Chapter 8 Managing client care

Patricia Mary Davidson, Louise Hickman

KEY TERMS

Accountability

Chronic care

Clinical outcomes

Clinical pathways

Clinical practice guidelines

Complexity

Evidence-based practice

Models of nursing care

Nursing-sensitive indicators

Patient/client safety

Positive practice environments

Quality of care

Registered nurse

Self-care

Self-management

Teamwork

LEARNING OUTCOMES

Mastery of content will enable you to:

• Define significant approaches to managing nursing care.

• Identify the attributes of a model of nursing care and what the key factors are in delivering nursing care.

• Describe and appreciate the legal, policy and regulatory frameworks influencing the context of nursing practice.

• Discuss models of nursing care which allow nurses to function in a professional, autonomous and accountable manner.

• Describe key approaches to delivering nursing care, including client-centred care, primary care and team-based approaches.

• Acknowledge the importance of recognising the scope of nursing practice and the levels of competency required to manage nursing care.

• Identify the importance of tailoring models of nursing care delivery to address the similarities and differences in patient/client/family experiences.

• Understand the importance of an evidence-based approach to managing client care.

• Discuss ways to apply strategies to promote client autonomy and promote self-management.

• Review the unique role of nurses in the interdisciplinary care team.

• Understand and demonstrate how nursing care contributes to clinical and organisational outcomes in the healthcare setting.

• Appreciate the nurse’s role in managing and coordinating care.

• Describe the importance of leadership in the clinical setting.

• Illustrate how the quality improvement process can promote optimal client outcomes and model of care development.

• Appreciate the importance of developing and monitoring nursing-sensitive patient outcome measures.

Nurses comprise over half of the healthcare workforce, and therefore contribute significantly to improving outcomes of patient care. Globally, healthcare systems are challenged by a range of factors, including workforce shortages, ageing populations, increasing rates of chronic conditions and escalating health inequities (Rechel and others, 2009). Yet, in spite of these challenges nurses have never before been equipped with such a robust body of research and scholarship to inform their practice. Although there is an increasing diversity of professionals in the healthcare setting, nurses are responsible for the greatest proportion of client care and are often required to coordinate that care. As a consequence, nurses are driving a range of healthcare reforms through innovative care delivery models, such as using link nurses in palliative care settings to improve cross-sector collaboration between primary, secondary and tertiary care (McIlfatrick and others, 2010). Nurses in contemporary healthcare systems are at the forefront of planning and managing care, directing the agenda of healthcare delivery in the policy setting as well as managing and delivering care in the preventive, acute, community and residential care settings.

Key overarching principles inform a nursing approach to care delivery. These principles include ensuring that models of care:

• are fiscally responsible, using resources such as people, facilities, equipment and time, appropriately and efficiently

• are informed by the best available evidence derived from high-quality patient-centred research and clinical guidelines endorsed by peak bodies

• promote a wellness model focusing on the health and wellbeing of the wider community

• promote autonomy of the individual and engage in activities to promote self-care

• tailor processes and desired outcomes to meet the unique needs of clients and their families

• are mindful of the unique role of nursing in the interdisciplinary team

• are culturally safe and appropriate and tailor care for culturally and linguistically diverse populations

• foster both independent and collaborative nursing practice, where nurses both initiate and evaluate nursing therapies and interventions and also work with other healthcare providers to achieve optimal outcomes

• are directed at promoting optimal client and organisational outcomes (Davidson and others, 2006).

Internationally, healthcare systems are looking at a range of reforms to address the increasing demands for healthcare and the need to decrease health disparities. In Australia the National Health and Hospital Reforms Commission (NHHRC) has prioritised better delivery of care as a goal of strategic health reform (Betihavas and others, 2011). In the United States, an recent collaboration between the Institute of Medicine and the Robert Wood Johnson Foundation, The future of nursing: leading change, advancing health, lays an important framework for developing nursing into the future (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011). This report recommends that nurses should be enabled to practise to the full extent of their education and training; achieve higher levels of education and training through an improved education system; be full partners, with doctors and other healthcare professionals, in healthcare reform; and engage in workforce planning and policy development based upon high-quality data. These recommendations are salient for managing client care internationally.

Evidence to inform nursing practice

Evidence-based practice is essential in optimising patients’ health outcomes and strategically allocating finite health resources. Adopting an evidence-based practice approach to care ensures that optimal clinical decisions are made, based on the best available research evidence, clinician expertise and patient/community preferences (Sackett and others, 1996). Nurses are in a unique position to make a significant difference to health outcomes for a broad range of individuals and communities by providing care in accordance with the best available evidence.

Contemporary approaches to managing client care are driven by evidence-based practice and a strong foundation of nursing scholarship. Innovative nursing research is driving clinical practice and defining the importance of nursing in both independent and collaborative practice settings. The research highlight opposite describes the findings of a systematic review of studies using telemonitoring and structured telephone support demonstrating the capacity to deliver specialised management to more patients with chronic heart failure (CHF). These initiatives are most commonly performed by nurses and have the potential to reduce health disparities by increasing access to support for self-management (Inglis and others, 2011). In regions of Australia where there are challenges in accessing healthcare professionals, such approaches may be advantageous.

The pressures facing healthcare systems also require nurses to respond effectively and appropriately to challenges such as skill-mix diversification and increasing financial pressures. Effective models of nursing care, a strong research base for practice and positive practice environments promoting quality, safety and clinical leadership are important drivers in promoting optimal client care and improving the working life of nurses. For example, the increased importance of the nursing role in primary care, particularly general practice, has led to an exponential rise in research internationally (Patterson and McMurray, 2011). However it is also important to be mindful of consumers’ views in developing innovative approaches and role substitution (Halcomb, 2011). For example, it may take consumers time to access nursing providers when they are accustomed to medical clinicians. In order to achieve role clarity for both healthcare consumers and other healthcare professionals, we need to work for an increased standardisation of titles (Duffield and others, 2011).

RESEARCH HIGHLIGHT

Research focus

Chronic heart failure is a condition responsible for significant burden to the individual, the healthcare system and society and is largely driven by population ageing. Increasing access and decreasing health disparities is an important consideration. Developing appropriate strategies in an important focus of health care planning.

Research abstract

These authors analysed 25 studies (9500 patients) using the method of a systematic review. Telemonitoring and structured telephone support appear to lead to benefits for patients with chronic heart failure particularly in decreasing rates of hospitalisation.

Evidence-based practice

Supporting individuals with telemonitoring and structured telephone support interventions has the potential to improve self-management improves health outcomes.

Reference

Inglis SC, Clark RA, McAlister FA, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. (8):2010. CD007228.

• CRITICAL THINKING

Consider using the model of critical thinking for case studies presented in this chapter and for your next clinical placement. Take time to reflect on your own working style:

1. How will you build confidence in questioning those in authority respectfully and collegially?

2. Using due process, how will you communicate change supported by the evidence so it can be translated into practice?

Remember, for many of us our greatest strengths are also our greatest weaknesses. Many of us go into nursing because we are passionate about improving patient care and are adamant about being patient advocates. However, an argument positioned by evidence and a strong rationale and data is much more likely to be effective than an emotive outburst. Think about your personal communication style and seek critical feedback from mentors and colleagues.

Preparing for complexity

The student nurse needs to develop and consolidate skills to develop, plan, implement and evaluate nursing care within complex and dynamic healthcare delivery systems. Importantly, this involves the capacity to access credible population data and evidence of effective clinical interventions. It is also important to recognise that nursing practice is undertaken in complex social, political and economic environments. For example, regulatory frameworks and policies determine the amount of resources allocated to healthcare services and also the level of nursing skill mix (Sochalski and others, 2009). For example, issues such as nurse-prescribing are strongly linked to regulatory frameworks (Dunn and others, 2010). As a consequence of regulatory frameworks and models of funding and reimbursement, these are critical factors in planning, managing and evaluating approaches to client care. Being aware of factors external to nursing practice and developing skills for addressing these issues as a student nurse will lay a strong foundation for developing as an effective nurse clinician, administrator, educator and researcher.

