Page 1 Coordinated Care Study Guide for the NCLEX-PN® exam

General Information

About 18% to 24% of the questions on the NCLEX-PN® test will be about coordinating care for clients. This topic occupies the largest percentage of test questions, so be sure to focus a significant portion of your studies on this section. Coordinated care involves working with various other healthcare professionals to provide effective client care. You’ll need to know things like client rights and your legal responsibilities with regard to issues like consent, ethics, and confidentiality of information. There’s a lot to know, so here’s an outline of the major points to study. Be sure to seek other information if there is anything here about which you have questions.

Client Care

Planning Care

As a nurse, you will need to strategize about what your client needs to feel cared for and have his or her health be directed toward a healing pathway. Tools to help achieve these states are discussed individually below.

Client Care Plans

Care plans are a tool used by nurses to organize the care needed for a client due to his or her issues, how to treat the issues, what the desired outcomes are, and if these outcomes were met or not. They are broken into four categories: diagnosis, intervention, outcome, and evaluation.

“Interdisciplinary” or “Nursing” Conferences

Interdisciplinary or collaborative care conferences are gatherings of all care team members from every aspect of client care. For example, if a total joint replacement client was not having desired outcomes, their care team members would meet together to discuss why this is occurring and what they can do together and individually in their roles to help the client succeed in meeting the goals of care. The attending physician, nurse manager, staff nurse, unlicensed assistive personnel, physical therapist, and social worker may be some members you would see in this type of meeting.

Roles of Members

As the nurse caring directly for the client, you need to know what every team member’s role is in the caregiving process to ensure those roles are being fulfilled. For example, you and the unlicensed assistive personnel give direct care, physical therapy works with the client on strengthening and mobility, and social workers help coordinate resources for clients when they are discharged from the hospital.

Your Role

Your role as the nurse is to give day-to-day direct physical and emotional care to the client. You are expected to actively include the client in his or her care, such as reviewing what medications you are administering, the purpose of the medication, and the potential side effects. You continually work on the nurse care plan by using the interventions to get desired outcomes as well as updating it when outcomes are met or new issues arise. You are the voice for the client and will need to speak up when you see the need for conferences with one or more of care team members.

Delivering Care

There is an art to delivering client care. One should be efficient yet available for their clients. Organization, prioritization, and time management are key elements to excelling in nursing and giving your clients the absolute best care possible. When discussed below, consider these instruments in your orchestra of coordinating care. Separately, they are important and each works in its own way, but together they make your care seamless and smooth.

Organization

Organization in nursing is a big part of being efficient. Ensuring you have the appropriate equipment and materials for the specific client and/or task saves time, since you won’t have to leave the room multiple times to go get things. For example, if you have to do an IV, make sure you have all the essentials, and even extra supplies, before you go into the client’s room so you can efficiently get that task done. It is your responsibility to be organized in whatever way is necessary for you, as long as you get your tasks done safely and efficiently.

Establishing Priorities

Prioritizing clients is another piece of the puzzle in efficient, quality client care. You do this based on your clients’ health statuses (most unstable first) or based on needs, if all are stable. For example, you have completed a bedside shift report on all your clients. One has no urgent needs, one has a lot of questions, one has severe pain, and one is having some mild shortness of breath. Who do you see first? Using your ABC (airway, breathing, circulation) tool tells you to see the client having shortness of breath before the pain client.

Time Management

Lastly, we have time management. This sounds pretty easy but can be difficult for many. Managing how you use your time—such as being organized with tasks to give you more time for other things—is the third component to this triad. You develop your own methods on how to do this effectively over time, but the basics include using prioritization and organization to best utilize the time during your shift. Some clients need more of your time and some need less. Assess who needs which, and develop your plan to deliver the best care for your clients.

Referrals

A client referral is the request for a specialist to review the client’s condition and medical record to see if that specialist would be an appropriate asset to the care team. It is your role to consult with the specialist as well as to request that a primary care provider make a referral when you think that a client needs additional care.

Recognizing Client Needs

As stated above, it is your responsibility as the nurse to recognize when your client needs additional assistance. For example, if you have concerns about a client’s ability to swallow, then you can request a speech therapist referral for evaluation of this. If a client has poor gait, then you can request a referral to physical therapy for balance and gait training.

Documentation

Documentation is huge in nursing. You may have heard the phrase, “If you didn’t document it, you didn’t do it.” Well, it’s true. Thorough, objective documentation is important for ensuring you have a record of your time with a client and the care you provided. Medication administration, care plans, vitals, intake/output, etc., are examples of things you can document to reflect your client care.

