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

2. 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

3. DELEGATION Know person’s capabilities Know job description

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

5. DELEGATION  Direct  Indirect

6. DIRECT DELEGATION Verbal Direction by the Registered Nurse

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

8. What is the Difference? Assignment vs. Delegation

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

10. DELEGATION NURSING PROCESS CONCEPT

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

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

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

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

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

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

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

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

19. GAMES …people may play

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

21. Karpman Triangle PersecutorRescuer Victim *Participants move from one to another

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

23. Karpman Triangle PersecutorRescuer Victim *Participants move from one to another

24. Models of Care

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

26. Traditional Models of Care Total Care Functional Team Modular Primary

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

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

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

30. 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

31. TEAMWORK WORKING TOGETHER

32. TYPES OF TEAMS Multidisciplinary Team Interdisciplinary Team Transdisciplinary Team

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

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

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

36. 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

37. 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.

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

39. 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

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

41. 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

42. 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

43. Quality Client Care Monitoring & Evaluating

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

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

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

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

48. What To Evaluate Three different aspects of health care

49. 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

50. Remember Outcome Measures -use measurable indicators (objective measures)

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

52. Integration into All Aspects of Health Care Organization ContinuousTotalQuality ImprovementManagement

53. 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

54. Quality Improvement at the Unit Level Quality Circle

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

56. Time Management Scheduling Time ----- To What End?

57. 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.

58. 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!

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

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

61. Nurses MUST Manage Time through effective time management skills.