This is difficult for several reasons:
1. Some nurses think they must do everything themselves.
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BOX 4–4
BASIC ENTITLEMENTS OF
INDIVIDUALS IN THE WORKPLACE Professionals in the workplace are entitled to:
❖
Respect from others in the work setting❖
A reasonable and equitable work- load❖
Wages commensurate with the job❖
Determine his or her own priorities❖
Ask for what he or she wants❖
Refuse without guilt❖
Make mistakes and be accountable for them❖
Give and receive information as a professional nurse❖
Act in the best interest of the client❖
Be humanSource: Adapted from Chevernet, M. (1988). STAT:
Special Techniques in Assertiveness Training for Women in Healthcare Professions(2nd ed). St Louis: Mosby.
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2. Some nurses distrust subordinates to do things correctly.
3. Some nurses think that if they delegate all the technical tasks, they will not reinforce their learning.
4. Some nurses are more comfortable with the technical aspects of client care than with the more complex issues of client teaching and discharge planning.
Families and clients do not always see profes- sional activities. They see direct client care.
Nurses believe that when they do not partici- pate directly in client care, they do not accom- plish anything for the client. The professional aspects of nursing, such as planning care, teaching, and discharge planning, help to pro- mote positive outcomes for clients and their families. Knowing the scope of practice of LPNs or vocational nurses helps in making delegation decisions.
CONCLUSION
The concept of delegation is not new. The del- egation role is essential to the RN/LPN and RN/UAP relationship. Personal organizational skills are a prerequisite for delegation. Before
the nurse can delegate tasks to others, he or she needs to understand individual client needs.
Using worksheets and Maslow’s hierarchy helps the nurse understand these individual client needs, set priorities, and identify which tasks can be delegated to others. Using the Delegation Decision-Making Grid assists the nurse in delegating safely and appropriately.
As the nurse, it is also important for you to be aware of the capabilities of each staff mem- ber, the tasks that may be delegated, and the tasks that the RN needs to perform. When delegating, the RN uses professional judgment in making decisions. Professional judgment is directed by the state nurse practice act and national standards of nursing. Institutions develop their own job descriptions for UAPs and other healthcare professionals, but insti- tutional policies cannot contradict the state nurse practice act. Although the nurse dele- gates the task or activity, he or she remains accountable for the delegation decision.
Understanding the concept of delegation helps the new nurse organize and prioritize client care. Knowing the staff and their capa- bilities simplifies delegation. Utilizing staff members’ capabilities creates a pleasant and productive working environment for everyone involved.
54 ❖ Essentials of Nursing Leadership and Management
S T U D Y Q U E S T I O N S
1. What are the responsibilities of the professional nurse when delegating tasks to an LPN or a CNA?
2. What factors do you need to consider when delegating tasks?
3. If you were the nurse manager, how would you have handled Laura’s situation?
4. How would you have handled the situation if you were Mary Ann?
5. Bring the client census from your assigned clinical unit to class. Using the Delegation Decision-Making Grid, decide which clients you would assign to the personnel on the unit. Give reasons for your decision.
C R I T I C A L T H I N K I N G E X E R C I S E
Steven works at a large teaching hospital in a major metropolitan area. This institution services the entire geographical region, including indigent clients, and because of its renowned reputation also administers care to international clients and individuals who reside in other states. Like all healthcare institutions, this one has been attempting to cut costs by using more UAPs. Nurses are often floated to other units. Lately, the numbers of indigent and foreign clients on
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R e f e r e n c e s
American Association of Critical Care Nurses (AACN).
(1990). Delegation of Nursing and Non-Nursing Activities in Critical Care: A Framework for Decision Making. Irvine, Calif.: AACN.
American Nurses Association (ANA) (1996). Registered Professional Nurses and Unlicensed Assistive Personnel.
Washington, D.C.: ANA.
Barter & Furmidge. (1994). Journal of Nursing Administration, 24(4), 36–40.
Conger, M. (1994). The nursing assignment decision grid:
Tool for delegation decision. Journal of Continuing Education in Nursing, 25(4), 21–27.
Habel, M. (2000). Delegating nursing care to unlicensed assistive personnel. Continuing Education for Florida Nurses 2001(pp. 39–54).
Hansten, R.I., & Washburn, M.J. (1998). National Council of State Boards of Nursing. (1990). Concept paper on delegation.Chicago: NCSBN.
Hayes, P. (1994). Non-nursing functions: Time for them to go. Nursing Economics, 12(3), 120–125.
Herrick, K., Hansten, R., O’Neill, L., Hayes, P., &
Washburn, M. (1994). My license is on the line: The art of delegation. Nursing Management, 25(2), 48–50.
Huber, D., Blegan, M., & McCloskey, J. (1994). Use of nursing assistants: Staff nurse opinions. Nursing Management, 25(5), 64–68.
Mahlmeister, L. (1999). Professional accountability and legal liability for the team leader and charge nurse.
JOGNN, 28, 300–309.
National Council of State Boards of Nursing. (1995).
Delegation: Concepts and decision-making process.
Issues(December), 1–2.
National Council of State Boards of Nursing (1997).
Delegation Decision-Making Grid. Chicago, Ill.:
National Council of State Boards of Nursing.
Nightingale, F. (1859). Notes on Nursing: What It Is and What It Is Not.London: Harrison and Sons. (Reprint 1992. Philadelphia: J. B. Lippincott.)
Parkman, C.A. (1996). Delegation: Are you doing it right? Am J Nurs, 96(2), 43–48.
Tappen, R., Weiss, S.A., & Whitehead, D.K. (1998).
Essentials of Leadership and Management.
Philadelphia, PA: F.A. Davis.
Zimmerman, P.G. (1996). Delegating to Assistive Personnel. J Emerg Nurs, 22, 206–212.
❖ Steven’s unit have increased. The acuity of these clients has been quite high, requiring a great deal of time from the nursing staff.
Steven arrived at work at 6:30 a.m., his usual time. He looked at the census board and discovered that the unit was filled, and bed control was calling all night to have clients discharged or transferred to make room for several clients who had been in the emergency department since the previous evening. He also discovered that the other RN assigned to his team called in sick. His team con- sists of himself, two UAPs, and an LPN who is shared by two teams. He has eight clients on his team: two need to be readied for surgery including preopera- tive and postoperative teaching, one of whom is a 35-year-old woman scheduled for a modified radical mastectomy for the treatment of breast cancer; three are second day post-ops, and two of these require extensive dressing changes, are receiving IV antibiotics, and need to be ambulated; one post-op client is required to remain on total bed rest, has a nasogastric tube to suction as well as a chest tube, is on TPN and lipids, needs a CVC line dressing change, has an IV, is tak- ing multiple IV medications, and has a Foley catheter; one client is ready for dis- charge and needs discharge instructions; and one client needs to be transferred to a subacute unit and report must be given to the RN of that unit. Once the latter client is transferred and the other one is discharged, the emergency department will be sending two clients to the unit for admission.
1. How should Steven organize his day? Set up an hourly schedule.
2. What type of client management approach should Steven consider in assigning staff appropriately?
3. If you were Steven, which clients and/or tasks would you assign to your staff? List all of them and explain your rationale.
4. Using the Delegation Decision-Making Grid, make staff and client assignments.
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57
Managing Client Care
O U T L I N E The Economic Climate in the
Healthcare System
Traditional Models of Care Delivery Total Care
Functional Team Primary Care
Contemporary Models of Care Delivery Case Management
Client-Focused Care
Product Line Management Differentiated Practice
Monitoring and Evaluating the Quality of Care
Quality Improvement
Aspects of Health Care to Evaluate Continuous Quality Improvement Quality Improvement at the Unit Level Conclusion
O B J E C T I V E S
After reading this chapter, the student should be able to:
• Describe the economic climate of the healthcare system.
• Compare and contrast the traditional and contemporary models of client care delivery.
• Discuss the role of the nurse in quality management.
• Discuss how continuous quality improvement methodology improves quality of care.
• Explain how a critical pathway can be used to measure patient outcomes.
C H A P T E R 5
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“All the results of good nursing, as detailed in these notes, may be spoiled or utterly negated by one defect, viz.: in petty management, or in other words, by not knowing how to manage.
. . . How few men, or even women, understand, either in great or in little things, . . . know how to carry out a ‘charge.’ To be ‘in charge’ is cer- tainly not only to carry out the proper measure yourself but to see that every one else does so too; to see that no one either willfully or igno- rantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appoint- ed” (Nightingale, 1859, pp. 20, 24).
Although Florence Nightingale wrote these words in the 1800s, they are still true today.
Major changes in our healthcare system are occurring as administrators in all types of agen- cies try to find the correct balance between
“lean and mean’’ efficiency and high-quality care (Sharp, 1994, p. 32). These efforts affect the way nursing care is delivered. The search for ways to provide safe, effective health care without spending too much money has led to the creation of new models for managing nurs- ing care.
This chapter will assist you in understanding and developing your role in the management of client care. The chapter begins by considering the economic context in which health care is provided. A review of the past, present, and future models for managing nursing care is pre- sented next. This includes the traditional models of total care, primary care, functional care, and team care. The contemporary use of case man- agement, the multidisciplinary team approach, product line management, and differentiated practice complete this section. This is followed by a discussion of the ways in which the quality of the care given is monitored and evaluated.