.

Concepts of Management and Supervision

A.
Review standards and/or position statements of the following agencies before del
egating any nursing tasks
1.
State board of nursing
2.
National Council of State Boards of Nursing (NCSBN)
3.
Nursing organizations
a.
American Nurses Association (ANA)
b.
National League for Nursing (NLN)
4.
Health care institutions
Don't Confuse these!
?Scope of Practice - determined by a state's Nurse Practice Act
?Standards of Practice - established by the nursing profession, i.e., the Americ
an Nurses Association
?Standard of Care - institutional policy and procedure documents
B.
Use critical thinking in management situations
C.
Nurses must understand the legal aspects of the nursing profession
1.
Provide safe competent care
2.
Advocate client's rights
3.
Provide care that is within their scope of practice
4.
Provide care that is consistent with established standards of care
D.
Use the six Quality and Safety Education for Nurses (QSEN) competencies as a gui
de for managing and supervising care
1.
Patient-centered care - the patient (or designee) is recognized as the source of
control and full partner; care that is provided is based on respect for patient
's preferences, values, and needs
2.
Teamwork and collaboration - open communication, mutual respect, and shared deci
sion-making are used to achieve quality patient care
3.
Evidence-based practice - health care delivery is the integration of best curren
t evidence with clinical expertise and patient/family preferences and values
4.
Quality Improvement - data is used to monitor the outcomes of care processes; im
provement methods continuously improve the quality and safety of health care sys
tems
5.
Safety - risk of harm to clients and providers is minimized through both system
effectiveness and individual performance
6.
Informatics - information and technology is used to communicate, manage knowledg
e, mitigate error, and support decision-making
E.

Establishing priorities
1.
Prioritizing involves decisions of which needs or problems require immediate att
ention or action and which ones can be delayed until a later time if they are no
t urgent
2.
Needs that are life-threatening or could result in harm to the client if left un
treated are high priorities
3.
Actual problems or needs have higher priority than potential problems or needs
4.
Problems or needs identified by client are of a higher priority
5.
Consider Maslow's principles (hierarchy of needs) or the ABCs (airway, breathing
, circulation) of emergency care to guide decisions
6.
Mutual decision-making for priorities may be made with the client based on the c
lient's physiologic needs, desires, and safety
F.
Communication skills and conflict resolution
1.
Communication
a.
involves perception to receive a message
b.
involves expectation - the unexpected may be ignored
c.
makes demands on nurses to think and respond
d.
is different than information
2.
Types of communication
a.
downward - used to relate organizational policy such as position description and
rules and regulations
b.
upward - include such things as staff meetings
c.
lateral - between staff members, i.e. to coordinate activities
d.
diagonal - staff from different levels work together on a project
3.
Causes of conflict
a.
inadequate communication
b.
incorrect facts
c.
unstable leadership or inadequate action plans
d.
misunderstood roles or responsibilities
e.
receiving directions from two or more delegators
f.
lack of or limited staff input into decisions
g.
inability to accept change
h.

power issues
4.
Prevention of conflict includes
a.
allocating resources fairly
b.
avoiding unexplained changes
c.
clearly stating expectations
d.
addressing staff fears
5.
Dealing with conflict
a.
take prompt action
b.
help parties resolve conflict among themselves (communicate trust that parties c
an accomplish resolution)
c.
maintain an objective approach
d.
avoid criticism
e.
use problem solving approach
f.
provide privacy for sensitive issues
g.
negotiate for agreements- not winning or losing
h.
focus on patient care interests
i.
avoid emotional outbursts
j.
include a third party when mediation seems the best choice
G.
Communication and collaboration techniques
1.
SBAR technique - provides a standardized framework for communication between mem
bers of the health care team
a.
S = situation (a concise statement of the problem)
b.
B = background (pertinent and brief information related to the situation)
c.
A = assessment (analysis and considerations of options - what you found/think)
d.
R = recommendation (action requested/recommended - what you want)
2.
"I PASS the BATON" - used to improve "handoffs" and transitions in health care,
with opportunities to ask questions, clarify, and confirm
a.
I = introduction (introduce yourself and your role/job)
b.
P = patient (name, identifiers, age, gender, location)
c.
A = assessment (presenting chief complaint, vital signs and symptoms and diagnos
is)
d.
S = situation (current status/circumstances, including code status, recent chang

