Management of Care Study Guide for the NCLEX-RN Exam

General Information

This category of questions falls under the broader umbrella of Safe and Effective Care Environment and asks you to make relevant decisions about nursing care. Your objective should be to determine the most effective way to deliver optimal care that preserves the health and safety of patients and personnel. These are some of the concepts you will need to know in order to make the appropriate decision(s) when questioned by NCLEX.

Advance Directives

Advance directives are legal documents that specify the wishes of patients regarding their care if they were to become incapacitated and unable to communicate on their own. Examples of advance directives include:

Living wills—written statements by a person with their desires regarding medical treatment in the event they will no longer be able to express their informed consent
Health care proxy—document that names a trusted individual as proxy or agent to act on a person’s behalf in the event they are rendered incapable of expressing their wishes
Power of Attorney for Health Care—legal document that allows a person to designate another person to make medical decisions for them in the event the person cannot make medical decisions for himself or herself

Self-Determination

In 1990, Congress passed the Patient Self-Determination Act. This bill requires that upon admission to a hospital, nursing home, home health agency, or other healthcare institution, patients must be advised of the right to accept or refuse care as well as their options for advance directives. If a patient already has an advance directive, the nurse should help document this in the patient’s chart. If not, the nurse may be involved in educating the patient on what advance directives are and discuss the patient’s healthcare goals for the future. This may also include the patient’s wishes for organ donation or making an anatomical gift as specified in the Uniform Anatomical Gift Act.

Life Planning

Advance directives help ensure that a patient’s wishes are carried out by the healthcare team. As a nurse, you will need to incorporate advance directives into your patient’s care plan. This may include determining if a patient needs an advance directive, facilitating conversations with family members, and educating staff members who may not be familiar with the document. You must also ensure that copies of advance directives are placed in the patient’s chart.

Advocacy

Advocacy is at the heart of nursing. Advocacy is promoting or acting on behalf of the interests of another. Nurses are advocates for their patients. Their duties can be varied and diverse. These duties include providing patients and their families education and explanation of various diagnoses, tests, and results; making sure the care plan is executed in a timely and safe manner; and serving as a source of information and communication between various members of the healthcare team. At times, you may need to seek the opinion of those involved in patient care, but with expertise outside of medicine, such as a social worker, dietician, or chaplain.

Assignment, Delegation, and Supervision

Delegation is an essential nursing skill. No matter how efficient you are as a nurse, you will need help to complete all aspects of patient care. The key to delegating success is finding the appropriate person to help, clearly explaining the assignment, and maintaining responsibility for the outcome while providing proper support and supervision.

Tasks for Professional Staff Only

Some tasks should never be delegated to non-professional staff. These include: nursing assessment, examination, diagnosis, care goals or progress plans, and interventions that require advanced knowledge, training, and skills.

Five Rights of Delegation

Prior to delegating a task, it is helpful to consider the five “rights” of delegation:

Right task—Should the task be delegated?
Right person—Is the person being asked qualified to perform the task?
Right circumstance—Is the patient stable and the outcome of the task predictable?
Right communication—Has the task been clearly explained and proper direction been given?
Right supervision—Will the nurse retain responsibility and ultimately be responsible for the outcome of the task?

Other Things to Consider

Tasks that are usually acceptable to delegate are those with unchanging protocols, such as feeding, bathing, transferring, and dressing. Delegation should only be considered in stable patients. Never delegate tasks when the patient is unstable, when the outcome is uncertain or unpredictable, or when the tasks require complex or complicated knowledge or technical skills.

As a nurse, you are a leader. Being a good leader means that you have the ability to unite a team of caregivers to complete tasks to reach an overall goal— to provide exceptional care to your patients.

Being a Good Supervisor

As a nurse, you may be asked to supervise a variety of nursing staff members. These may include other RNs, licensed practical nurses (LPNs), licensed vocational nurses (LVNs), and nursing assistive personnel (NAPs). You may be responsible for coordinating the tasks of the nursing team. This will require clear communication, adequate follow-up, active listening, technical knowledge of all aspects of the supervised work, problem-solving, and conflict resolution skills when these needs arise. A supervisor can evaluate the skills and abilities of each team member, especially with regard to time management, and use this knowledge to more effectively and appropriately delegate. Likewise, these skills will also be necessary and useful for performance evaluations of those you supervise.

Case Management

Nurses are responsible for developing, implementing, and revising care plans that help patients reach and maintain their independence after they are discharged from medical care.