When planning a new nursing initiative, there are a number of factors that need to be considered. These include:

• Developing a business case which includes costing factors such as staffing and equipment. A business case also involves examining the strengths, weaknesses, opportunities and threats of a planned approach to managing client care. For example, a nurse undertaking a home visit in the community needs to be mindful of safety risks; introducing innovative strategies for pressure ulcer management may require additional expenditure for pressure-relieving devices.

• Demonstrating that nursing activities are conducted within professional, legal, regulatory and ethical frameworks. For example, nurses can only work within their scope of practice. When developing a model of care, nurses need to be mindful that they work within frameworks approved by regulatory and professional bodies.

• Considering how nursing initiatives affect other healthcare professionals. For example, an accelerated discharge plan may need the cooperation and collaboration of pharmacists, resident medical officers and administrative staff, general practitioners and community health teams.

• Undertaking client care within a context of acceptable community standards and within a framework of cultural competence. For example, some cultural groups may not find it acceptable to have both men and women in the same ward or exercising together in cardiac rehabilitation settings (Davidson and others, 2010).

Chronic care

Population ageing requires that healthcare services be configured to meet the needs of older persons within the acute care hospital environment. The Chronic Care Model (CCM) developed by Wagner (Coleman and others, 2009; Epping-Jordan and others, 2004) has been used by the World Health Organization (WHO) for the development of the Innovative Care for Chronic Conditions (ICCC) framework. The WHO has promulgated the CCM as an organising conceptual framework for the development and delivery of integrated care for community healthcare organisations and other healthcare organisations. This aims to strengthen partnerships, policy, advocacy, consistent financing, and allocation of resources across sectors (Hickman and others, 2010). Through using a person-centred care approach, nurses can empower people and communities to be active in their healthcare journey, engage them in self-management strategies and promote adherence. This approach also requires nurses to be active in communicating across healthcare providers and services (Berra and others, 2011).

Positive practice environments

Positive practice environments are endorsed by the International Council of Nurses (2011). Positive practice environments are characterised by supporting excellence, striving to ensure the health, safety and personal wellbeing of staff, supporting high-quality client care as well as enhancing motivation, productivity and performance of individuals (Eaton-Spiva and others, 2010). The characteristics associated with positive practice environments are shown in Box 8-1. These factors underscore the importance of policy, regulatory, legal and ethical frameworks that provide a strong foundation for healthcare delivery. They also emphasise the importance of quality improvement and reflective practice. In Australia, universal healthcare coverage is an important driver for ensuring optimal health outcomes, as it promotes models of care that are accessible and equitable. This allows the development of models of nursing care that promote continuity and coordination of care delivery.

BOX 8-1 ELEMENTS OF POSITIVE PRACTICE ENVIRONMENTS

• Occupational health, safety and wellness policies that address workplace hazards, discrimination, physical and psychological violence and issues pertaining to personal security

• Fair and manageable workloads and job demands/stress

• Organisational climate reflective of effective management and leadership practices, good peer support, worker participation in decision making, shared values

• Healthy work–life balance

• Equal opportunity and treatment

• Opportunities for professional development and career advancement

• Professional identity, autonomy and control over practice

• Job security

• Decent pay and benefits

• Safe staffing levels, recruitment and retention

• Support, supervision and a safe working environment

• Open communication and transparency

• Recognition programs

• Access to adequate equipment, supplies and support staff

From International Council of Nurses, available at www.icn.ch/matters_ppe.htm, under Human resources, planning and development, 11 July 2011.

The diversity and skill mix of the healthcare team, including nursing roles, is rapidly changing. This makes it important to consider the attributes, scope of practice and key competencies of nursing roles. The work undertaken by nursing assistants is vastly different to that of the registered nurse (RN). Allocated responsibilities and activities are commensurate with level of education and level of responsibility for client care. Increasingly, the role of the RN is to engage in clinical decision making, planning and coordination of care. This set of skills goes beyond advanced clinical knowledge; it includes communicating, delegating and coordinating, as well as promoting cohesion and collaboration between an increasing number of healthcare and social services. This requires that the nurse commit not only to acquiring clinical knowledge and skills, but also to engaging in personal development strategies to enable effective and active participation in the healthcare team. This entails using strategies such as appreciative inquiry, which promotes a manner of reflective review, to promote positive relationships and build on the organisation’s capacity for collaboration and change through critically evaluating activities and building upon strengths and capacities (Kavanagh and others, 2010). As you move through your nursing career, it will be important to find positive practice environments and also recognise your individual contribution to making these supportive and enabling environments.

Nurses are expected to engage in client interactions in a manner that, both personally and professionally, will maintain public trust and confidence in the profession. Nurses have a responsibility to the individual, society and the profession to provide safe and competent nursing care. Professional behaviour is based upon principles of accountability (ultimate responsibility), autonomy, promoting trust among clients, monitoring of professional standards and scope of practice, observing ethical principles, taking personal responsibility for professional competence and adhering to accepted codes of practice (see Box 8-2).

BOX 8-2 CODE OF PROFESSIONAL CONDUCT FOR NURSES IN AUSTRALIA

1. Nurses practise in a safe and competent manner.

2. Nurses practise in accordance with the standards of the profession and broader health system.

3. Nurses practise and conduct themselves in accordance with laws relevant to the profession and practice of nursing.

4. Nurses respect the dignity, culture, ethnicity, values and beliefs of people receiving care and treatment, and of their colleagues.

5. Nurses treat personal information obtained in a professional capacity as private and confidential.

6. Nurses provide impartial, honest and accurate information in relation to nursing care and health care products.

7. Nurses support the health, wellbeing and informed decision making of people requiring or receiving care.

8. Nurses promote and preserve the trust and privilege inherent in the relationship between nurses and people receiving care.

9. Nurses maintain and build on the community’s trust and confidence in the nursing profession.

10. Nurses practise nursing effectively and ethically.

From Nursing and Midwifery Board of Australia 2008 Code of professional conduct for nurses in Australia. Online. Available at www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx, 26 Mar 2012.

The Australian Nursing and Midwifery Accreditation Council (ANMAC) is the independent accrediting authority for nursing and midwifery under the National Registration and Accreditation Scheme, and determines standards for accreditation and accredits nursing and midwifery courses and providers. Nurses are also required to work within an ethical framework that reflects the prevailing social mores and legal context of Australian society. A breach of this code may constitute professional misconduct or unprofessional conduct. It is useful to reflect upon the premises of professional practice and what distinguishes the RN role from other providers of nursing care. Exploring the boundaries of professional practice of nursing roles will allow you to identify the skills and attributes of RNs and the factors which contribute to professional status and the associated accountabilities.

The role of the registered nurse

As you develop as a nursing professional, you need a clear understanding of how the role and responsibilities of the RN contribute to professional status. For example, key elements distinguishing the RN role from the enrolled nurse (EN) role are the capacity for the RN to be responsible for independent practice and the potential to plan and scope clinical care. All tiers of nursing are critical in developing clinical care; it is important that you obtain a clear understanding of the role and scope of each designation of nurse in the contemporary healthcare system.

The Nursing and Midwifery Board of Australia (NMBA) is the peak national nursing and midwifery organisation; this Boards sits within the Australian Health Practitioner Regulation Agency (AHPRA) established in July 2010. In consultation with state and territory nursing and midwifery regulatory authorities, the NMBA strives to develop a national approach to nursing and midwifery professional standards. As part of this process, national competency standards have been developed to ensure safe and effective care. Registered nurses provide care in a wide range of settings, such as acute care, community, residential and extended-care settings, homes, educational institutions or other work settings. Care provided across these settings needs to be tailored and modified according to the practice setting and model of care delivery. Importantly, the NMBA advocates that professional practice should be planned and evaluated within a context that considers societal and epidemiological trends in health and illness (Australian Health Practitioner Regulation Agency, 2011).