es, response to treatment)

e.
S = safety concerns (critical lab values/reports, socioeconomic factors, allergi
es, alerts such as falls, isolation, etc.)
f.
B = background (co-morbidities, previous episodes, current medications, family h
istory)
g.
A = actions (what actions were taken or are required and provide brief rationale
)
h.
T = timing (level of urgency and explicit timing, prioritization of actions)
i.
O = ownership (who is responsible - nurse/doctor/team and patient/family respons
ibilities)
j.
N = next (what will happen next? anticipated change? what is the PLAN? what is t
he contingency plan?)
3.
CUS - a process used to more effectively advocate for clients when there is a co
ncern
a.
C = concern ("I am concerned...")
b.
U = uncomfortable ("I am uncomfortable...")
c.
S = safety ("this is unsafe...")
II.
Delegation
A.
Definitions
1.
Delegation: a process by which responsibility and authority for performing tasks
are transferred from one individual to another who accepts that authority and r
esponsibility
2.
Delegation involves
a.
responsibility: an obligation to accomplish a task
b.
accountability: accepting ownership for the results or lack of
c.
authority: right to act or empower over others
B.
Delegation overview
1.
A nurse can only delegate those tasks for which that nurse is responsible (as ou
tlined in the state's Nurse Practice Act)
2.
The delegator remains accountable for the task
3.
Along with responsibility for a task, the nurse who delegates must also transfer
the authority necessary to complete the task
4.
The delegator knows how to perform the task being delegated
5.
Delegation is a contractual agreement that is entered into voluntarily
6.
Consider the scope of practice of nursing personnel (as determined by a state's

Nurse Practice Act)

a.
Registered Nurses (RNs):
i.
baccalaureate prepared nurses are equipped to care for individuals, families, gr
oups and communities in both structured and unstructured health settings
ii.
associate degree prepared nurses are equipped to care for individuals in a struc
tured health care environment
iii.
RNs cannot delegate the following activities to unlicensed assistive personnel (
UAP)
assessment of clients
evaluation of client data
nursing judgment
client/family education/counseling and evaluation
nursing diagnosis/nursing care planning
b.
Licensed Practical or Vocational Nurses (LPN/VN)
i.
assist in implementing a defined plan of care and to perform procedures accordin
g to protocol
ii.
assessment skills involve collecting data and are directed at differentiating no
rmal from abnormal
iii.
may reinforce information that has been given to the client by the RN
iv.
competence to care for physiologically stable clients with predictable condition
s
c.
Unlicensed Assistive Personnel (UAP)
i.
because they are unlicensed, they have no scope of practice
ii.
in general, nursing tasks that may be delegated include non-invasive and non-ste
rile treatments
assist in a variety of direct client care activities or tasks, e.g., bathing, tr
ansferring, ambulating, feeding, toileting, and obtaining measurements (vital si
gns, height, weight, intake and output, blood glucose levels)
perform indirect activities such as housekeeping, transporting people and stocki
ng supplies
iii.
some states allow for the practice of medication administration in specific sett
ings by medication aides - refer to your state's Nurse Practice Act for specific
information
C.
Steps of delegation
1.
Right task - define the task and determine if it can be safely delegated
a.
match the delegatee to the task
b.
determine if the task is within the scope of practice for the delegatee
c.
determine agency policies, procedures, and standards
d.
understand standards of practice, e.g., the American Nurses Association (ANA) St