Continuity of Care

Continuity of care means ensuring the clients have received all they need to continue to be cared for by other healthcare providers taking over. Giving objective, thorough reports at change of shift, sending medical records to healthcare team members taking over care, time-outs during procedures, and thorough documentation are ways to have a seamless flow through the care system.

Following Up on Clients

Once a client has been approved for discharge from the hospital, several things need to be in place before he or she leaves. A client should always have a follow-up visit scheduled with the provider scheduled to take over care in the outpatient setting. They should also have written discharge instructions as well as prescriptions, if appropriate. The nurse is responsible for verifying that the client is educated on the discharge instructions and that all questions are addressed. The nurse also needs to make sure the client knows the follow-up appointment date/time/location as well as the proper resources (e.g., transportation) to successfully attend that appointment.

Using Agency Guidelines

Facility policies and procedures are tools to satisfactorily execute continuity of care. We have already discussed how care plans aid in client care, but these plans are also a great tool for the flow of continuity of that client care involving other nurses and providers. Clinical pathways are also great tools for all of the interdisciplinary team to follow. They are evidence-based interventions that flow either in a daily or weekly pattern in how the client is expected to respond to the illness/issue and trend in the direction of the desired outcome for the client, which is ultimately improvement and discharge from the facility. Facilities now more commonly have a policy of bedside shift report to decrease subjective and incorrect information. Reporting at bedside ensures both nurses agree to the client’s current care level and baselines.

Working with Other Healthcare Professionals

Management and Supervision

There are several levels of management and supervision in nursing. Staff nurses manage and supervise other employees below them, delegating and supervising tasks as needed to guarantee accurate performance. Charge nurses manage the staff nurses in doling out assignments appropriately, floating or receiving nurses based on census, and assisting the staff nurses when needed. Nurse managers are in charge of all staff on the unit. They handle issues between staff members, make staffing schedules, conduct classes for continuing education, and assign staff to various positions based on experience (preceptors, shared-governance committees, etc.).

Assess Abilities of Staff Members

When working with other team members, the nurse must ensure tasks are being knowledgeably and appropriately carried out. Assessing your teammates’ abilities, delegating/monitoring tasks, and continuing education courses enable nurses to carry this out. Whether they be new employees, unlicensed assistive personnel, or current employees getting checked off on new tasks, it is the supervising nurse’s responsibility to ensure the staff member is completing tasks correctly and safely. Nurses should know their scopes of practice along with other team members’ to make sure all are practicing within their level. When assessing an individual’s ability to do an assignment, it is important to know his or her training background and experience level. Once staff is checked off on a particular task, it is still the delegating nurse’s responsibility to follow up with further evaluation.

Assigning and Monitoring Tasks

It is the nurse’s responsibility, whether a staff or charge nurse, to be thoughtful when making assignments. Staff nurses need to follow up with unlicensed assistive personnel on delegated tasks to verify completion and make sure they understand the task assignment. Charge nurses make client assignments and follow up through the shift as nurses get admissions/discharges to ensure a proper assignment balance for all staff. Evaluation of team members’ performance with positive feedback as well as constructive criticism is critical for improvement. It is also important to note conflict between staff members and enable quick resolution to provide the best care for clients.

Continuing Education

Continuing education involves classes on the unit, online credit courses, and community course opportunities. It is important for nurses to continue to be educated in all aspects of healthcare to be up to date with what is evidence-based practice. Nurses should advocate for each other if they notice a team member needs more education in a particular area.

Performance/Quality Improvement

Quality improvement in healthcare is based on research and evidence supporting the way healthcare providers practice. It is a vital component in healthcare because it is continually changing in relation to current, factual, and scientific evidence that supports what nurses do.

Your Participation

Nurses participate in quality improvement by assisting in data collection of objective, factual information as well as research. Attending inservices with updated, evidence-based practice guidelines as well as attending quality improvement committees ensure the new data gets to all staff so they can practice nursing at the highest standard.

Reporting Concerns

When an issue in client care arises and is noted to be an ongoing problem, quality improvement projects start. It is important to know the appropriate individual to whom issue reports should be taken. This is also where chain of command comes into play. The correct and trackable route of reporting is also important. For example, incident reports are a great way for risk management to track issues that need to be addressed by quality improvement committees.