The RN should:

• demonstrate competence in providing nursing care, as specified by the registering authority’s licence to practise, educational preparation, relevant legislation, standards and codes and context of care

• practise independently and interdependently assuming accountability and responsibility for their own actions

• delegate aspects of client care to ENs and health workers, considering their educational preparation and the context of care

• monitor and evaluate aspects of client care delegated to other nurses and healthcare professionals

• provide evidence-based nursing care to people of all ages and cultural groups, including individuals, families and communities

• promote and maintain health and prevention of illness for individuals with physical or mental illness, disabilities and/or rehabilitation needs

• provide effective, appropriate, ethical and acceptable palliative care at the end of life

• assess, plan, implement and evaluate nursing care in collaboration with the client and the multidisciplinary healthcare team so as to achieve goals and health outcomes

• recognise that ethnicity, culture, gender, spiritual values, sexuality, age, disability and economic and social factors affect an individual’s responses and beliefs about health and illness, and plan and modify nursing care appropriately

• assume a leadership role in the coordination of nursing and healthcare within and across different care contexts to facilitate optimal health outcomes

• contribute to high-quality healthcare through promoting a culture of lifelong learning and professional commitment to nursing research, clinical supervision and development of policy and clinical practice guidelines.

• CRITICAL THINKING

Tamara, a newly registered nurse, is working in a small regional hospital in the coronary care unit. A client she is caring for is suffering central chest pain and is diaphoretic. Tamara administers glyceryl trinitrate and performs a 12-lead electrocardiogram which shows ST-segment elevation across the anterior leads. She suspects that the client is suffering from an acute myocardial infarction and calls the medical officer on duty. After Tamara has related the information, the medical officer asks her to administer a bolus dose of thrombolytic therapy. She is certain this is beyond her scope of practice and tells the medical officer so. He becomes irate and argumentative.

1. What would you do in Tamara’s case?

2. Who would you contact to seek support and clarification?

3. How would you communicate with the medical officer in a collegial and professional manner?

Box 8-3 describes the core competencies of the RN. Greater detail and updates due in 2012 are provided on the NMBA website (see Online resources). You should take the time to familiarise yourself with these competencies. As a student nurse, these competencies should shape your professional goals and crystallise what the expectations will be of you when you enter the workplace. Although the list may be daunting, remember that nursing is a collegial profession where there is a strong emphasis on an integrated and collaborative approach to delivering nursing services. As a consequence, there are many people to help you in your professional journey, including clinical nurse educators, clinical nurse consultants nursing practitioners and medical and allied health colleagues.

BOX 8-3 NATIONAL COMPETENCY STANDARDS FOR THE REGISTERED NURSE IN AUSTRALIA

PROFESSIONAL PRACTICE

This relates to the professional, legal and ethical responsibilities which require demonstration of a satisfactory knowledge base, accountability for practice, functioning in accordance with legislation affecting nursing and healthcare, and the protection of individual and group rights.

CRITICAL THINKING AND ANALYSIS

This relates to self-appraisal, professional development, and the value of evidence and research for practice. Reflecting on practice, feelings and beliefs and the consequences of these for individuals/groups is an important professional benchmark.

PROVISION AND COORDINATION OF CARE

This domain relates to the coordination, organisation and provision of nursing care that includes the assessment of individuals/groups, planning, implementation and evaluation of care.

COLLABORATIVE AND THERAPEUTIC PRACTICE

This relates to establishing, sustaining and concluding professional relationships with individuals/groups. This also contains those competencies that relate to the nurse understanding their contribution to the interdisciplinary healthcare team.

From Nursing and Midwifery Board of Australia 2006 National competency standards for the registered nurse. Online. Available at www.nursingmidwiferyboard.gov.au/Codes-and-Guidelines.aspx#competencystandards, 13 Jul 2011.

In New Zealand, the Nursing Council of New Zealand is the statutory body governing the practice of nurses that also monitors the standards of practice (Nursing Council of New Zealand, 2007).

Models of nursing care

Nursing care is provided in a range of settings and contexts. The way in which care is planned, delivered and evaluated should be based upon a prospective plan or template appropriate to the care setting, which can also be known as a model of nursing care.

Models are tools that are a standard for comparison, describing the relationship of concepts (Davidson and others, 2006). In nursing, models should be dependent on the needs of the client group, the scope and skills of the nursing workforce and anticipated health outcomes. In parallel with international trends, the Australian healthcare system faces workforce shortages with increasing pressure on the acute care sector. These factors are compelling nurses to explore innovative approaches to care delivery. Nursing and nursing models should be flexible and responsive to the needs of clients and the healthcare system. Nurses can work independently, such as in the nurse practitioner role; dependently based on delegation, such as in the general practice setting; interchangeably, as in the doctor assistant role; and collaboratively, such as in nurse-coordinated models of care. These approaches challenge traditionally hierarchical approaches and functional models of care, and have provoked discussion and debate surrounding the benefits and disadvantages of approaches to models of nursing care.

Describing a model of care provides a structure for nurses to systematically plan, deliver and evaluate client care (Davidson and others, 2006). This structure should become the blueprint to scope and plan care delivery. It is therefore important for nurses to appreciate the conceptual underpinnings and goals of a nursing model of care. For example, what does client-focused care mean, and how can nurses measure and evaluate these goals? As the diversification of the workforce increases, along with acknowledgement of the importance of interdisciplinary care, the importance of team work is underscored (Hobgood and others, 2010).

Models of nursing care promoting wellness, autonomy and self-care

Contemporary models of nursing care should be culturally sensitive, flexible, focusing on collaborating with clients and meeting their needs (Banner and others, 2010). This is in contrast to traditional nursing models of care, such as functional nursing, which can be inflexible and prescriptive. Key goals of nursing models of care should be to promote independence and wellness. Pivotal to promoting client independence and autonomy is engagement in activities which promote self-care. Self-care refers to the activities that an individual undertakes to manage their condition. This can include taking medications, performing activities of daily living (ADLs) and having strategies for monitoring their condition. Self-management embraces the concepts of self-care, but also refers to a broader set of knowledge, skills, attitudes and beliefs that prepares the individual to interact collaboratively with healthcare professionals, including nurses, to achieve negotiated goals (Riegel and others, 2009). As a consequence, it may be advisable to work with clients to develop and assess their competency in undertaking self-management tasks, such as daily weights, rather than doing these tasks for patients.

Nurses need the necessary skills to be culturally sensitive to the needs of individuals and their families, and they need to engage in strategies for supporting belief in the individual’s ability to learn self-management skills. In the clinical setting, nurses need to empower clients to be independent and undertake monitoring of their own condition. For example, a client with diabetes should undertake the monitoring of their blood sugar levels and be encouraged to discuss appropriate strategies in response to these readings.

Migration and globalisation are defining characteristics of the contemporary world, and countries such as Australia and New Zealand have a rich and diverse cultural mix. As health and illness behaviours are embedded in culture and ethnicity, it is important that nurses approach client care with a context of cultural competence. The terms ‘culture’ and ‘ethnicity’ both refer to combinations of socioeconomic, religious and political qualities of human groups, including language, diet, dress, customs, kinship systems and historical or territorial identity, whereas ‘competence’ implies having the capacity to function effectively (Davidson and others, 2010). A failure to respect and address these factors can result in marginalisation and potentially adverse health outcomes for clients. It is also important to consider that sometimes adverse behaviours can actually be labelled as racist (Durey, 2010).