andards of Practice
e.
remember - nursing tasks that be delegated to unlicensed assistive personnel (UA
P) are intended to assist, but not replace, the nurse
2.
Right circumstances
a.
determine if there is anything about the client's condition or the environment w
hich would preclude this delegatee from performing the task as delegated
b.
determine if staff members have the resources, equipment, and supervision needed
to work safely
3.
Right person - is the right person delegating the right task to the right person
to be performed on the right patient?
a.
determine if staff members have the necessary knowledge, skills, and abilities (
KSA) to perform the delegated tasks and if this information is documented
b.
determine if the client's condition is stable with predictable outcomes prior to
delegating care
4.
Right direction/communication - clearly communicate the specific steps of the ta
sk, expectation about performance, reporting, and documentation of the task
a.
potential problems and solutions are discussed
b.
the nurse intervenes if necessary
c.
staff members must be able to decline without jeopardizing their jobs
5.
Right supervision/evaluation - appropriate monitoring, intervention, evaluation,
and ongoing feedback
a.
the nurse must have the appropriate skills to assist, teach and guide the indivi
dual who is completing the task
b.
the nurse will determine if client needs were met
c.
the nurse can continue or withdraw the delegation
d.
problems, particularly and sentinel events, are clarified or reported to supervi
sors
D.
Client care assignments
1.
Assign the right task
2.
Assign the task to the right person
3.
The LPN may assign tasks to the unlicensed assistive personnel or nursing assist
ants (if allowed by that state's Nurse Practice Act)
4.
Unlicensed assistive persons (UAP) or nursing assistants cannot delegate to othe
r UAPs or nursing assistants
The 4 C's of Communication
1. Clear - Does the team member understand what I am saying?
2. Concise - Have I confused the direction by giving too much unnecessary inform

ation?
3. Correct - Is the direction given according to policy, procedures, job descrip
tion, and the law?
4. Complete - Does the delegatee have all the information necessary to complete
the task?
III.
Performance Improvement & Quality Assurance
A.
Quality: the degree to which client care services increase the probability of de
sired outcomes and reduce the probability of undesired outcomes given the curren
t state of knowledge
B.
Performance improvement/assurance: the process of attaining a new level of perfo
rmance or quality that is superior to any previous level of performance or quali
ty
C.
Total quality management: a philosophy that emphasizes a commitment to excellenc
e throughout the organization
D.
Six characteristics of total quality management
1.
Focus on customer, i.e., client
2.
Focus on outcomes
3.
Total organizational involvement
4.
Multi-professional approach
5.
Use of quality tools and statistics for measurement
6.
Identification of key areas for improvement with an emphasis on SAFETY
E.
Mandated by the Joint Commission

IV.
Nursing Care Delivery Systems
A.
Functional nursing (task nursing)
1.
Needs of clients are broken down into tasks
2.
Tasks are assigned to various levels of health care workers according to licensu
re and skill
3.
Example: RN gives medications and UAP give bed baths for one group of clients
B.
Team nursing
1.
Most common nursing care delivery system
2.
A team of nursing personnel provides total care to a group of clients
3.
Team leaders supervise client care teams, which usually consist of an RN, LPN, a
nd UAP
4.

