Nursing 235

Application of Nursing Concepts II

General Concepts (Essentials of Managing Patient Care in the Clinical Area)

Breakdown of Reading for Management (Huston 11th Ed.)

Chapter 1: Decision Making, Problem Solving and Critical Thinking: pp. 2-3, 8-13, 16-20.
Chapter 4: Ethical Issues: pp. 81-92.
Chapter 5: Legal and Legislative Issues: pp. 103-115, 118-122.
Chapter 6: Advocacy: pp. 129-144
Chapter 7: Organization Planning: pp. 172-177.
Chapter 9: Time Management: pp. 204-215
Chapter 14: Organizing Patient Care: pp.339-346
Chapter 20: Delegation: pp. 509-523
Chapter 21: Conflict/Workplace Violence: pp. 547-551, 560-561

Decision making, Problem Solving, and Critical thinking

Decision-making: Choosing a particular course of action

Critical Thinking in Nursing

 Look for patterns and relationships

 Ability to transfer knowledge from one situation to another
 Is a key component for the nurse whether caring for a patient or answer a test question
 Evaluates according to established criteria

Basic Level Critical Thinker

 Assumes that the person in authority has all the right answers
 Believes that there is right answer that correct in every situation (i.e., applying oxygen).
 Uses this thinking in clinical or with a test question.

Complex Level Critical Thinker

 Analyzes the situation

 Determines what is happening

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  Chooses the safest choice for the patient
 Accepts that a particular action in one situation may not be the best choice in all
situations
 Can apply in clinical or with a test question
Problem Solving: A systematic process

The Nursing Process: Is a problem-solving process that requires us to critically think, and
problem solve in order to plan, organize and implement patient care
 Assess
 Identify problem (NDX)
 Planning (outcomes)
 Implementation
 Evaluation

Time Management Steps

 Learn to manage your time and set priorities.

 Avoid priority-setting traps
 Set priorities for the day of clinical assessment and the day of clinical. (Come with a plan).
 Complete the highest priority task.
 Finish one task before beginning another.
 Avoid procrastination

How to Manage Time

Plan how you will manage your day with the following tasks:

 Attend Preconference: Follow the information on the clinical paperwork form.

 Get Report: You must be updated on your patients before beginning care
 Medications: Review the medication schedule for each patient (times due). You must do this
early on.
 Determine which medications are priority (ie, medications scheduled to be administered more
than once on a shift, pre-op meds, pain medications, Insulin etc).
 Treatments: times, types, frequency; (sterile dressing changes, pin site care, tube feedings,
scheduled labs
 Visit Your Patient: Deciding which patient you will see first: (unstable patients, patients leaving
the unit for tests, surgery, therapy, diagnostic tests.
 Provide Care throughout the Day: (Assessments, meds activities, I&O, vital signs, treatments).
 Documentation: Must be done according to the time the care was actually performed.
 Provide end of shift report:

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Learn to be Efficient

 Learn to set priorities

 Be familiar with the steps of performing a skill. Review the policy.
 Work at a steady pace.
 Don’t spend too much time on one task.
 Become time conscious. Watch the clock. Use all available time.
 Gather all supplies before beginning.
 Group activities that are in the same location. If you have walked a long distance down a
hallway, attempt to do several things there before going back to the nurses’ station.
 Use time estimates.
 Take regularly scheduled breaks from work. They allow the worker to refresh both
physically and mentally.
 Deal with interruptions (i.e., avoid frequent socializing, don’t be too accessible).
 Document nursing interventions as soon as possible. This decreases the risk of
inaccuracies and incomplete documentation.
 Strive to end the workday on time. Delegating appropriately to others and making sure
that the workload goal for any given day is reasonable are two strategies that will
accomplish this goal.

Organizing Patient Care

Choosing the most appropriate organizational mode to deliver patient care for each unit or
organization depends on

• The skill and expertise of the staff,

• The availability of staff (especially RN’s),

• The economic resources of the organization,

• The acuity of the patients

• The complexity of the tasks to be completed.

Team Nursing

The team leader is in charge of the team and is responsible for providing direction to
team members.
Ancillary personnel collaborate in providing care to a group of patients under the
direction of a professional nurse.
The team usually consists of a registered nurse, who serves as team leader, a licensed
practical nurse, and one or more certified nursing assistants.

