Nursing Management 2

An analysis of some management factors influencing a chosen aspect of client care

Introduction

When nursing care is broken down into its constituent elements it could be described as an “art and science involving the application of knowledge and skills related to basic social sciences, physical sciences, bio-behavioural sciences, ethics, contemporary issues and nursing knowledge” (Potter & Parry, 2001). Key to all of these aspects is the skill of assessment along with the subsequent interpretation of the results that it provides. Nurses, regardless of their health care setting, are constantly seeking information about their patient’s health status (Potter & Perry, 2001) and the assessment is their tool for gathering that information either through casual assessments like a cursory ‘does my patient look well?’ to more formal clinical examinations like the measuring and recording of vital signs. The expertise and clinical judgement required to collect and interpret the results of any assessment is the “essence of nursing care and the basis of advanced nursing practice and nursing science” (Carnevali & Thomas, 1993).

Patient assessment, also known as triage, upon arrival to an Accident and Emergency (A&E) department is a specialised form of this skill. For the A&E nurse performing triage, the ability to think critically and interpret patient behaviours and physiological changes becomes very important (Barkausas V, 1998) and the ability to carry out a comprehensive assessment would enable an accurate and objective discovery of needs and is the cornerstone of identifying the necessity for further assessment and intervention (Kenworthy, Snowley & Gilling, 2002).

However, possessing clinical skills and knowledge on topics like vital signs, inspection, palpation, auscultation and percussion etc. needs to be balanced by an understanding of management issues that surround triage.

Management issues around triage

The practice of triage is to sort patients according to need by assigning them degrees of urgency and hence decide their order of treatment (Cooke M & Jinks S, 1999). It involves a complete health assessment of a detailed review of the patient’s condition by collecting a history and performing a behavioural and physical examination, with, according to Potter and Perry, each examination being tailored to the patient’s needs (Potter & Perry, 2001). In an ideal care setting, each patient that arrives at the A&E department would never need triage as they would be seen by a doctor and nurse, fully assessed and treated in rapid succession. However the NHS is not an ideal care setting due to overuse of A&E departments for non-emergencies and “chronic under-funding and resource shortages” (Hutton et al, 2000), resulting in a system that can regularly, operate close to capacity. As such, triage has become more of a queue management system based around the concept of resource allocation.

Resource allocation

According to the ‘Commission on the NHS’ (Hutton et al, 2001), over the last decade there has been a relentless drive towards efficiency within the NHS with resources being allocated and re-allocated in an attempt to seek ever improving efficiency. The commission’s definition of resource allocation is woven around the idea of rationing, the most controversial word in the NHS’s vocabulary, and their unremarkable claim that the demand for free health resources will outstrip their supply has become laden with ideological insinuations and value judgements and is already apparent in waiting lists for non-urgent surgery and that, due to “myopic cost-cutting” (Hutton et al, 2001) there is at times of high seasonal demand, inadequate spare bed capacity within the NHS to cope.

Yet what is efficiency? According to the dictionary (Oxford, 2003) efficiency is the ratio of useful work done to total energy expended yet often the term is often used to look at simple economics. This is, on the surface, not wholly related to triage when the economics alone are examined, instead other definitions of ‘resources’ need to be examined.

Time is a valuable resource within any health care setting, particularly within A&E recently due to government guidelines and the 4-hour ‘window of treatment’ target established by central government (Department of Health, 2000). Time management skills are a useful way of dealing with patient needs and staff stress levels with the skills involve learning how, where and when to use one’s time with the patients (Gustafson, Duchene & Baker, 1992). Building upon the National Council of State Boards of Nursing (National Council of State Boards of Nursing (NCSBN) NCSBN, 1995) definition, time management deals with…

Goal setting Reviewing the patient’s goals of care for the day and any goal you have for activities (i.e. completing documentation, preparing medications for administration)

Time analysis Reflection on how time is used, and while working keeping track of how time has been used in different activities as it provides valuable information about how well organised you are, and how long certain activites will take in the future.

Priorities Set priorities that need to be established for patient within set time frames. Determine when is the best time, for example, to do wound care, practice ambulation etc.

Interruption control Everyone needs time to socialise or to discuss issues with colleagues. However, do not let this interfere with important patient care activities. Use time during report, mealtime, or team meetings to best advantage. Also, plan time to assist fellow colleagues so that it compliments your patient care schedule.

Evaluation At the end of each shift, take time to think about how effectively time has been used. Think critically about how improvements could be made and take pride in tasks done well.

Resources, in this case, also include members of the health care team. In any setting, the administration of patient care occurs more smoothly when staffs are working together (Potter & Perry, 2001). It allows for a greater ‘unity’ and efficiency in care as processes do not need duplication because everybody involved in the care is aware of the roles of the other team members and can hence concentrate on their aspect of care.

Building upon the earlier claim that triage has become little more than a medically skilled queue managing exercise, it can be seen that the nurse at triage selects those patients at greatest medical need who need the resources of the department first, while allocating the non-urgent cases into a ‘holding pattern’, to receive resources at a later time.

Additionally, and regardless of whether a complete or partial physical assessment is performed, an examination should be integrated into routine care. This practice makes more efficient use of time as, while a wound is being cleaned it can be accurately assessed; while a patient is walking to and from the triage desk a nurse can assess their range of motion and gait; and while talking to them, an assessment of their breathing and level of understanding, among other things, can be carried out.