Team leader reviews the client's plan of care and progress with team members dur
ing team conference
C.
Total client care (case method)
1.
An RN is responsible for all aspects of care of one or more clients
2.
The LPN may be assigned to assist the RN
3.
This type of care is usually provided in areas requiring high level of nursing e
xpertise, such as the critical care unit (CCU) or the post-anesthesia recovery u
nit (PACU)
D.
Primary nursing
1.
The RN maintains a client load of primary clients
2.
The primary nurse designs, implements and is accountable for the nursing care of
those clients during their entire stay on the unit
a.
has the benefit of continuity of care but may not be feasible with varying sched
ules
b.
has been found to result in greater nurse satisfaction, more personalized care,
less turn over, and fewer negative outcomes for patients
E.
Practice partnerships
1.
An RN and an assistant (UAP, LPN, less-experienced RN, graduate nurse, or nurse
intern) agree to be practice partners
2.
Partners work together on same schedule with same group of clients
3.
Senior partner directs the work of the junior partner within the scope of each p
artner's practice
F.
Case management
1.
Model for identifying, coordinating, and monitoring the implementation of servic
es needed to achieve desired client outcomes within a specified period of time
2.
Organizes client care by major diagnosis or Diagnosis Related Group (DRG)
3.
A collaborative health care team defines the expected outcomes of care and care
strategies for a client population by defining critical paths
4.
A registered nurse manager is assigned to coordinate, communicate, collaborate,
problem solve, facilitate and evaluate client care for a group of clients
5.
Case manager usually does not provide direct client care but coordinates care pr
ovided by licensed and unlicensed nursing personnel according to a critical path
6.
Critical pathways are plans for providing care to the client and family
a.
identify desired outcomes
b.
state expected amount of time and resources to be used
c.
focus on specific diagnoses or procedures that are high volume and or high resou

rce use (and therefore costly)

d.
promote collaboration among disciplines (health care professionals)
7.
The essential components of case management include
a.
collaboration of all health care team members
b.
identification of expected patient outcomes with time frames
c.
use of principles of continuous quality improvement (CQI) and variance analysis
d.
promotion of professional practice
8.
Client involvement and participation is key to successful case management
G.
Differentiated practice
1.
Identifies distinct levels of nursing practice based on defined abilities that a
re incorporated into job descriptions
2.
Structures nursing roles according to education, experience, and competency
H.
Client-centered care
1.
The RN coordinates a team of multi-functional unit-based caregivers
2.
All client care services are unit-based, including admission, discharge, diagnos
tic testing and support services
3.
Uses UAPs to perform delegated client care tasks
V.
Information & Documentation
A.
Types of patient records
1.
Problem-oriented medical record (POMR)
a.
a decision is made on the nature of the client's problem or problems and these p
roblems are assessed regularly
b.
recorded using a standardized format, by narrative notes in the S.O.A.P. format
or by flow sheets
c.
discharge summary relates the overall assessment of progress during treatment an
d plans for follow-up care, encouraging continuity of care
d.
four parts
i.
data base: the client's present health status
ii.
problem list: numbered list of health problem(s)
iii.
initial plan: plan to help overcome health problem(s)
iv.
progress notes: all disciplines chart on the same page
2.
Source-oriented

a.
most traditional type of charting, with different disciplines charting on separa
te forms
b.
drawback: records become very bulky, very quickly
Documentation has six key components (CO-ACTS)
Confidential
Organized (chronologically)
Accurate
Complete
Timely
Subjective and objective data
B.
Methods (styles) of charting
1.
Narrative charting
a.
the nurse records observations, data (including reactions from the client) in a
sequential and chronological order
b.
baseline charted every shift
c.
source-oriented
2.
S-O-A-P: problem-oriented charting; comes from a medical model
a.
S = subjective; what client tells you
b.
O = objective; what you observe, see, etc.
c.
A = assessment; what you think is going on based on the data
d.
P = plan; what you are going to do
3.
D-A-R
a.
D = data - collecting information about a problem
b.
A = action - the task to be completed about the problem
c.
R = response - the client's response to the problem
4.
Focus charting
a.
charting on an acute condition, a potential problem, a treatment or procedure, o
r a client behavior
b.
components of this type of charting include: information about the condition/pro
blem, action, and client's responses
5.
A P-I-E charting - uses the nursing process
a.
A = assessment
b.
P = problem
c.
I = intervention

