Table of Contents:
1. Continuity of Care
2. Quality Improvement
3. Conflict Resolution
4. NCLEX Practice Questions
Management Principles
1. Continuity of Care
Documentation
Documentation is the written record of client care
that supports:
y Effective communication
y Legal accountability
y Team collaboration
y Quality improvement
y Billing and reimbursement
When documenting, nurses must:
Document in a timely manner to avoid delays in care.
Do not delay documentation until the end of
the shift.
y Maintain client confidentiality.
y Do not share client records with individuals not
directly involved in care (see LEGAL CHEAT SHEET
for more information on confidentiality).
y Follow facility policy and best practices for
documentation (TABLE 1).
y Use only facility-approved terminology; avoid acronyms.
y Example: Do not use trailing zeros, or “Q.D.”
or “Q.O.D.”
Common errors in documentation:
y Omission or incomplete charting: Failing to
chart interventions or client responses (e.g., failing
to document follow-up pain score after
administering analgesics)
y Charting in advance: Documenting care before it is
provided is falsification
y Bias: Using subjective statements (e.g., “client
is difficult”)
Documentation: Document care immediately after
it is performed, not at the end of the shift. Record
only objective and factual information, avoid
opinions, and never chart care before providing it.
TABLE 1. BEST PRACTICES FOR DOCUMENTATION
Practice
Examples
Be specific.
Respirations even and
unlabored at 12/min.
Client appears to be
breathing comfortably.
Record objective
facts, not opinions.
Client refused antibiotic,
stating, “I won’t do anything
you say until you give me
pain medicine.”
Client being uncooperative
and demanding.
Be accurate
and thorough.
VAD site is patent and
intact without any redness,
swelling, or drainage.
VAD site assessment
appears normal.
When documenting nursing assessments, interventions,
and teaching, include:
Time performed, equipment used, and client response.
Reporting and communication
Effective communication is a high priority to prevent
safety issues.
Use SBAR format (Situation, Background,
Assessment, Recommendation/Readback) to provide
a standardized, effective report (TABLE 2).
y Handoff report: Communicating client information
when care is transferred from one nurse to another
(shift change, client transfer)
SBAR: Use the SBAR format (Situation,
Background, Assessment, Recommendation/
Readback) to ensure reports are standardized
and include all necessary information.
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Management of Care
Continuity of care involves providing consistent,
coordinated client care through effective teamwork
and communication.
1. Continuity of Care, Continued
TABLE 2. SBAR REPORT
Step
Example
Situation:
Reason for calling, caller’s
name and title, and client
name/identifier
“This is Nurse Adams
calling because Mr. Smith
has dyspnea.”
Background:
Pertinent history
(diagnosis, medications)
“The client has asthma
and is on oxygen at
2 L/min via nasal cannula.”
Assessment:
Current VS and status
“He has dyspnea and
wheezing with an oxygen
saturation of 88%.”
Recommendation/
Readback:
Recommended actions
and readback of
important information
“I recommend immediate
evaluation by the HCP
and an order for an
albuterol nebulizer.”
Interprofessional collaboration:
y Nurses must collaborate with the interdisciplinary
team to meet the client’s holistic needs.
y Assess the need for referrals to other disciplines
(TABLE 3).
Discharge planning and education:
y Discharge planning and education begins
upon admission.
y Case managers support discharge needs and
monitor expected client progress (critical pathways).