Risk management

For many years, the concept of risk management has been used by organisations like insurers and the airline industry, among others, to assess the likelihood of an adverse event happening and to estimate how this would impact on the organisation and its market. Accurate risk management has allowed enterprises to focus their investments into areas that are likely to succeed or have a reduced chance of serious incidents that would affect their profits. However the notion has, along with the drive for efficiency that is explored later, become increasingly important within the NHS (Kenworthy et al, 2002). For example, with the removal of Crown immunity from the NHS during the 1990’s health care is now exposed to the possibility of litigation.

Risk management is a system of ensuring appropriate nursing care (Eggland, 1995), and so all nurses should be risk managers. It requires good documentation (NMC, 2003 and UKCC, 1993) around the details of care given and details associated with it like feedback from the patient and a record of when, how and whom was informed about any change in the patient’s condition.

Many hospitals now have membership of the Clinical Negligence Scheme for Trusts (CNST) (Kenworthy et al, 2002), which is a system for assisting hospital trusts to identify and manage their risk in a proactive fashion aimed at limiting their exposure to damaging and expensive litigation. In 2002, the potential bill to the NHS for litigation had breached the £1 billion per annum level taking much-needed funds away from the clinical setting (Kenworthy et al, 2002).

It is important to view risk management as a proactive and positive measure, a goal more likely now that it is incorporated into clinical governance systems (Kenworthy et al, 2002). This is done by working with other health care providers to focus on quality and clinical standards as a way of ensuring that the prospects for untoward incidents or mistakes occurring is reduced to an absolute minimum.

Quality management

Within any health care setting the demands of looking after patients combined with other responsibilities a nurse holds, it can prove difficult to take the time to critically reflect upon practice and consider how improvements can be made (Potter & Perry, 2001). It can become far too easy for a nurse to say they don’t have the time to consider such things while they try to balance their demanding workload, and, though it is perhaps an understandable response, it is important to remember that not trying to improve a service directly and negatively affects those under your care.

Patients are becoming increasing concerned with the quality of health care (Hutton et al, 2000) due to rising media coverage around incidents of ‘poor care’, escalating financial costs and that they are more informed (DoH, 2001 – The expert patient). They want easy access to services, timely and safe delivery of coordinated and effective care that results in a positive outcome. This is where the philosophy of total quality management (TQM) comes in.

TQM has become the philosophy of change for many commercial and industrial organisations and businesses by influencing every department and every individual within that organisation. Its guiding principle is that employees need to think differently and therefore act differently from their usual habits (Triolo et al, 1997), and that perfection is never attained. TQM is a defined as a structured system for satisfying internal and external customers and suppliers by integrating the business environment, continuous improvement, and breakthroughs with development, improvement, and maintenance cycles while changing organisational culture (MSN Encarta, 2004). One of the keys to implementing TQM can be found in this definition. It is the idea that TQM is a structured system. In describing TQM as a structured system, I mean that it is a strategy derived from internal and external customer and supplier wants, in this case patients and their relatives, and needs that have been determined through consultation with health care professionals, government agencies and the communities in which hospitals exist.

Within healthcare, TQM is intended to broaden each member of staff’s concept of relationships with others in doing work as, according to Perry & Porter, 2001 and Triolo et al, 1997), to make improvements in health care, each employee must be willing to work with others.

TQM also supports the principle of the ‘process’, and that processes make up systems through which care is delivered (Triolo et al, 1997). For example, many individuals are involved in a single process such as medication administration. The nurse may administer the medication but it is the physician that prescribes it and the pharmacist that prepares it and arranges for it to be delivered to the care environment. With so many individuals involved within most work processes, strong leadership, good collaboration, effective communication and a network of support for staff are essential factors.

Quality improvement is what TQM is all about and has a direct effect on nursing care if it is implemented within the health care organisation (Triolo et al, 1997). The quality of nursing practice is the principle responsibility of each registered nurse and their manager (NMC, 2003), and as such, each professional nurse must learn to assess their own success in delivering appropriate and effective care and “recognise that good outcomes are the product of all the individual actions that relate directly or indirectly to the care received by a patient” (Scoble & Hembrough, 1993). The outcomes of care are a measure of the performance of the entire health care team (Potter & Perry, 2001) so managing quality becomes a multi-disciplinary team (MDT) effort.

Relating this to the practice of triage, quality could be defined as the rapid and accurate assessment of a person’s reporting symptoms and assigning them a ‘place in the queue’ appropriate to their medical need that would ensure they are seen by a physician or other health care provider in the most time and resource efficient manner possible with the understanding that re-assessment may be needed upon change in symptoms or other external influencing factors i.e. the arrival of a more medically urgent case.

Conclusions

For nurses in practice, the underlying rationale for quality improvement and risk management programmes is the goal of attaining higher care and while resource allocation is also about better care, it is also principally about efficient care. These tools apply in all areas of nursing practise including triage. Ensuring a high quality of practise is the concern of every nurse (NMC, 2003) while, as established earlier triage is essentially about resource management around efficient care. Risk management applies especially within the A&E departments as they nationally have one of the highest occurrences of staff and patient incidents (DoH, 2003). I have personally witnessed and suffered from the abuse that patients within the A&E setting have brought to bear on staff, highlighting the essential need for risk management, not only involving the normal ward assessments of health and safety (i.e. safe disposal of sharps and infection control), but also of security. Indeed, there have been instances where patients had to be escorted off the hospital premises due to the staff at triage assessing them via risk management techniques to be a danger to other patients and staff while appearing medically stable enough to leave the department. Therefore, while quality improvement should have only a positive outcome, resource allocation and risk management within triage focus their decisions on the ‘greater good’ issues like who should be treated first and is it safe to treat them?

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