NCLEX: Safe, Effective Care Environment

Safe, Effective Care Environment: MANAGEMENT OF CARE

focus topic: Safe, Effective Care Environment


focus topic: Safe, Effective Care Environment

A. Definitions

1. Case management—process that involves comprehensive coordination of activities and services provided to the client throughout the continuum of care or episode. Activities include: case finding, screening, intake, assessment, problem identification, prioritization of client’s problems and needs, planning, reassessment, evaluation, documentation, designing and monitoring clinical pathways, and identification of variances.

2. Continuous quality improvement—process used to make improvements in client care; indicators of excellence are identified and process involves actively including input from and collaboration with the client (whose needs are at the center of the process), the family, and all health-care team members.

3. Incidents/variance reports—part of quality improvement, where occurrences take place in a health-care agency that are not typical according to medical orders, may be an accident, or may be a violation of policy and procedures (e.g., wrong medication dose, a client or visitor falls, needle stick by nurse). These are considered unexpected incidents, exceptions that happen during client care.

4. Quality assurance—activities that evaluate the quality of care provided to clients to ensure that it meets predetermined standards of excellence.

5. Resource management—providing appropriate number and type of resources needed by clients to achieve desired outcomes.

6. Supervision—process of guiding, encouraging, and assessing the work of others to whom tasks were delegated.

7. Delegate responsibility and direct nursing care provided by others—based on particular client/ family needs and on job description, roles, functions, and skills of other nursing personnel: client’s condition (stable or medically fragile), complexity of required care, potential risks for harm to client, degree of needed problem-solving expertise, predictability of outcome, type and level of client interaction required. Important: The person who delegated the task has the responsibility and final accountability for effective completion of the task.

Safe, Effective Care Environment

B. Management theories

1. Microlevel theories: clarify and predict behavior (e.g., motivation) of the individual, with input on the group/organization (e.g., group dynamics).

2. Macrolevel theories: focus on best ways to make changes within an organization, organizing projects, obtaining resources, attaining goals.

3. Intrapersonal/interpersonal theories:

  • Cognitive: belief—a person’s motivation is based on expectations about what will happen as a result of own behavior; involves goal setting, with regular feedback to increase motivation to achieve.
  • Scientific management: belief—repetition of task will result in expertise.
  • Neoclassical management: based on Maslow (i.e., person continuously strives to meet higher level needs); ERG (Existence, Relatedness, Growth); job redesign (i.e., ensures that task has validity, significance, autonomy, and feedback).
  • Social/reinforcement: belief—motivation comes from learning from those with whom a person identifies; conditioned by reinforcement.

C. Management behaviors

1. Decision maker

  • Initiator of new projects.
  • Crisis handler (e.g., interpersonal conflicts among staff).
  • Resource allocator (people, physical, financial).
  • Negotiator.

2. Communicator

  • Monitor of data collection and processing.
  • Dissemination of collected information.
  • Speaker on behalf of agency.

3. Representative

  • Institutional figurehead.
  • Group leader.
  • Liaison between agency and community.



focus topic: Safe, Effective Care Environment

A. When managing a number of clients at the same time, the nurse needs to set priorities by assessing types of care needed:

  •           Decide on the most important nursing activity (giving a medication? performing a treatment? taking vital signs? providing nutrition? measuring I&O? etc.).
  •           Identify the first action the nurse needs to take.
  •           Select the best nursing action.
  •           Determine which client needs immediate care.

B. Determine priorities with the guidance of:

1. Maslow’s hierarchy of needs.

  •           Choose physiological needs (survival) as the highest level of priority.
  •           Followed by safety needs.
  •           Then psychological needs (care and belonging).
  •           Lastly, self-actualization needs.

2. Steps of the Nursing Process (A2DPIE)

  •           First is assessment (data collection).
  •           Next, analyze the data (nursing diagnoses).
  •           Then, plan (goals).
  •           Followed by implementation (actions).
  •           Finally, evaluation (outcome).


  •           Airway (e.g., patent airway)
  •           Breathing
  •           Circulation
  •           Safety

4. RACE (e.g., in event of fire)

  •           Remove the client.
  •           Then sound the alarm.
  •           Call the fire department.
  •           Extinguish the fire.


focus topic: Safe, Effective Care Environment

A. Definition: any man-made (e.g., toxic material spill, riot, explosion, structural collapse) or naturally occurring (e.g., communicable disease epidemic, flood, hurricane, earthquake) event that results in destruction or devastation that causes suffering, creates human needs, and cannot be alleviated without support

B. Goal: reduce vulnerability to prevent recurrence

C. Benefits of a disaster plan:

  •           Decrease in costs of damage control.
  •           Decreased extent and duration of injury.
  •           Decreased loss of life
  •           Increased ability to respond to unforeseen disasters.

