unit. She tells the staff to address the unit’s deficiencies during a meeting. Which
concept of management is the nurse manager displaying?

A. Benchmarking
B. Continuous Quality Improvement
C. Performance Improvement
D. Quality management

Answer: B
Choice B is correct. Continuous quality improvement continually assesses and evaluates
the effectiveness of client care.

Choice A is incorrect. In Benchmarking, the nurse manager compares best practices from
top hospitals to her unit and adapts the best unit’s methods to improve unit performance.

Choice C is incorrect. This establishes a system of formal evaluation for job performance
and recommends ways to improve performance as well as promote professional growth.

Choice D is incorrect. Quality management is the act of overseeing all activities and tasks
needed to maintain a desired level of excellence. This includes the determination of a
quality policy, creating and implementing quality planning and assurance, as well as quality
control/improvement.
NCLEX Question
The nurse is reviewing leadership and management concepts with a student
nurse. It would require further teaching if the student nurse made which of the
following statements?

A. “The Laissez-faire leadership style is a passive leadership approach.”

B. “A Registered Nurse (RN) may delegate accountability to a Licensed Practical
Nurse (LPN).”
C. “The rights of delegation include task, circumstance, person, direction,
supervision.”
D. “The State Nurse Practice Act defines roles and responsibilities of nursing
professionals.”

Answer: B
Choice B is correct. An RN may delegate certain responsibilities to an LPN but cannot delegate
accountability. The RN retains accountability when delegating patient assignments and tasks but
maintains accountability.

Choices A, C, and D are incorrect. The Laissez-faire leadership style is a passive leadership approach
where the leader acts more as a consultant versus an active leader. This type of leader is hands-off. The
rights of delegation do include the right task, circumstance, person, direction, and supervision. Finally,
the Nurse Practice Act is unique to each state and defines the roles and responsibilities of nursing
professionals.

Additional information: Delegation is the process of transferring responsibility and authority to another
individual. Responsibility is an obligation to complete the task. Accountability is assuming responsibility
and appropriate consequences for certain actions. The RN may delegate to responsibilities, as
appropriate, but maintains accountability.