TABLE 3. HEALTHCARE TEAM MEMBERS
Role
Examples of Referral Needs
Pharmacist: Manages
medication regimens
and drug interactions
y Assists with adjusting
medications or doses
based on client allergies
or condition (renal failure)
y Determines medication
interactions
Physical therapist/
physiotherapist:
Assists with gross
mobility (“legs”) and
physical exercise
y Performs strengthening
exercises
y Teaches clients to use
mobility devices (walker)
y Provides prosthetic
training after amputation
Occupational
therapist: Assists with
ADLs and with using
adaptive equipment
focused on fine motor
skills (“hands”)
y Recommends adaptive
equipment for dressing
(button hooks) and eating
y Assists with improving
hand coordination for
writing
Registered dietitian:
Manages nutritional
needs and dietary
plans
y Adjusts diets based
on diagnoses (e.g., low
sodium for hypertension)
y Provides education and
support for tube feedings
Respiratory
therapist: Provides
pulmonary hygiene
and respiratory
interventions
y Administers nebulizer
treatments
y Adjusts mechanical
ventilator and oxygen
settings
Social worker:
Addresses
psychosocial needs
and access to
resources
y Connects clients to
support groups
y Seeks out financial
resources for clients
unable to afford
medication or equipment
Management of Care
y When completing a handoff report:
y Conduct at the bedside if possible.
Emphasize priorities of care (allergies, changes
in condition, critical lab results).
y Avoid unnecessary details.
y Allow the receiving nurse to ask questions.
y Document the date, time, and individuals
involved in the handoff report.
Referrals: Case managers coordinate discharge planning and evaluate client progress. Physical therapists
focus on gross mobility and exercises (“legs”), while occupational therapists assist with adaptive tools and
fine motor skills (“hands”).
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TABLE 3. HEALTHCARE TEAM MEMBERS, CONTINUED
Role
Examples of Referral Needs
Case manager:
Coordinates
treatment, services,
and discharge
planning throughout
care
y Evaluates client progress
compared to expected
progress (critical pathways)
y Coordinates discharge
plans for clients (home
health consult)
Speech-language
pathologist:
Assists with
speech, language,
and swallowing
disorders
y Provides therapy for
speech alterations
(aphasia, dysphasia)
y Teaches safe swallowing
techniques for clients with
dysphagia
Chaplain/clergy:
Provides spiritual
and emotional
support
y Offers spiritual support
(prayers, religious services)
at the client’s request
y Provides support for clients
and families during palliative
and end-of-life care
2. Quality Improvement
Quality improvement (QI) enhances care delivery through
process improvement initiatives:
y Identifying safety issues: Monitor for trends
and problems.
y Root cause analysis (RCA): Investigate adverse
events after they occur to identify the cause.
y QI projects: Implement evidence-based changes to
improve care (e.g., improving hand hygiene, reducing
infection rates).
y Risk management: Identify and address organizational
risk factors to prevent adverse events.
Nurses’ role in QI:
Implement current EBP when providing care.
y Example: Removing indwelling catheters as soon
as possible to prevent infections
y Participate in QI projects and activities to improve
client care.
Quality improvement: Nurses should participate in
QI by implementing evidence-based practices and
reporting unsafe work conditions.
Identify and report potential safety issues
in practice.
Complete an incident report when an unexpected
safety event occurs (wrong site surgery, fall,
medication error).
y Document an objective description including:
y What you observed/incident details
y Client response
y Follow-up actions
Do not document the existence of an incident
report or include a copy of the report in the
client’s health record.
3. Conflict Resolution
Conflict occurs when differing opinions or priorities
among team members cause tension.
y Open and professional communication can reduce
unnecessary conflict.
y Effective conflict resolution ensures team cohesion
and client safety.
y Unresolved conflict is a barrier to effective client
care; conflicts should be resolved promptly.
y Different conflict resolution styles are used to
address conflicts (TABLE 4).
TABLE 4. CONFLICT RESOLUTION STYLES
Response
Examples
Accommodation:
Giving in to another’s
desires while neglecting
one’s own
“Let’s do your plan even
though it’s not what I
wanted.”
Avoidance: Ignoring
or withdrawing from
conflict
“Let’s talk about this
later when we’re both
calmer.”
Collaboration: Seeking
a solution that satisfies
both parties
“Let’s work together to
find a solution.”
Competition: Pursuing
one’s own goals at the
expense of another
“I think my approach
is best, and I will stick
with it.”
