Question

Develop a teaching plan for a patient-care problem or professional nursing staff issue. The plan should be based on a health behavior framework (model or theory) that promotes changes in behavior through educational intervention strategies. Provide a rationale for the selected framework.

Answer 1

Nursing is a profession that is focused on collaborative relationships that promote the best possible outcomes for clients. These relationships may be interprofessional, involving a variety of health care professionals working together to deliver quality care within and across settings; or it may be intraprofessional, with multiple members of the same profession working collaboratively to deliver quality care within and across settings.

A nursing care plan provides direction on the type of nursing care the individual/family/community may need. The care plan is essentially the documentation of this process. It includes within it a set of actions the nurse will apply to resolve/support nursing diagnoses identified by nursing assessment.

Care plans provide direction for individualized care of the client. A care plan flows from each patient's unique list of diagnoses and should be organized by the individual's specific needs. Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff.

Healthcare organisations monitor patient experiences in order to evaluate and improve the quality of care. Because nurses spend a lot of time with patients, they have a major impact on patient experiences. To improve patient experiences of the quality of care, nurses need to know what factors within the nursing work environment are of influence.

Guiding Principles

The following principles guide nurses’ practice expectations and are the basis for decision-making when working within the intraprofessional team:

• The goal of professional practice is to obtain the best possible outcome for clients.
• RNs and RPNs study from the same body of nursing knowledge. RNs study for a longer period of time, allowing for greater foundational knowledge in clinical practice, decision-making, critical thinking, leadership, research utilization and resource management. As a result of these differences, the level of autonomous practice of RNs differs from that of RPNs.
• The complexity of a client’s condition influences the nursing knowledge required to provide the level of care the client needs. A more complex client situation and less stable environment create an increased need for consultation and/or the need for an RN to provide the full range of care requirements.
• Respecting and understanding the expectations and contributions of the health care team facilitates appropriate utilization of nurses, enhances collaboration and leads to improved client outcomes.

The Three-Factor Framework

Making effective decisions about which nursing category (RN or RPN) to match with client needs involves considering three factors of equal importance: the client, the nurse and the environment, and deliberating on how they apply to the situation.

Client factors

Decisions about the utilization of an RN and an RPN are influenced by:

1. Complexity:

• the degree to which a client’s condition and care requirements are identifiable and established
• the sum of the variables influencing a client’s current health status, and
• the variability of a client’s condition or care requirements.

2. Predictability:

• the extent to which a client’s outcomes and future care requirements can be anticipated.

3. Risk of negative outcomes:

• the likelihood that a client will experience a negative outcome as a result of the client’s health condition or as a response to treatment.

Client continuum

The three client factors described above combine to create a representation of the client that can be placed on a continuum. The continuum goes from less complex, more predictable and low risk for negative outcomes, to highly complex, unpredictable and high risk for negative outcomes.

All nurses can autonomously care for clients who have been identified as less complex, more predictable and at low risk of negative outcomes. The more complex the care requirements, the greater the need for consultation and/or the need for an RN to provide the full spectrum of care.

Nurse factors

The factors that affect a nurse’s ability to provide safe and ethical care to a given client include leadership, decision-making and critical-thinking skills. Other factors include the application of knowledge, knowing when and how to apply knowledge, and having the resources available to consult as needed. It is important for nurses to be aware of the limits of their individual competence and their practice.

Based on individual practice reflection and the current requirements of their practice environments, nurses must continually enhance their knowledge and competence through ongoing learning, education, experience and participation in quality assurance activities. Nurses can become experts in an area of practice within their own nursing category; however, enhanced competence through continuing education and experience does not mean that an RPN will acquire the same foundational competencies as an RN. This will only occur through the formal education and credentialing process.

Nurses consult with one another when a situation demands nursing expertise that is beyond their competence. Consultation involves seeking advice or information from a more experienced or knowledgeable nurse or other health care professional. The amount of consultation required is determined by the complexity of client care needs and the nurse’s competence. The practice setting influences the availability and accessibility of these consultation resources.

An important aspect of efficient consultation is providing nurses with the time and resources needed to consult as often as is necessary to meet client needs. Nurses also need to clarify their reasons for consulting and determine an appropriate course of action. Unless care is transferred, the nurse who sought consultation is still accountable for the client’s care.

Consultation results in one of the following:

a) the nurse receiving advice and continuing to care for the client

b) the nurse transferring an aspect of care to the consultant

c) the nurse transferring all care to the consultant.

When any care is transferred from one nurse to another, the accountability for that care is also transferred.

When a care provider assignment involves the expectation of consultation, nurses must assess that the required consultative supports are available.

When supports are inadequate to meet client needs and ensure quality care, nurses must take appropriate action.

Whenever the need for consultation exceeds the efficient delivery of care, it is most likely that the client requires an RN to provide all care.

Environment factors

Environment factors include practice supports, consultation resources and the stability/predictability of the environment. Practice supports and consultation resources support nurses in clinical decision-making. The less stable these factors are, the greater the need for RN staffing. The less available the practice supports and consultation resources are, the greater the need for more in-depth nursing competencies and skills in the areas of clinical practice, decisionmaking, critical thinking, leadership, research utilization and resource management.

Conclusion

The more complex the client situation and the more dynamic the environment, the greater the need for the RN to provide the full range of care, assess changes, reestablish priorities and determine the need for additional resources. The technical and cognitive aspects of nursing practice cannot be separated. Decisions about utilizing an RN or RPN are made after considering client care requirements and the nurse’s cognitive and technical expertise in a given environment. By considering the client, nurse and environment factors, nurses and key stakeholders can determine which category of nursing is appropriate for specific roles in client care. The application of the three-factor framework will help decisionmakers determine which roles and activities are not appropriate for autonomous RPN practice. Examples include, but are not limited to, the following:

• triage nurse
• circulating nurse
• administering conscious sedation or monitoring sedated clients (includes deep sedation and general anaesthesia).