As part of becoming culturally competent practitioners, nurses need to be aware of their own beliefs and attitudes about ethnic minorities in order not to impose them on clients. In addition, the nurse needs to understand the worldview of the client and their family without judging them, and to use culturally competent skills when interacting with ethnically diverse clients and groups. Key factors in developing culturally competent models of care include administration and leadership; policy making and governing boards; clinical standards and guidelines; and an effective vision and mission to drive organisational priorities. As discussed above, positive policy environments that prime the practice setting for respect and reciprocity are pivotal in achieving optimal health-related outcomes.

Although particular settings drive characteristics of models of nursing care, generic principles that underpin the shaping of care delivery need to incorporate interventions and strategies for:

• promoting clients’ understanding of their clinical condition, treatment plan and anticipated trajectory of their condition

• developing clients’ skills and opportunities necessary for negotiating and following a care plan in partnership with their healthcare professionals

• providing resources and knowledge for clients monitoring and managing the signs and symptoms of their condition

• encouraging clients to adopt lifestyles that promote risk-factor modification and focus on prevention and early intervention to promote health and wellbeing

• increasing client access to support services, including social and financial support.

Within Australia and New Zealand, addressing the health disparities of the indigenous peoples are important considerations in developing and evaluating nursing and midwifery models of care (Thompson and others, 2011). It is important to ensure that clinical environments are culturally safe and welcoming for indigenous peoples (Browne and others, 2009).

Building a nursing team

A range of descriptors have been applied to nursing care models. Regardless of the term used to describe the approach to nursing care, nurses work in a multidisciplinary milieu and the nursing role cannot be considered externally to the roles of other healthcare professionals and overarching drivers affecting the healthcare system, such as financial constraints.

Teamwork is seen when a group of people contribute their knowledge and skills and work together to achieve a common goal/task. The complexity of contemporary healthcare demands effective teamwork, and it is important that healthcare professionals contribute to the work of their teams (Pearce and others, 2011). A team can be described as a group of people with a range of experiences and skills who have come together with a common purpose. It is the common purpose or goal that defines this group as a team. More importantly, people have to work together to achieve this goal; there is an assumption that the contribution and input of a group of individuals is more beneficial than the contribution of the individuals alone. In addition, the more tangible and measurable the team goal, the more effective the team is likely to be. Defining measurable goals has led to a range of clinical improvements through the use of collaborative methodology. Collaborative methodology is a method of driving improvements in clinical care by closing the gap between what is known and what is practised. Collaborative methodology uses a continuous improvement cycle to bring about small, rapid changes that create a larger change within the system over a finite period, by using change management principles and evidence-based goals and targets. This method is being used increasingly in Australia and internationally to drive quality improvement. For example, 16 acute adult mental health inpatient services across Queensland have worked together to develop clinical indicators related to the inpatient treatment of schizophrenia (Plever and others, 2010).

Goals of practice that do not provide effective and tangible goals for planning, delivering and evaluating care are likely to be inadequate. In the instance where constructs are poorly defined, they can have a range of meanings for different people. A more appropriate way of negotiating a goal is to make it measurable. For example, a goal of care could be to deliver care in accordance with best-practice guidelines with assessable outcomes, such as the proportion of people admitted to hospital with a stroke who are assessed for their ability to swallow, or the proportion of women who have a vaginal delivery as compared with caesarean section. These examples show that client outcomes are often dependent on the role of nurses in the broader healthcare system.

For the most part, nurses deliver care in complex and dynamic circumstances, in collaboration with health and social service providers, as well as with family members and caregivers. Teams do not occur spontaneously but are grown and developed and nurtured by positive practice environments and effective managers and leaders. A range of factors contribute to developing an effective team, and many of these factors are dependent on the aptitudes and capabilities of clinical leaders. Some of the characteristics of effective teams and leaders include:

• negotiating goals and intended outcomes of nursing interventions

• leading by inspiring, enabling and motivating rather than dominating

• communicating effectively strategies and processes for sharing information

• clarifying the roles, responsibilities and accountability of team members

• collaborating and seeking external opinion and expertise

• reflecting regularly on team progress and how this relates to the team goals

• taking the time to celebrate successes and support each other when things are not going well.

Effective teams are supported by the International Council of Nurses recommendations for positive practice environments as described in Box 8-1. As discussed in Box 8-1, factors affecting a positive practice environment include:

• leadership and support at all levels along the healthcare spectrum

• effective formal and informal communication processes that are transparent

• participation in decision making regarding clients and organisational decision making in respect of clinical care delivery models

• promoting of a safe work environment that provides adequate education and opportunity for personal and professional development and recognition of achievements

• implementation and monitoring of equitable and manageable workloads.

Regardless of the approach to nursing care, nurses work within an interdisciplinary context and are subject to a range of internal and external factors. Examples of internal factors include the organisation’s approach to management, while external factors can include funding and staff-mix models prescribed by government bodies.

Approaches to delivering nursing care

A range of nursing models have been used to describe the organisation of nursing care. Yet it is important to recognise that many models implemented in the clinical setting are actually hybrid approaches; that is, they incorporate a range of elements from different models. Increasingly, in clinical environments nurses are required to be flexible and responsive to policy demands and changes (Fairbrother and others, 2010). Dynamic staff mix and acuity of case-mix mean that various models can be used interchangeably, depending on the needs of the clinical setting and staffing arrangements in place. The key approaches to providing nursing care are described below. Table 8-1 summarises the strengths and limitations of each of these approaches. As you review each of these nursing models, consider which clinical environments these approaches will be most applicable to in the care settings that you have been exposed to. Take the time to reflect on your clinical experiences to date and categorise the approaches to client care in these settings, and consider whether the approach used was optimal to the clinical setting and client’s needs.

TABLE 8-1 STRENGTHS AND LIMITATIONS OF NURSING APPROACHES TO CARE DELIVERY

MODEL OF NURSING CARE DELIVERY STRENGTHS LIMITATIONS
Functional nursing

Nurses become proficient in a designated task

Potential for efficiencies in time management

Lack of an integrated approach to care management

Client needs subsumed in organisational demands
Team nursing

Accommodates a range of skill mix and scopes of practice

Allows for a collaborative approach and uses a range of expertise

Less registered nurse (RN) involvement may impact adversely on client outcomes

Dependent on high-level organisational, delegation and coordination skills of the RN
Total patient care

High level of coordination of care

Access to high-level clinical skills and decision making

Increased costs associated with high numbers of RNs

Decreased capacity for skill development in more junior members of the nursing team
Primary nursing

Strongly client-centred model of care promoting autonomous decision making

Promotes continuity of care and interdisciplinary communication

Efficacy of the model dependent on the quality of the care plan and communication within the healthcare team

Greater dependence on RN models of care

Potential for role burden for the RN
Case management

Promotes continuity of care

Optimal for clients with chronic and complex care needs

Creates a point of contact for clients and the healthcare team

Need for communication structures such as regular team meetings which can be time-consuming

Dependent on coordinating and communication skills of case manager

Team nursing

The team nursing approach is based on using nurses with a range of skill mix and scopes of practice. For example, assistants in nursing, ENs and RNs work under the leadership and coordination of the RN. Ideally, in this model nurses are assigned client-based tasks, based upon assessment of the needs of the individual and the clinical area. This approach is often undertaken in acute care hospitals and residential aged care.

Total patient care

In a total patient care approach, the RN retains overall responsibility for the client, working collaboratively with other team members to coordinate clinical care. The RN may delegate elements of clinical care to other members of the healthcare team, but retains overall responsibility and accountability of care. Adequate staffing models of RNs are necessary for this approach.

Functional nursing

In a functional nursing model, nursing workload is based upon task allocation where nurses exclusively perform a designated task, such as medication administration for a range of patients. These tasks are traditionally assigned by the nurse coordinating the shift. The appropriateness and relevance of functional nursing models is dependent on the nursing skill mix, patient acuity and complexity and scope of practice of nursing tasks.

Primary care nursing

The primary care nursing model designates an RN’s responsibility for a set of clients over a designated period, such as an episode of care. Based on a comprehensive and holistic assessment, the RN develops a care plan (see Chapter 7). When the primary-care RN is off duty, the plans are continued by associate nurses. There is scope to negotiate care plans within the broader healthcare team. A primary care nursing model is often applicable to the community nursing sector.

Case management

Relying on a comprehensive assessment and expert knowledge of the clinical situation, the RN liaises with health and social service professionals and agencies and advocates on behalf of clients. The case management model is an iterative, responsive approach to care where goals are constantly re-evaluated and care modified according to the client’s conditions and changing social circumstances. In some settings, such as mental health, terms such as ‘care management’ are used as it is considered that this is a more client-centred terminology. Case management approaches are often used in the mental health setting.

Approaches to managing client care

The approaches outlined above describe the relationship between the individual client and the nurse. A range of roles also exist for coordinating client care on an organisation level. At a macro level, where there is a focus on development of policy and strategic directions at a government level, roles such as chief nursing officer (CNO) are pivotal in shaping workforce issues. At a meso level, directors of nursing function to develop professional nursing issues and strategic directions on an organisational basis; while at a micro level, the nursing unit manager (NUM) is responsible for directing and monitoring implementation of organisational policy and operational matters. Many organisations are focusing on decentralising decision making and responsibility to an operational level. This has increased the nurse manager’s responsibility for the unit or ward’s budget, workforce performance and welfare of nursing staff, as well as monitoring the quality of patient care. The nurse manager has a multifaceted role of being an expert nurse, clinical leader and manager (DeCampli and others, 2010).

As you can see, the NUM position is a demanding and challenging role, incorporating a range of responsibilities. To function effectively in this role, the RN requires more than expert clinical and technical knowledge; they also need to be an effective communicator, demonstrate clinical leadership and have knowledge of financial and management principles. Box 8-4 describes the roles and responsibilities of the NUM. Because of the demands of this position, roles such as clinical coordinator, team leader, liaison nurse and team educator have been introduced into the clinical setting. In these roles, senior and expert nurses, many of whom are clinical nurse specialists, are responsible for coordinating and directing clinical care, usually on a shift basis. Often, in these roles the RN does not have a client mix assigned to their direct care; as nursing skill mix diversifies, the proportions of ENs and assistants in nursing are increasing in number in the workforce. Therefore, the RN may monitor and support clinical care on a ward or unit basis. In these models, delegation and monitoring skills are particularly important. It is also important to consider that nursing care is delivered on a 24-hour basis, so there is a need to ensure that there are adequate expert nursing knowledge and managerial skills available around the clock.

BOX 8-4 ROLES AND RESPONSIBILITIES OF THE NURSING UNIT MANAGER

• Determine the vision and model of care for the clinical setting in consultation with the organisational goals and mission

• Identify best-practice standards and guidelines for the clinical discipline.

• Develop a mechanism for monitoring professional standards and practice

• Continually evaluate nursing standards and practice and amend care plans accordingly

• Determine appropriate staff and skill mix and engage in recruitment and retention issues

• Ensure that scheduling and rostering of staff is appropriate and consistent with the acuity and complexity of the client mix

• Engage in negotiating professional goals with staff and actively monitoring these in regular appraisals

• Encourage and reinforce the use of clinical portfolios in appraisal and evaluation systems

• Establish and monitor mechanisms for communicating information internally within the nursing team and externally with other health and service providers

• Represent the clinical specialty and nursing role in interdisciplinary and organisational committees

• Provide clinical leadership in the clinical setting

• Communicate with clients and consumer representatives

• Promote a culture of evidence-based practice and reflective practice

• Manage the clinical setting within fiscal requirements

• Promote a culture of transparent and accountable practice

• Develop and monitor a business case for the clinical setting in consultation with the nursing team, consumer representatives and other health professionals

• Encourage and promote professional development and a culture of lifelong learning

• Promote a culture of collegiality and mutual respect among all team members

• Promote clinical care that is culturally competent and appropriate to client needs

In addition to the RN competencies described in Box 8-3, nurses have a range of responsibilities associated with optimal client outcomes (Box 8-5). As you can see, every nurse has a responsibility to contribute collaboratively to the care team. Effective teamwork leads to improved staff job satisfaction, improved patient safety and improved quality of care (Manthous and Hollingshead, 2011). Your capacity to be successful and enjoy your work environment will depend on your capacity to work in a team. Taking the time to evaluate your own working style is important in relation to how you will function in a team in the healthcare environment (Halm, 2011).

BOX 8-5 RESPONSIBILITIES OF NURSES IN CLINICAL SETTINGS

• Seek clarification of the vision for nursing and model of care in the clinical setting

• Identify the reporting and monitoring structure within the clinical setting

• Report and monitor actual and potential adverse events

• Document appropriately and accurately all clinical care and other relevant information

• Actively contribute to clinical evaluation and engage in quality improvement initiatives

• Engage in professional development activities

• Maintain a clinical portfolio and have a personal professional development plan

• Communicate effectively and accurately and promote a culture of accountability and transparency

• Function as an effective role model engaging in accountable, clinical practice models

• Identify preceptors and mentors to support your professional growth

• Provide clinical care that is culturally competent and appropriate to client needs

Tools to support managing client care

A range of tools are available to support managing client care, and the internet provides a rich and informative source. The list below is not exhaustive, but will give you an example of strategies to promote the coordination and quality of care. There are many websites that will provide you with useful resources to help you in planning your care (see Online resources). For example, the Cochrane Collaboration and the Joanna Briggs Institute provide evidence-based resources and best-practice information sheets that have been developed following a critical appraisal of the evidence using the systematic review process. Peak bodies nationally and internationally, such as the Royal College of Nursing Australia and Sigma Theta Tau International, provide rich and reliable information as well as the capacity for networking and information sharing.

Accessing accurate and timely information is important in making effective clinical decisions and monitoring clinical conditions. Communication of information across care settings, particularly from the acute care sector to the community, is also critical in coordinating care. Consequently, significant resources and focus are being placed on developing effective technological solutions for promoting high-quality client care (Hannan, 2011). As a student nurse you need to develop and consolidate technological skills that allow you to work effectively with information technology solutions in addressing management of information. It is likely that in the future much of the work of the nurse will be undertaken in a technological milieu (Gray and Sim, 2010).

Clinical practice guidelines and clinical care should be based upon the best available evidence in accordance with the client’s values and clinical expertise. Accessing the vast amount of information is beyond the scope of the individual clinician, so a number of expert bodies have developed clinical practice guidelines to assist in providing evidence-based care. These are readily accessible through the National Health and Medical Research Council, National Institute for Clinical Studies, the Joanna Briggs Institute and the Australian Resource Centre for Healthcare Innovations, as well as a range of peak bodies such as the National Heart Foundation and Cancer Australia. In New Zealand, peak bodies include the Health Research Council of New Zealand and the Cancer Society of New Zealand.

Clinical pathways are tools used to organise, sequence and integrate healthcare from a range of health and social service providers. These are derived by a process of negotiation, consensus and appraisal of best-practice guidelines. These tools describe the sequence of events necessary to identify anticipated client outcomes and achieve desired outcomes with optimal efficiency, along with also measuring variances that occur in the anticipated course of clinical care. Clinical pathways are sometimes referred to as critical pathways (see Chapter 7). Clinical pathways are used in both the acute and community-based settings to guide clinical care. They can be a valuable resource in achieving an integrated and coordinated approach to care.

A range of risk assessment tools are available to assist in planning and managing care. These can be used for predicting conditions such as delirium, risk of falls and pressure ulcers (Webster and others, 2011). Remember that astute clinical assessment and anticipation of risk are key aspects of the RN’s role (see Chapter 6). Valid and reliable assessment tools can assist you in clinical decision making, particularly in your early years working as an RN. Learn to use these risk assessment tools to monitor your client’s clinical condition and avoid adverse health outcomes.

• CRITICAL THINKING

You have just received the morning shift hand-over report on your clients. You have been assigned the following clients:

• Joan, a 68-year-old woman, who is day 3 following a total hip replacement. She has an intravenous cannula and a patient-controlled analgesia infusion.

• Frank, a 72-year-old man admitted to hospital for a fractured femur, has new-onset shortness of breath and is becoming agitated.

• Olga, a 54-year-old woman, was admitted to hospital with a stress spinal fracture as a consequence of bony metastases. She has a morphine infusion running and you note in hand-over that she has scored 7 on a 0–10 pain rating scale.

In what priority order do you need to attend to these clients? Justify your answer.

Communication among the clinical team

Communicating with nursing colleagues and other members of the healthcare team is critical in delivering effective coordinated care. Increasingly, the quality of communication has been identified as a predictor of patient outcome. The hand-over process, team meetings, communication books and noticeboards are ways of communicating not only clinical but also organisational and operational information (Matic and others, 2011). As a RN, it is your responsibility to actively engage in communicating with the healthcare team to promote optimal client care. The Joint Commission of Accreditation of Healthcare Organizations (JCAHO) in the United States has identified ineffective communication as a root cause of over 65% of sentinel adverse events during the period of 1995 to 2005 (Greenberg and others, 2007). Effective communication networks, clearly delineated staff roles and responsibility are important strategies in promoting the quality and safety of patient care. Implicit in creating effective communication networks is providing a vision and direction for the healthcare team through effective leadership and a positive policy environment.

Philosophy and vision for nurses managing client care

A philosophy and vision for nursing provides direction for all levels of the nursing profession and provides visibility and strategies to support nursing practice throughout the organisation. In order to successfully plan and implement strategies to provide optimal clinical care, it is important that nursing leaders negotiate a strategic work plan with their colleagues to provide direction in enhancing professional nursing practice and promoting quality client-centred care. Increasingly, there is a correlation between the dynamism and effectiveness of nursing leadership and the quality of work environments.

Magnet status is an award given by the American Nurses Credentialing Center (ANCC), an affiliate of the American Nurses Association, to hospitals that satisfy a set of criteria designed to measure the strength and quality of their nursing. An accredited Magnet hospital provides exemplary nursing care delivering optimal clinical outcomes within the framework of the organisation’s goals and mission (see ANCC at www.nursecredentialing.org). Nurses working in Magnet hospitals have higher levels of job satisfaction and higher rates of nursing retention compared with other institutions. Magnet status is also said to indicate active nursing involvement in organisational decision making in respect of clinical care delivery. Importantly, Magnet nursing leaders value the nursing team; promoting evidence-based nursing practice and acknowledging development of nursing practice. Nursing leadership is noted to be critical in developing and sustaining a viable nursing workforce in the complex environments of contemporary clinical settings, whether this is in the acute care sector or community-based. In addition to improvement in recruitment, retention and work satisfaction, there is recognition of improved clinical outcomes in Magnet hospitals that promote excellence, accountability, professionalism and individual growth. Currently, in Australia several hospitals have been successful in obtaining Magnet status. Appreciating the metrics of this accreditation, such as the value of teamwork and monitoring of practice, are important in appraising and developing the practice environment.

Leadership skills for nursing students

Contemporary clinical environments are placing increasing pressure on the RN to focus on clinical care and team coordination, rather than being solely responsible for a small number of patients as in the total patient care models evident in previous decades. This is particularly the case in non-critical-care settings. In order to do this, the RN requires not only expert skills in clinical care, but also, equally importantly, needs to appraise the clinical situation, delegate appropriately and promote effective communication with clients, their families and other healthcare professionals. As a student you can develop your clinical leadership skills by using critical thinking strategies for making effective clinical decisions through astute clinical assessment, appraisal of the evidence and assessment of client needs (see Chapter 6); learning from your mistakes and those of others and actively seeking guidance and mentorship; and collaborating closely with professional nurses and striving to improve your performance during each client interaction. This can be as simple as taking the time to look up any terms or diagnostic tests you do not know about, or talking to clients about the aspects of clinical care that they find most satisfying. There are certain leadership skills that the nursing student can learn to use, including clinical care coordination, team communication, delegation and knowledge building. Seeking feedback from your preceptors, facilitators and fellow students can be useful in developing your communication and coordination skills. It is never too early to develop and refine your leadership skills, and often this is a process just as much of personal as of professional growth (Hendricks and others, 2010).

Measuring outcomes of nursing care

Nurses play a critical role in the quality and safety of clinical care. Adverse events in the clinical setting are the leading cause of death and injury, and are responsible for high healthcare costs as well as distress to families and clinicians (Massó Guijarro and others, 2010). It is estimated that adverse events may occur in at least a third of admissions to hospital (Classen and others, 2011). The reasons for the high rates of adverse events in the healthcare setting are multifactorial and can be attributed to system, clinician and client factors. Nursing models of care and systems for promoting information flow between healthcare providers are important strategies in preventing adverse events and promoting patient/client safety and quality of care. Impaired access to accurate, reliable and valid information to inform decision making, as well as ineffective communication among the healthcare team, have been shown to cause adverse events, such as delays in diagnosis, inappropriate treatments and adverse health outcomes.

Measuring the impact of nursing interventions on client outcomes is becoming increasingly important as there is a growing emphasis on evidence-based practice and monitoring client outcomes (see Chapter 7) (Twigg and others 2010a). It is often difficult to separate nursing from the inputs of other professional groups and incorporate patients’ perspectives. As a consequence, there is an increasing focus on nurse-sensitive patient outcome indicators and on how these factors contribute to the quality of clinical care. Measurements, assessing both process and outcome measures of nursing care, are important for developing and evaluating approaches to nursing care delivery (Chaboyer and others, 2010). For example, in a patient suffering from an acute myocardial infarction, the process measure can be the time to a definitive revascularisation strategy, such as thrombolysis or percutaneous coronary intervention; while an outcome measure can be in-hospital mortality. The impact of nursing can be evaluated in terms of costs, length of stay and clinical outcomes as well as client and carer satisfaction. For evaluation of nursing outcomes to occur, there needs to be a culture that supports evaluation, as well as adequate infrastructure and resources.

Quality improvement processes for nurses

Nurses should strive to provide care which is evidence-based, culturally appropriate, client-centred and designed to achieve optimal clinical outcomes and organisational efficiencies. The primary goal of quality improvement programs should be the ongoing improvement of the delivery, quality, efficiency and outcome of patient care and services. This is accomplished through a systematic examination of information generated through ongoing monitoring, evaluation and quality-improvement activities. Organisations should strive to promote a culture that enables critical review of practice and a no-blame culture promoting review and development of nursing practice. All quality activities should be benchmarked in accordance with core nursing competencies, scope of practice and regulatory, ethical and legal frameworks. Box 8-6 provides examples of quality-improvement initiatives. Figure 8-1 provides a conceptual model for an iterative and reflective process for engaging in processes to improve nursing care delivery.

BOX 8-6 EXAMPLES OF GOALS FOR IMPROVEMENT IN CLINICAL CARE

• Increase the rate of smoking cessation programs to clients identified as smokers

• Improve identification of patients at risk for falls

• Reduce utilisation of restraints

• Initiate appropriate isolation precautions upon identification of established criteria

• Decrease medication errors

• Decrease delay in transfer to the clinical area from the emergency department

• Decrease the incidence of pressure ulcers

image

FIGURE 8-1 EQuIP5 quality cycle.