Management of Care
1. Continuity of Care, Continued
Incident reports: An incident report must be
completed whenever an unexpected safety event
occurs. Do not mention or include the incident
report in the client’s health record.
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4. NCLEX Practice Questions
1. “Client reports severe nausea; antiemetic administered.”
2. “Client reports nausea after pain medication. Administered
ondansetron 4 mg IVP.”
3. “Client states, ‘I feel nauseated after morphine.’ Administered
ondansetron 4 mg IVP. Client reports decreased nausea.”
4. “Client appears nauseated after pain medication
administration. Administered ondansetron 4 mg IVP.
Will contact HCP if symptoms do not improve.”
Hint: Only one option demonstrates specific
and objective documentation.
SBAR: Which is the best example of an
appropriate SBAR report?
1. “Mr. Smith has dyspnea and needs oxygen immediately.”
2. “Mr. Smith has dyspnea and needs new orders. Can you
assess the client?”
3. “Mr. Smith, who has COPD, has acute dyspnea and wheezing.
I recommend supplemental oxygen.”
4. “Mr. Smith, who has COPD, has dyspnea. I administered
nebulizer medications, and he is not improving.”
Hint: Only one option includes all elements of
an SBAR report.
Consults: A nurse receives an order to decrease
the medication dose for a client with renal failure.
Which team member should the nurse contact?
1. Pharmacist
2. Social worker
3. Case manager
4. Registered dietitian
Correct:
3. This option provides objective and specific
information, including client quotes, medication
name and dose, and client response.
Incorrect:
1. Does not provide specific information (medication
name and dose, client quote) or client response
to intervention.
2. Does not provide specific information (client quote)
or client response to intervention.
4. Provides subjective opinion instead of facts (e.g.,
client appears).
Correct:
3. This option describes the situation,
background, assessment findings,
and care recommendations.
Incorrect:
1 & 2. Do not provide background or assessment
findings.
4. Does not provide assessment findings or care
recommendations.
Correct:
1. Pharmacists assist with determining safe
medication dosing.
Management of Care
Documentation: Which is the best
example of appropriate documentation?
Incorrect:
2, 3, & 4. These health care team members do not assist
with determining safe medication dosing.
Hint: Only one team member provides guidance on
medication dosing.
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Documentation should be _____ (objective or
subjective?), factual, and performed immediately
_____ (before or after?) care is provided.
What are the elements of an SBAR report?
Which health care team member should the nurse
contact for care coordination and discharge
planning? For assistance with gross mobility and
exercise? For adaptive tools for fine motor skills?
Name two ways nurses should participate in
quality improvement.
Whenever an unexpected safety event occurs,
nurses should complete a(n) _____ report.
Incident reports should be mentioned in the
client’s health record (true or false?).
Answers: 1. objective, after 2. Situation, Background, Assessment, Recommendation/Readback; SBAR provides a standardized format that ensures all
necessary information is included in the report. 3. Case managers; Physical therapists; Occupational therapists 4. Implement evidence-based practices,
report unsafe work conditions 5. incident; false
Astle, B., Duggleby, W., Potter, P. A., Stockert, Perry, A. G., & Hall,
A. M. (2024). Potter and Perry’s Canadian Fundamentals of
Nursing (7th ed.). Elsevier.
Callahan, B., Hand, M., & Steele, N. (Eds.). (2023). Nursing: A
concept-based approach to learning (4th ed., Vol 2).
Pearson.
Berman, A. B., Snyder, S. J., & Frandsen, G. (2021). Kozier & Erb’s
fundamentals of nursing: Concepts, process, and practice
(11th ed.). Pearson.
Huston, C. J. (2024). Leadership roles and management functions in
nursing: Theory and application (11th ed.). Wolters Kluwer.
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (Eds.). (2023).
Fundamentals of nursing (11th ed.). Elsevier.
Waddell, J. I. & Walton, N. A. (2020). Yoder-Wise’s leading and
managing in Canadian nursing (2nd ed.). Elsevier.
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Management of Care
References: