Plan-Managing Self, as the Nurse and Client Care Class 8 November 4, 2009 Judith Anne Shaw, Ph.D., R.N.

Plan-Managing Delegation of Client Care –Standards for Nursing Practice –Communication Games Models of Care Delivery –Contemporary –Traditional Monitoring & Evaluating Quality of Care Quality Improvement Time Management

DELEGATION Know person’s capabilities Know job description

DELEGATION  Concept  Skill  Process  Art (Hansten & Jackson, 2004)

DELEGATION  Direct  Indirect

DIRECT DELEGATION Verbal Direction by the Registered Nurse

INDIRECT DELEGATION Approved list of activities or tasks established in policies and procedures within an agency

What is the Difference? Assignment vs. Delegation

Five Rights of Delegation 1.Right task 2.Right circumstances 3.Right person 4.Right direction/communication 5.Right supervision/evaluation

DELEGATION NURSING PROCESS CONCEPT

DELEGATION and the NURSING PROCESS 1.Assessment 2.Plan 3.Implementation/Intervention 4.Evaluation

Assessment  Know your world -Practice -Organization  Know yourself - Barriers - Benefits  Know your delegate - Competency - Motivation (Hansten & Jackson, 2004)

Plan  Know what needs to be done - Professional - Technical - Amenity - Based on outcome (Hansten & Jackson, 2004)

Implementation/Intervention  Prioritize &Match the Job to the Delegate  Know how to communicate  Know how to resolve conflict (Hansten & Jackson, 2004)

Evaluation Know how to give feedback Evaluate and problem solve (Hansten & Jackson, 2004)

Delegation Decisions Level of client acuity Level of unlicensed assistive personnel (UAP) capability Level of licensed nurse capability

Delegation Decisions Possible injury Times skill performed by unlicensed assistive personnel Level of decision-making needed for activity Client’s ability for self-care

Criteria for Safe Delegation Potential for harm to the client Complexity of problem solving and innovation required Predictability of the outcome Extent of interaction

GAMES …people may play

Organizational Game Karpman Triangle: –3 roles 1.Victim 2. Persecutor 3. Rescuer

Karpman Triangle PersecutorRescuer Victim *Participants move from one to another

Call The Game! Refuse to play any ofthe roles Give an adult response

Karpman Triangle PersecutorRescuer Victim *Participants move from one to another

Models of Care

Models …remember that a picture (even a word picture) is worth a thousand words

Traditional Models of Care Total Care Functional Team Modular Primary

Total Care Gains 1. Extremely client focused Losses 1. Not most efficient use of staff

Functional Care Delivery Gains 1. Efficient 2. Economical 3. Productive Losses 1. Fragmentation of care

Team Approach Gains 1. Holistic care 2. Increased client & employee satisfaction Losses 1. Time consuming 2. Expensive 3. May increase workload stress

Contemporary Challenge of the Team Approach AIM -Develop a group of individuals into a cohesive whole -Share goals, expectations, and behavioural norms by team members -Individual differences and contributions acknowledged -Develop and promote best practices

TEAMWORK WORKING TOGETHER

TYPES OF TEAMS Multidisciplinary Team Interdisciplinary Team Transdisciplinary Team

TEAM BUILDING CHALLENGE How to build a well-functioning team?

TEAM HIGH PERFORMANCE LEVELS Participative leadership Shared responsibility Aligned on purpose Strong communication Future-focused Focused on task Rapid Response

Modular Approach GainsLosses Located nearer. Use of the clientparaprofessionals Efficient. Dependent on skill of coordinator

Primary Care Gains 1. Decreases fragmented care 2. Increases accountability & client satisfaction Losses 1. Limits number of clients a nurse can provide care to- 2. Client may be in jeopardy

Mini-Nurse Manager Quiz Of the traditional models of Care Delivery, which model do you think optimizes the provision of quality client care? Provide explanation for your choice.

Contemporary Models of Care Delivery Case Management Client-Focused Product Line Management Differentiated Practice

Case Management Gains 1.Continuity of care 2. Efficient use of resources 3. Professional development & satisfaction 4. Holistic approach Losses 1. May be in jeopardy 2. Possibly, limited prepared staff

Client-Focused Care Gains 1. Possible increased client & staff satisfaction Losses 1. Possible staff dissatisfaction & stress 2. Institutional licensure 3. Quality of care giver

Product Line Management Gains 1. Cost effective 2. Potential for being more efficient 3. Allow nurses to provide direct care Losses 1. Potential of not focusing on client 2.Potential of not being able to adequately access client needs

Differentiated Practice Gains 1. Potential for nurse increased satisfaction 2. Potential for cost benefit for agency 3. Improved client care Losses 1. Potential for limited use of nurse who has higher competency skill level vs. educational preparation

Quality Client Care Monitoring & Evaluating

Structured Care Methodologies Guidelines Protocols Algorithms Standards of Care Critical (Clinical) Pathways

Critical Pathways Outgrowth of nursing care plan Multidisciplinary representatives Provides a communication & documentation framework

Critical Pathways Key Elements Discharge planning Consultations Activities Nutrition Medications Diagnostic Tests Treatments

Quality Improvement What to evaluate –Structure, process & outcomes Continuous quality improvement –Quality Circle at the Unit Level

What To Evaluate Three different aspects of health care

1.Structure: setting and resources 2. Process: actual activities “carried out” by the health care provider 3. Outcome: results of the activities THREE MUSTS Comprehensive Evaluation Program

Remember Outcome Measures -use measurable indicators (objective measures)

Continuous Quality Improvement Continuously improve the capability of involving everyone in providing quality care

Integration into All Aspects of Health Care Organization ContinuousTotalQuality ImprovementManagement

Total Quality Management [Unit Level] Assign Responsibilities Identify Vital Areas Define Scope of Care Analyze Area in Terms of: Aspects Standards Indicators Criteria Measure Actual Performance Measure Patient Outcomes Evaluate Performance and Outcomes Recommend and Implement Actions Evaluate Degree of Improvement

Quality Improvement at the Unit Level Quality Circle

Accreditation of Healthcare Organizations. Cost. Quality  the interest of consumers, healthcare payers, and healthcare providers.

Time Management Scheduling Time To What End?

Consider... It is not important how much activity can be packed into each day rather how much closer we get to achieving the desired results.

Ask yourself... “To what end” are you as keeper of your appointment book filling in the spaces? Catch a vision…a goal and work towards it!

Each day must --be planned with the end-result in mind!

Nurse Time 35%-direct client care 20%-documentation Remainder - “Other”

Nurses MUST Manage Time through effective time management skills.