From Australian Council on Healthcare Standards (ACHS). 2010 The EQuIP guide, ed 5. Sydney, ACHS. Reproduced with permission.

The Australian Council on Healthcare Standards (ACHS) is an independent, not-for-profit organisation dedicated to improving the quality of healthcare in Australia. The ACHS is the principal independent authority for measuring and implementing quality-improvement systems in Australian healthcare. The ACHS Evaluation and Quality Improvement Program (EQuIP), launched in 1996, provides healthcare organisations with a continually updated framework to deliver a consumer-centred service focusing on the continuum of care by incorporating systematic external peer review. In addition to organisational quality indicators, there is an increasing emphasis on the unique role that nurses play in achieving optimal health-related outcomes.

• CRITICAL THINKING

John is an RN working in a community nursing centre. He notices that the referrals from the acute aged-care ward are not providing sufficient information to effectively prioritise and deliver care. He finds that he is wasting time chasing up discharge summaries and is concerned that the medication lists are not always appropriate. John raises this at the team meeting, and the NUM suggests that he liaise with the acute care ward to coordinate a quality project to improve the quality of the discharge summary.

1. How would you advise John to approach this topic?

2. Who should John choose to be on the project team?

3. Can you suggest some data items that might reflect that the quality of the discharge summaries have improved? Consider the key competencies of ’provision and coordination of care’ and ‘collaborative and therapeutic practice’ in Box 8-3.

Nursing-sensitive indicators

Increasing the emphasis on guaranteeing the quality of care, ensuring financial efficiencies and evaluating the diversity of skill mix in the healthcare setting have led to the development of outcome indicators that are sensitive to nursing interventions and staffing levels. Nursing-sensitive outcomes are defined as changes in health status upon which nursing care has had a direct influence. Variables affecting patient outcomes include diagnosis, socioeconomic factors, family support, age and gender, and the quality of care provided by other professionals and support workers.

Examples of nursing-sensitive indicators include:

• adverse events such as urinary tract infections, pressure ulcers, hospital-acquired pneumonia and deep vein thrombosis/pulmonary embolism

• wound infection and respiratory failure in surgical patients, and

• failure to respond to deterioration in clinical conditions such as shock, cardiac arrest and deep vein thrombosis, also known as failure to rescue.

The use of nursing-sensitive outcome indicators helps to focus attention on the safety and quality of patient care, and is important in demonstrating the critical difference that nurses make in providing safe and effective clinical care. Studies comparing staffing levels and patient outcomes show that when there is a greater proportion of RNs in the skill mix, there are fewer adverse events, fewer complications, shorter lengths of stay, decreased mortality rates and even lower overall costs (Twigg and others, 2010b). Higher levels of nursing personnel are associated with fewer adverse effects such as urinary tract infections, pneumonia and upper gastrointestinal bleeding.

Skill mix for the student nurse

Often during the undergraduate course there is a preoccupation with gaining competencies in technical skills, such as blood pressure assessment and inserting a nasogastric tube. Equally as important as these skills is developing a suite of skills to prepare to be an effective and efficient member of the healthcare team and a lifelong learner. Key skills that you need to develop are your capacity for effective communication (written, oral and non-verbal), for critical, reflective practice and for consciously engaging colleagues and mentors to stimulate and monitor your professional development (see Chapter 5).

Managing your workload and time management can be challenging, particularly in the early period following registration. Being able to determine priorities based upon clinical assessment is an important skill to develop. Often you will need to be adaptive and flexible. It is important to determine the priorities at the beginning of each shift, to provide a baseline of the patients’ clinical progress. Taking time to plan for your shift and seeking advice from other clinicians can increase your efficiency. Develop your own system to prioritise your work plan, such as a notebook with a checklist. As discussed in the section above, to be an effective practitioner it is imperative that you spend some time identifying and evaluating your work style. Box 8-7 will provide you with some additional strategies in planning care delivery.

BOX 8-7 TIME MANAGEMENT CONSIDERATIONS IN MANAGING CLIENT CARE

The more organised and focused your activities are, the more efficient you will be—this means taking time to plan, evaluate, reflect and seek advice.

GOAL-SETTING

Review the goals of care for the day for your allocated clients and accommodate the processes required, for example, providing handover and writing reports.

TIME ALLOCATION

Anticipate how long it will take you to attend to planned activities, such as administration of medications.

SETTING PRIORITIES

Using the process of prioritising the acuity of client needs, plan the activities for the day; for example, it is important to assess intravenous therapy and invasive treatments such as chest tubes at the beginning of your shift. A to-do list can be useful.

ALLOW FOR INTERRUPTIONS

Anticipate interruptions; these will occur. Try not to become annoyed or frustrated when they do occur. Also take the time for your meal breaks and attending to your professional development, such as attending in-service education; this will assist in improving your efficiency.

EVALUATION

At the end of each day, take time to think about how effectively time was used. If you are having difficulties in managing your time, ask for help sooner rather than later. Also remember that handing over care to your nurse colleagues is an expected part of care delivery. Do not feel inadequate; develop skills for participating in a care delivery team and accept tasks graciously when they are given to you. Using an activity log can be a useful reflective practice strategy.

Many new graduates take on existing practices in clinical areas because of power relationships and socialisation. It is important to evaluate all practices critically and strive to ensure that your nursing care is optimal in meeting the needs of clients, rather than a prevailing culture based upon historical care models.

It is also important to take care of your own physical and mental health to sustain your stamina in demanding clinical settings. Taking time to exercise and engage in stress management are important strategies in promoting your own health and being an effective role model to other staff members and clients.

Also take the time in your early career to critically evaluate the management and clinical styles of your peers. It is often through this reflective process that we develop and cultivate our own working style. Look for favourable role models and adopt their practices. If possible, it is also optimal to identify a mentor, an individual who can assist and support you in your career development.

KEY CONCEPTS

• A positive practice environment is required to develop and sustain an effective and efficient nursing workforce.

• Evidence-based practice should be the platform for effective nursing care.

• Nurses work in a range of settings in independent, dependent and collaborative nursing roles.

• Acknowledging key competencies is an important step in becoming a registered nurse.

• The nursing unit manager plays an important role in establishing a philosophy of nursing practice and monitoring nursing standards.

• Key competencies for the registered nurse relate to professional practice, recognising the professional, legal, regulatory and ethical responsibilities of the RN.

• Coordinating, organisation and provision of nursing care include the assessment of individuals/groups, planning, implementation and evaluation of care.

• Nurses make an important contribution to the interdisciplinary healthcare team to improve client outcomes.

• Nurses are required to develop and consolidate professional relationships with individuals and groups to optimise clinical care.

• Models of nursing care should be tailored to the needs of individuals and their families.

• Approaches to nursing care should be developed and evaluated within the context of the clinical setting, client needs, available nursing skill mix and considering the strengths and weaknesses to approaching care delivery.

• Nursing management models are dependent on the organisational structure and vision, although key concepts relating to vision, leadership, reflective practice, commitment to evidence-based practice and supporting lifelong learning should be integral to all management models.

• Effective communication is critical in ensuring optimal patient care.

• Integrated quality-improvement initiatives are important in driving improvements in clinical care.

ONLINE RESOURCES

Australian Nursing and Midwifery Accreditation Council (ANMAC), www.anmac.org.au

Australian Resource Centre for Healthcare Innovations, www.archi.net.au

Cancer Australia, canceraustralia.gov.au

Cancer Society of New Zealand, www.cancernz.org.nz

Cochrane Collaboration, www.cochrane.org

Health Research Council of New Zealand, www.hrc.govt.nz

International Council of Nurses, www.icn.ch

Joanna Briggs Institute, www.joannabriggs.edu.au

National Health and Medical Research Council, www.nhmrc.gov.au

National Heart Foundation, www.heartfoundation.org.au, www.heartfoundation.org.nz

National Institute for Clinical Studies, www.nhmrc.gov.au/nics

Nursing and Midwifery Board of Australia, www.nursingmidwiferyboard.gov.au

Nursing Council of New Zealand, www.nursingcouncil.org.nz

Royal College of Nursing Australia, www.rcna.org.au

Sigma Theta Tau International, www.nursingsociety.org

REFERENCES

Australian Health Practitioner Regulation Agency. Nursing and Midwifery Board of Australia. Online. Available at www.nursingmidwiferyboard.gov.au/About, 2011. 26 Mar 2012.

Banner D, MacLeod MLP, et al. Role transition in rural and remote primary health care nursing: a scoping literature review. Can J Nurs Re. 2010;42(4):40–57.

Berra K, Miller NH, et al. Nurse-based models for cardiovascular disease prevention: from research to clinical practice. J Cardiovasc Nurs. 2011;26(4):S46.

Betihavas V, Newton PL, et al. Australia’s health care reform agenda: implications for the nurses’ role in chronic heart failure management. Aust Crit Care. 2010;24(3):189–197.

Browne AJ, Varcoe C, et al. Cultural safety and the challenges of translating critically oriented knowledge in practice. Nurs Philos. 2009;10(3):167–179.

Chaboyer W, Johnson J, et al. Transforming care strategies and nursing sensitive patient outcomes. J Adv Nurs. 2010;66(5):1111–1119.

Classen DC, Resar R, et al. ‘Global Trigger Tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. 2011;30(4):581.

Coleman K, Austin BT, et al. Evidence on the Chronic Care Model in the new millennium. Health Affairs. 2009;28(1):75.

Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health. Washington D.C.: National Academies Press, 2011.

Davidson P, Halcomb E, et al. Beyond the rhetoric: what do we mean by a ‘model of care’? Aust J Adv Nurs. 2006;23(3):47.

Davidson PM, Gholizadeh L, et al. A review of the cultural competence view of cardiac rehabilitation. J Clin Nurs. 2010;19(9–10):1335–1342.

DeCampli P, Kirby KK, et al. Beyond the classroom to coaching: preparing new nurse managers. Crit Care Nurs Q. 2010;33(2):132.

Duffield CM, Gardner G, et al. National regulation in Australia: a time for standardisation in roles and titles. Collegian. 2011;18(2):45–49.

Dunn SV, Cashin A, et al. Nurse practitioner prescribing practice in Australia. J Am Acad Nurse Practitioners. 2010;22(3):150–155.

Durey A. Reducing racism in Aboriginal health care in Australia: where does cultural education fit? Aust N Z J Public Health. 2010;34:S87–S92.

Eaton-Spiva LA, Buitrago P, et al. Assessing and redesigning the nursing practice environment. J Nurs Admin. 2010;40(1):36.

Epping-Jordan J, Pruitt S, et al. Improving the quality of health care for chronic conditions. Qual Safety Health Care. 2004;13(4):299.

Fairbrother G, Jones A, et al. Changing model of nursing care from individual patient allocation to team nursing in the acute inpatient environment. Contemporary Nurse. 2010;35(2):202–220.

Gray K, Sim J. Factors in the development of clinical informatics competence in early career health sciences professionals in Australia: a qualitative study. Adv Health Sci Educ. 2010;16(1):31–46.

Greenberg CC, Regenbogen SE, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204(4):533–540.

Halcomb EJ. Expansion of nursing role in general practice: studies suggest patients think that nurses can manage simple conditions but have some concerns about knowledge and competence in some areas. Evidence Based Nurs. 2011;14(1):28.

Halm B. Employee engagement: a prescription for organizational transformation. In: Wolf JA, Hanson H, Moir M, et al, eds. Organization development in healthcare: conversations on research and strategies (Advances in health care management, vol 10). Bradford, UK: Emerald Group Publishing; 2011:77–96.

Hannan TJ. E-health in Australia: time to plunge into the 21st century. Med J Aust. 2011;194(4):211.

Hendricks JM, Cope VC, et al. A leadership program in an undergraduate nursing course in Western Australia: Building leaders in our midst. Nurse Educ Today. 2010;30(3):252–257.

Hickman LD, Rolley JX, et al. Can principles of the Chronic Care Model be used to improve care of the older person in the acute care sector? Collegian. 2010;17(2):63–69.

Hobgood C, Sherwood G, et al. Teamwork training with nursing and medical students: does the method matter? Results of an interinstitutional, interdisciplinary collaboration. Qual Safety Health Care. 2010;19(6):1.

Inglis SC, Clark RA, et al. Which components of heart failure programmes are effective? A systematic review and meta-analysis of the outcomes of structured telephone support or telemonitoring as the primary component of chronic heart failure management in 8323 patients: abridged Cochrane Review. Eur J Heart Failure. 2011;13(9):1028–1040.

International Council of Nurses (ICN). Positive practice environments. Geneva: ICN, 2011. Online Available at www.icn.ch/projects/positive-practice-environments 26 Mar 2012.

Kavanagh T, Stevens B, et al. Process evaluation of appreciative inquiry to translate pain management evidence into pediatric nursing practice. Implementation Sci. 2010;5(1):90.

Manthous CA, Hollingshead AB. Team science and critical care. Am J Resp Crit Care Med. 2011;184(1):17–25.

Massó Guijarro P, Aranaz Andrés J, et al. Adverse events in hospitals: the patient’s point of view. Qual Saf Health Care. 2010;19(2):144.

Matic J, Davidson PM, et al. Review: bringing patient safety to the forefront through structured computerisation during clinical handover. J Clin Nurs. 2011;20(1–2):184–189.

McIlfatrick S, Mawhinney A, et al. Assessing the educational needs of palliative care link nurses. Int J Palliative Nurs. 2010;16(11):555.

Nursing Council of New Zealand (NCNZ). Framework for professional standards. Wellington: NCNZ, 2007. Online Available at www.nursingcouncil.org.nz/index.cfm/3,16,48/framework-standards-march-2007.pdf 26 Mar 2012.

Patterson E, McMurray A. Collaborative practice between nurses and medical practitioners in Australian general practice: moving from rhetoric to reality. Aust J Adv Nurs. 2011;20(4):43–48.

Pearce C, Phillips C, et al. Following the funding trail: Financing, nurses and teamwork in Australian general practice. BMC Health Services Res. 2011;11(1):38.

Plever S, Emmerson B, et al. The Queensland Mental Health Clinical Collaborative and the management of schizophrenia. Australas Psychiatr. 2010;18(2):106–114.

Rechel B, Doyle Y, et al. How can health systems respond to population ageing? Geneva: World Health Organization, 2009. Online. Available at www.euro.who.int/__data/assets/pdf_file/0004/64966/E92560.pdf 26 Mar 2012.

Riegel B, Moser DK. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. 2009;120(12):1141.

Sackett DL, Rosenberg W, et al. Evidence-based medicine: what it is and what it isn’t. Br Med J. 1996;312(7023):71.

Sochalski J, Jaarsma T, et al. What works in chronic care management: the case of heart failure. Health Affairs (Project Hope). 2009;28(1):179–189.

Thompson SC, Shahid S, et al. Not just bricks and mortar: planning hospital cancer services for Aboriginal people. BMC Res Notes. 2011;4(1):62.

Twigg D, Duffield C, et al. The impact of nurses on patient morbidity and mortality—the need for a policy change in response to the nursing shortage. Aust Health Rev. 2010;34(3):312–316.

Twigg D, Duffield C, et al. The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: a retrospective analysis of patient and staffing data. Int J Nurs Stud. 2010;48(5):540–548.

Webster J, Coleman K, et al. Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial (the ULCER trial). BMJ Qual Saf. 2011;20(4):297.