Things to Consider

Nursing case management not only involves patient care in your facility but also includes helping patients find and utilize post-care resources. You will help your patient do this by identifying his or her individual needs and discussing his or her goals. Patient needs may include access to medical therapy and/or medical devices following discharge from healthcare facilities. Commonly ordered medical devices include oxygen machines, suction machines, wound care supplies, and ambulatory assistive devices (braces, crutches, wheelchair, etc.). Effective case management ensures the patient’s safety and the ability to care for himself or herself while also considering options that are most cost-effective for the patient.

Additional Resources

When possible, incorporate evidence-based findings into your patient’s care plan. Regularly review the research within medical literature to maintain the most current level of knowledge and familiarize yourself with any newly advised standards of care. Also, don’t hesitate to access local professionals who may have the knowledge you need to manage a case.

Evolvement of Plan

In addition to initiating the care plan, it will also be your job to revise it at times. Discussing the care plan with your patient will help you identify if changes are necessary and evaluate his or her individual needs. You must also provide information on medications that must be continued, repeat labs or imaging tests that are necessary for care, and any follow-up visits that are needed after discharge.

Patient Rights

The nurse is responsible for not only explaining and educating patients on their conditions and treatment options but also informing them of their rights as patients upon admission to the hospital or other healthcare facility. The right to accept or refuse care is specified in the Patient Self-Determination Act. The nurse needs to be familiar with other healthcare laws that govern and protect a patient, as well.

HIPAA

HIPAA stands for the Health Insurance Portability and Accountability Act. It was designed to protect a patient’s personal information such as his or her name, social security number, birth date, and sensitive medical information, such as a diagnosis or treatment received. Only those involved in direct patient care, insurance reimbursement, or patient management can access and share this information.

Patients’ Bill of Rights

Adopted by the President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry, this document specifies what each patient’s rights and responsibilities are as recipients of healthcare. It includes:

Information disclosure—the right to accurate and easily understood information about healthcare providers, facilities, and health plans
Choice of providers and plans—the right to choose healthcare providers that give high-quality care when needed
Access to Emergency Services—the right to have evaluation and stabilization by emergency services when and wherever needed (These services may be given without authorization and must be given without financial penalty.)
Participation in treatment decisions—the right to be informed of all treatment options and make decisions about one’s care (This right also extends to other healthcare proxies should the patient not be able to make decisions.)
Confidentiality of health information—the right to speak privately with healthcare providers and have all healthcare-related information kept private (This also includes the right to access, read, and copy one’s own healthcare record.)
Complaints and appeals—the right to a fast, fair, and objective review of a complaint against a healthcare plan, provider, care personnel, or facility
Consumer responsibilities—specifies that a patient must disclose relevant information about medications and past illnesses to his or her healthcare provider

Evaluating the Understanding of Rights

Your duty as a nurse is to ensure that your patient understands his or her rights and responsibilities under the Patients’ Bill of Rights, including the right to informed consent. You also are responsible for evaluating your patients’ understanding of privileged communication and duty to disclose as it pertains to informed consent. You must also assess other healthcare team members’ knowledge of patients’ rights and provide education to them as needed.

Collaboration

Collaboration, in this case, is defined as the interdisciplinary interaction between the various areas of healthcare. Nurses work with physicians, social workers, dieticians, pharmacists, and many other healthcare specialties to achieve proper patient care. Collaboration requires integration, cohesiveness, and teamwork. As a nurse, you will often have the closest contact with the patient, and you must be ready to initiate interdisciplinary discussions based on your observations and patient-given information. In effect, you will serve as the central point of contact for your patient’s collaborative healthcare team.

Management

A nurse often functions as the manager of the healthcare team. You must know the roles and responsibilities of each team member, and you will serve as a liaison between the team and the patient. You are a frontline problem-solver: you will need to use conflict resolution skills to settle problems both between team members and between your patient and the team. Developing an overall strategy for handling problems is key to your success in this role. Supervision of properly delegated work is also a key function of a nurse as a manager.

Confidentiality and Information Security

A nurse’s role includes both maintaining confidentiality and taking steps to ensure a patient’s privacy is maintained. Understanding HIPAA (the Healthcare Insurance Portability and Accountability Act) is crucial to this end. You should take steps to ensure only authorized personnel have access to the medical record and that sensitive, private patient information is kept out of public view. This also includes conversations that may relay this type of information to unauthorized persons. Intervention may be necessary if you observe these types of breaches from other healthcare team members.

Continuity of Care

Continuity of care refers to the proper communication of information between different departments and agencies, from one agency to another, to ensure that all parties (including the patient) agree upon and understand the patient’s healthcare goals. The nurse must understand the proper procedures for admission, transfer, and discharge to and from a facility, as well as the proper forms or referral paperwork that is required in the patient’s medical record. You will also be responsible for following up on any unresolved issues for your patient and forwarding this information to the appropriate agency or department such as lab or imaging results. You may also need to be prepared to give report to the patient’s new nursing staff.