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 As team leader the nurse is responsible for knowing the condition and needs of all
patients assigned to the team and for communicating with all members on the team.
The team leader is ultimately responsible for assigning patients to each team member
and is responsible for overseeing the activity of patients and team members.
Each member of the team provides the level of care for which he is best prepared. The
least skilled and experienced members care for the patients who require the least
complex care, and the most skilled and experienced members care for the sickest
patients who require the most complex care.
Team nursing allows the team leader to shift, match, and redistribute patient
assignments to team members according to their level of education and expertise (the
acuity level of the patient influences the patient assignment).
Team nursing enables the team leader to supervise, coordinate, and manage the care
given to all the team’s patients for the assigned shift. The team leader reports to the
head nurse
Team leader’s duties vary depending on the patient’s needs and the workload. These
duties may include assisting team member, giving direct personal care to patients,
providing instruction and direction, and coordinating patient activities.
Requires effective communication between the team leader and the team members to
be effective.
Associated with democratic leadership.
The team shares responsibility and accountability collectively.
The registered nurse team leader oversees all care for a particular shift, makes
assessments, and documents responses to care. The licensed practical nurse team
member provides direct care by performing treatments and procedures and reports
patient responses to the team leader. The certified nursing assistant provides routine
direct, personal care. Licensed practical nurse can be the team leader or charge nurse in
some settings.

Advantages

 Potential for team spirit

 Provides comprehensive care
 Each worker’s abilities are used to the fullest.
 Promotes job satisfaction
 Decreases nonprofessional duties of registered nurses.

Disadvantages

 Must allow time for team planning and communication.

 All team members must work together, or this approach is unsuccessful.

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  Team composition varies from day to day, can be confusing and disruptive and
decreases continuity of care.
 Insufficient planning can lead to blurred lines of responsibility, error, and fragmented
care.
 Requires effective communication between team members.

The Team Leading Experience

 Can be implemented in different ways

 Includes team leader and team members and in some instances a medication nurse.
Responsibilities of the members vary and depend on the number of team members
available. The team leader may be required to take a patient assignment in addition to
all other team leading duties.
 Requires that all members work together as a team (the actions of one team member
affects all others).
 Team members must be able to get along regardless of individual differences.
 Members on the team will be required to do peer evaluations of each other.

Some responsibilities of the team leader include:

 Making the assignment for each team member,

 deciding how break times/lunch times/ will be allocated
 overseeing and coordinating the activities of team members,
 communicating with all team members involved (to include new orders, relaying lab
results patient updates)
 collaborating with team members to stay abreast of changes in patient status
 assisting team members as needed.

Things to Consider When Planning the Patient Assignment

Time required to provide care to a patient

Complexity of care needed
Acuity
Knowledge level and ability of the staff person
Stability of the patient
RN is ultimately responsible for assessment, patient teaching, and evaluation. Cannot be
delegated to others.

What is the Team Leader Responsible for Communicating?

 Changes in patient status

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  New orders
 Changes in the assignment
 Patients going to surgery, transfer, diagnostic tests
 Patient concerns

Factors That Affect Nursing Care

Scope of Practice

Nurse Practice Act (NPA)

 It is the most important statutory law affecting nurses. It emphasizes safe,

competent nursing.
 Together the NPA and rules/regulations guide and govern nursing practice
 Defines the legal scope of nursing practice. Duties and functions that nurses can
perform.
 Defines the responsibilities and authorities of the state board of nursing.
 Defines important terms and activities in nursing including legal requirements and
titles for RNs and LPNs.
 Determines the legal titles and abbreviations nurses may use.
 Sets the educational qualifications and other requirements for licensure.
 Provides for disciplinary action of licensees for certain causes.
 Directs the state board of nursing in establishing criteria for licensure.
 Established in each state and is revised from time to time to keep up with new
developments in health care and changes in nursing practice.

Registered Nurse Role (RN)

Nursing care expectations are beyond that learned by the LPN.

Manage the care of patients with basic as well as those with complex care.
Manage complex nursing situations (those situations that the patient’s clinical
condition is not predictable and medical or nursing orders are likely to involve
continuous change.
Assessment, planning, implementation, evaluation and/or teaching of nursing care
is ultimately the responsibility of the RN.
Oversee and coordinate nursing care.
Pathways to becoming a registered nurse (RN) include diploma, associate degree,
and baccalaureate degree.

Licensed Practical Nurse Role (LPN)

 Scope of practice focuses on meeting basic patient needs in hospitals, long-term

care facilities, and homes.