d.
E = evaluation
6.
Charting by exception
a.
uses flowsheets
b.
emphasis on abnormal (or what is abnormal for this particular client); normal ro
utine is presumed as having been done, without any problems
C.
Documentation guidelines
1.
General
a.
check that you have the correct chart
b.
record the facts as accurately as possible
c.
chart as you go
d.
never chart for another person
e.
do not mention incident reports
f.
avoid the use of abbreviations - when in doubt, write it out!
i.
all health care institutions have a list of accepted abbreviations
ii.
refer to the Joint Commission's official "Do Not Use" list of abbreviations
g.
never alter a client's record (altering a client chart is a criminal offense)
h.
six things that nurses must document
i.
assessment
ii.
nursing diagnosis and client needs
iii.
interventions
iv.
care provided
v.
client response to care
vi.
client's ability to manage continuing care after discharge
2.
Legal guidelines for charting
a.
electronic health record (EHR) charting
i.
never share access or password with another person
ii.
change your password frequently
iii.
maintain confidentiality of documented information printed from the computer
iv.
carefully check your information before you press enter
v.

access information for clients under your care only

vi.
log off when you are finished
vii.
date and time are automatically recorded
b.
paper-ink
i.
do
write in chronological order
use permanent black ink
chart the time and date for each entry
include consent for or refusal of treatment, client responses to interventions,
calls made to other health care professionals
write legibly
cross through the error once, date and initial the change
correct any errors in a timely manner
ii.
do not
erase, scratch out or use correction fluid (Liquid Paper or White Out)
document for others or change documentation by others
leave blank spaces
recopy any charting form
make photocopies without permission
VI.
Legal Responsibilities
A.
Sources of law
1.
Federal Regulations
a.
The Health Insurance Portability and Accountability Act (HIPAA)
b.
The Americans with Disabilities Act (ADA)
c.
The Mental Health Parity Act (MHPA)
d.
The Patient Self-Determination Act (PSDA)
e.
The Uniform Anatomical Gift Act and the National Organ Transplant Act
2.
State law - Nurse Practice Act
a.
passed by each state legislature to regulate the practice of nursing in that sta
te
b.
administered by the board of nursing in each state or jurisdiction
c.
scope and responsibilities vary state-to-state, therefore nurses are responsible
for knowing regulatory requirements for nursing in each state where they are pr
acticing
d.
Nurse Practice Acts define
i.
scope of practice (what the nurse is allowed to do)
ii.
nursing titles that are allowed to be used
iii.
qualifications for licensure

iv.
actions that can or will happen if a nurse does not follow the nursing law
Types of law
1.
Criminal Law
a.
deals with acts of intentional harm to individuals and society as a whole
b.
categorized as a felony or misdemeanor
c.
the defendant is either guilty or not guilty
d.
the burden of proof is "beyond a reasonable doubt"
A former client sues a nurse for negligence. The client must prove that the nurs
e not only committed a breach of duty but that this breach of duty was the proxi
mate cause of any damages incurred by the client.
2.
Civil Law
a.
deals with disputes between parties or negligent acts that cause harm to others
protects the individual rights of people
b.
deals with tort law - unintentional, quasi-intentional or intentional torts
c.
the burden of proof is "preponderance of the evidence"
d.
negligence and malpractice are examples of unintentional torts
i.
negligence: a breach of the duty to provide nursing care to the client
ii.
malpractice is professional negligence; the unintentional failure of an individu
al to perform or not perform an act that a reasonable person would or would not
perform in a similar set of circumstances
iii.
negligence involves four legal concepts
duty: nurses have a legal obligation to provide nursing care to clients
must meet a reasonable and prudent standard of care under the circumstances
must deliver care as any other reasonable and prudent nurse of similar education
and experience would, under similar circumstances
breach of duty: failure to provide expected, reasonable standard of care under t
he circumstances (includes errors of omission or commission)
proximate cause
relationship between the breach of duty and the resulting injury
the injured party must prove that the nurse's action or omission led to the inju
ry
damages: the injury and the monetary award to the plaintiff