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  Can take care of stable patients with predictable outcomes.
 Must practice under the supervision of a physician or registered nurse.
 Must be able to recognize and report changes in patient status.
 Assist with the following: data collection, planning strategies for patient care,
implementing nursing interventions, and evaluation of patient responses.
 Administer medications (varies with educational background and nurse practice
act) safely.
 Role focuses on technical skills, general knowledge, and judgment needed to
provide basic care to patients with commonly occurring medical conditions.
 Practical nursing programs typically lasts 12 months.

State Board of Nursing

o Actions, responsibilities, and authorities are defined by the Nurse Practice Act.
o Are responsible for enforcing the nurse practice acts in the various states.
o Approves individuals to take the license examination.
o Have the authority to deny, suspend, or revoke a license or to otherwise
discipline a licensee or to deny an application for licensure.

Licensure

 Purpose: Protects the public by protecting those who receive care

 Licensure is mandatory and identifies minimum competency.
A graduate is eligible to apply to take a national licensing examination.
Applicants (graduates) must successfully meet the requirements from an
approved school of nursing.
Is granted state by state.
 The license must be renewed every 2 years. In some states continuing education
is required to maintain licensure.
 NCLEX-PN or NCLEX-RN.
 The license and the right to practice nursing can be denied, revoked, and or
suspended for professional misconduct (e.g., incompetency, negligence,
chemical impairment, or criminal actions).

Communication: (Verbal, in writing, EHR)

Documentation

 Must be legible if documenting on paper. Never leave spaces in your charting.

 Must be consistent and accurate. Avoid discrepancies.
 Use only approved abbreviations.

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  Follow agency policies that related to documentation.
 Document in a professional and objective manner.
 Correct charting errors appropriately and according to agency policy
 Never document before the care is actually provided.
 Time entries for when they occurred

Delegation:

Five Rights of Delegation

 Right task: must be delegable for a specific patient. Remember nurse practice
act.
 Right circumstances: appropriate patient setting, available resources, etc.
 Right person: Delegating the right tasks to the right person (refer to job
description and experience)
 Right direction/communication: Clear, concise description of the task, including
its objective, limits, and expectations.
 Right level of supervision: appropriate monitoring, evaluation, intervention, as
needed and feedback

Effective Delegation

• Plan ahead
• Identify the skill or educational level necessary to complete the job.
• Identify the person best able.
• Clearly communicate what you want done.
• Set timelines.
• Evaluate the performance.
• Reward appropriate completion of tasks

Examples of Task that Can Be Delegated

 Answering phones
 Cleaning up after procedures
 Patient transportation (stable patients)
 Ordering some supplies and other clerical tasks.
 Stocking procedure and exam rooms.
 Assisting with some procedures
 Data collection without analysis (such as vital signs on stable patients, performing
ECGs, etc.)

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 Examples of Tasks that Cannot Delegated

Any task that involves nursing judgment or sophisticated application of the nursing
process.
Initial assessment on new patients.
Assessment to include unstable or potentially unstable patients.
Patient teaching
Evaluation
Establishing plans of care
Identifying patient needs
Triage
Counseling, teaching, disciplining and matters of confidentiality

Things to Remember When you Delegate

 You are responsible for what you delegate.

 Define the Task
 Match the task to the individual (skill level and abilities, experience, initiative,
intelligence, enthusiasm.
 Determine the importance of the task.
 Legality: Can the person legally perform the task?
 Provide clear instructions on what is to be done.
 Monitor the results
 Provide praise and thanks

Professional Values

 Aesthetics: qualities of objects, and people that provide satisfaction

 Adapts the environment so that it is pleasing to the patient.

 Creates a pleasant work environment for self and others.
 Presents self in a manner that promotes a positive image of nursing.

 Altruism: concern for the welfare and well-being of others. In professional practice, altruism is
reflected by the nurse’s concern for the welfare of patients, other nurses, and other healthcare
providers.

 Gives full attention to the patient when providing care.

 Assists other personnel in providing care when they are unable to do so.
 Expresses concern about social trends and issues that have implications for health care.
 Demonstrates understanding of cultures, beliefs, and perspectives of others.
 Advocates for patients, particularly the most vulnerable.
 Takes risks on behalf of patients and colleagues.
 Mentors other professionals.

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 Autonomy: the right to self-determination. Professional practice reflects autonomy when the
nurse respects patients’ rights to make decisions about their healthcare.

 Plans care in a partnership with patients.

 Honors the right of patients and families to make decisions about healthcare.
 Provides information so that patients can make informed choices.

 Equality: Having the same rights, privileges, or status

 Provides nursing care based on the patient’s needs irrespective of personal

characteristics.
 Interacts with other providers in a nondiscriminatory manner.
 Expresses ideas about the improvement of access to nursing and health care.

 Freedom: Capacity to exercise choice.

 Honors individual’s right to refuse treatment.

 Supports the rights of other providers to suggest alternatives to the plan of care.
 Encourages open discussion of controversial issues in the profession.

 Human Dignity: respect for the inherent worth and uniqueness of individuals and populations.
In professional practice, human dignity is reflected when the nurse values and respects all
patients and colleagues.

 Protects the patient’s privacy.

 Addresses others as they prefer to be addressed.
 Maintains/preserves the confidentiality of patients and healthcare providers.
 Treats others with respect regardless of background.
 Provides culturally competent and sensitive care.
 Designs care with sensitivity to individual patient needs.

 Integrity/Truth: acting in accordance with an appropriate code of ethics and accepted

standards of practice. Integrity is reflected in professional practice when the nurse is honest
and provides care based on an ethical framework that is accepted within the profession.
Faithful to fact and reality

 Provides honest information to patients and the public.

 Documents care accurately and honestly.
 Seeks to remedy errors made by self or others.

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  Demonstrates accountability for own actions.
 Obtains sufficient data to make sound judgments before reporting infractions of
organizational policies.
 Participates in professional efforts to protect the public from misinformation about
nursing.

 Justice: Upholding of moral and legal principles

 Acts as a healthcare advocate.

 Allocates resources fairly
 Reports incompetent, unethical, and illegal practice objectively and factually.

Principles of Ethical Reasoning

1. Form the basis for decision making

2. Involve focusing on moral duty. Do your moral duty.
3. Incorporate the professional values
4. Choosing to do that which you know to be your duty. Support prior
judgments about our moral responsibility.

Ethical Principles that Affect Decisions that Nurses make

 Beneficence: Principle of doing good. Doing actions that promote good and bring about
a benefit to someone.
 Nonmaleficence: the principle of doing no harm. It compliments beneficence.
 Paternalism: A person decides for someone else. The person believes that the decision
maker knows more about the situation and knows what is best. Is a less than desirable
principle.
 Utilitarianism: Ethical decisions are made according to the accomplishments of the
greatest good for the greatest number of people. It diminishes the needs of the
individual for the needs of the larger group of society. Is based on whether a decision is
useful to a small or to a larger number of people.
 Justice: Obligation to be fair. Assumes that everything is just, right, and fair. An
individual works hard to see that all personal behavior meets this criterion.
 Veracity: An obligation to tell the truth. Implies honesty, transparency, and
trustworthiness. Using this principle assumes others also are telling the truth.
 Fidelity: Keeping one’s promises or commitments (devotion and faithfulness). It requires
a high level of accountability.
 Autonomy: freedom of choice or accepting the responsibility for one’s choices; involves
the right of self-determination (the employee has the choice to meet organizational
expectations or be disciplined further.
 Respect for others: Highest level of performance of all ethical principles.

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Patient Bill of Rights:

Advocacy

Advanced Directives

Code of Ethics: A set of principles, established by a profession to guide the individual

practitioner. It guides our conduct.

Conflict/Workplace Violence: Incivility, mobbing, bullying, mistreatment or discourtesy,

workplace violence

Standards of Care:

• Is the minimal level of expertise that may be delivered to the patient. Standards
of care outline the level or degree of quality considered adequate by a given
profession. They can be found in the state nurse practice act, professional
organizations federal agency guidelines and regulations, hospital policy and
procedure manuals, nurse’s job descriptions.

• Each nurse is responsible for following standards of care for his or her area of
practice. Policy and procedure manual is one place that they are located. If ever
a question regarding care comes up in court, a lawyer will use the hospital’s
policy and procedure manual as one guide to expected behavior. Does not
overrule your state’s Nurse Practice Act.

Negligence: Conduct that falls below the standard of care established by law for the protection
of others and involves an unreasonable risk of harm to the patient. It is failure to do
something that a reasonably prudent person would do (an act of omission) or as doing
something that a reasonably prudent person would not do (an act of commission).
Failure to exercise the proper degree of care required by the circumstances.

Malpractice: Failure of a professional person to act as other prudent professionals with the
same knowledge and education would act under similar circumstances or failure of a
person with professional training to act in a reasonable and prudent manner.
Misconduct or lack of skill of a professional person. Also called professional negligence.

Elements of Malpractice:

Five elements must be present for a professional to be held liable for malpractice

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 o Duty: Obligation to use due care defined by the standard of care. A standard of
care must have been established that outlines the level or degree of quality
considered adequate by a given profession.
Foreseeability: It is a part of duty. It is knowledge or availability of information
that not meeting the standard of care could result in harm. The nurse must have
reasonable access to information about whether the possibility of harm exists.
Example: The drug handbook specifies that the wrong dosage or route may
cause injury. If a puddle of water on the floor, the nurse is responsible for
anticipating the risk of a patient fall.
o Breach of duty: Failure to meet the standard of care. Not giving the care that
should be given under the circumstances (Example failure to give medications
accurately, completely or on time). A breach is shown by calling other nurses
who practice in the same specialty area as the defendant to testify as expert
witnesses.
o Causation: A direct relationship between failure to meet the standard of care
(breach) and injury can be proved. The breach of duty caused harm, and the
nurse’s action or lack of action caused harm to the patient. Harm to the patient
was the result of the nurse’s actions. It is the most difficult to prove. Example:
Wrong dosage causes patient to have a convulsion.
o Injury: Actual Harm to the patient because of failure to meet the standards of
care. Example: Convulsion or other serious complication occurs.

Reduce Your Malpractice Risk

o Practice within the scope of the Nurse Practice Act

o Observe agency policies and procedures.
o Model practice after established standards by using evidence-based practice
o Always put patient rights and welfare first.
o Be aware of relevant law and legal doctrines and utilize rational nursing
decisions.
o Practice within the area of individual competence.
o Upgrade technical skills consistently by attending continuing education programs
and seeking specialty certification.
Malpractice Insurance.

 Nurses should purchase their own liability insurance

 Understand the limits
 Should protect the nurse from financial ruin if a malpractice claim occurs.

Student Responsibilities in Clinical Settings

 Must carefully prepare for each new clinical experience.

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  Notify the clinical instructor if unprepared to execute a nursing procedure.
 Do not attempt a clinical procedure if unsure of the correct steps involved.
 Must be familiar with agency policies and procedures.
 Must notify the instructor and licensed staff nurse of any significant changes in
the patient’s condition.
 If working as a nursing assistant in some other health care role the student can
legally offer only the services contained in their job description.

Student Responsibilities with Maintaining Patient Privacy

Keep patient information confidential

Don’t’ discuss patient information in non-private places
Completely log out of the computer when documentation is completed
Safeguard your computer access code.
Knock before entering a patient’s room
Close curtains, room doors, use linen to cover the patient during procedures that
require exposure of the patient’s body.

Malpractice Case

A four-month-old child, born at 34 weeks with birth problems of the GI system was on Total
Parenteral Nutrition (TPN) because of recent GI tract surgery and frequent infections. A nurse
was sent to the patient’s home to properly train the mother on administration of TPN
(connecting a Broviac catheter using a CAD pump). The nurse, who was holding the baby as the
mother did the connections, did not notice that the mother had improperly connected the line
before the air was "primed out". The mother was getting the air out of the line when the nurse
looked down and saw the TPN connected to the Broviac catheter. She immediately
disconnected the tubing. Air entered the child’s lungs. The mother took the baby and began
bouncing him. The nurse saw the baby’s eyes roll back into his head, took the baby, and told
the mother to call 9-1-1. The nurse said that the baby’s lips had turned blue and that he
became unresponsive, so she began CPR. The baby was taken to the hospital via ambulance
where he was put on a ventilator.

The child suffered extensive brain damage and experts predicted a life span of 18 years. Even
though the child had medical issues prior to the incident, the medical reports indicate that this
child’s neurological problems are solely a result of the improper connection, which put air
directly into the blood system of the baby resulting in an air embolism and stroke.

It is alleged that the nurse failed to properly monitor the procedure and is directly responsible
for this injury.

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Identify the Elements of Malpractice

 Duty owed
 Breach of duty
 Foreseeability
 Causation
 Injury
 Damages

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