D. Health-care components

  •           Early warning signals, with realistic expectations.
  •           Brief and succinct assessment of those at risk.
  •           Simple, flexible rescue chains that unfold in organized stages/steps.

E. Nursing responsibilities

  •           Nurses at the scene: assisting with rescue, evacuation, and first aid.
  •           Nurses at the hospital: triaging victims and providing acute care.

a. Triage: a system of client evaluation to set up priorities, assign appropriate staff, and start treatment

  •           In emergencies: greatest risk receives priority.
  •           In major disasters: selection is based on doing what can be done to benefit the largest number; those needing highly specialized care may be given minimal or no care. First, take care of those    needing minimal care to save their lives, and who in turn can be available to help others.
  •           Nurses at community shelters or health clinics: assessing, planning, implementing, and evaluating ongoing health-care needs of victims.

F. Level of prevention

  •           Primary prevention: prevention of disaster and limiting consequences when cannot be prevented.
    a. Nursing activities: identification of factors that pose actual or potential problem.
  •           Secondary prevention: responding to the disaster, halting it, and resolving problems caused by it.
    Nursing activities: assessment of extent of injuries; tagging victims for treatments and evaluation; providing first aid; identifying complications; coordinating activities of shelter workers.
  •           Tertiary prevention: recovery and prevention of recurrence.
    a. Nursing activities: implementing community’s disaster plan; providing continuous assessment, planning, implementation, and evaluation; providing counseling as needed to victims and coworkers; educating the public about disaster preparedness.


focus topic: Safe, Effective Care Environment

A. Know location of:

1. Escape routes, escape doors. Keep fire exits clear.

2. Available equipment.

  •           Fire alarms.
  •           Fire sprinkler controls.
  •           Fire extinguishers.

B. Identify fire hazards.

  •           Faulty electrical equipment and wiring.
  •           Overloaded circuits.
  •           Plugs not properly grounded.
  •           Smoking.
  •           Combustible substances → spontaneous combustion.

C. Prevention.

  •           Report frayed or exposed electrical wires.
  •           Avoid overloaded circuits.
  •           Don’t use extension cords.
  •           Use only three-pronged grounded plugs.
  •           Avoid clutter.
  •           Remove cigarettes and matches from room; control smoking according to institutional policy; limit smoking to designated areas.
  •           Immediately report smoke odors and burning.

D. Action to take in event of fire in immediate vicinity:

  •           Move clients to safety (triage those who are not ambulatory or are otherwise incapacitated).
  •           Sound alarm.
  •           Close all windows and doors.
  •           Shut off valves for O2.
  •           Follow agency policy about announcing fire and location, notifying fire company, and evacuation plan.
  •           Avoid using elevators.


focus topic: Safe, Effective Care Environment

A. Suspect malfunction in equipment when it:

  •           Does not work consistently or correctly.
  •           Makes unusual noise.
  •           Gives off unusual odor.
  •           Produces extreme temperature.
  •           Produces sparks.

B. Replace immediately; don’t repair it.

C. Call maintenance department to check for safety and repair.

D. When O2 is in use:

  •           Secure the O2 according to institutional policy.
  •           Remove flammable liquids from the area.
  •           Put up “oxygen in use” signs.


focus topic: Safe, Effective Care Environment

With increasing ethnocultural diversity among healthcare clients and staff, health-care providers must increase their sensitivity to and knowledge of cultural concepts, be aware of both similarities and differences in values and beliefs that exist across cultures, and know how this may affect health-care delivery. Important objectives are to increase respect and sensitivity for diversity in order to minimize potential for transgressing cultural norms, and to provide culturally conscious health-care and working relationships among clients and staff from dissimilar cultures.

The purpose of this section is to provide a framework/ structure for assessing, planning, and implementing culturally conscious interventions.

We have selected 10 essential areas as guidelines for assessing cultural characteristics that have implications for health and health care: communication, family roles, biocultural ecology, high-risk health behaviors, nutrition, pregnancy and childbearing practices, death rituals, spirituality, health-care practices, and health-care practitioners.


focus topic: Safe, Effective Care Environment

A. Language

1. What is the usual volume and tone of speech?

  •  Guidelines: use interpreters (to provide meaning behind words) rather than translators (who just restate words); avoid use of relatives and children; use interpreters of same age and gender when   possible. Select the words you use carefully, avoiding buzz words and jargon. Speak clearly, pacing yourself to be neither too fast nor too slow. Words that are slurred, have many syllables in them, or are too technical make communication more difficult. Speaking too fast may overload the client and make it difficult for the client to follow. Speaking too slowly may lose the client’s attention. (1)Select the gestures you use with care, using your nonverbal behavior to underscore your words and your actions. The proper use of gestures can clarify a message, and drawings can sometimes be helpful. Be careful, however; not all gestures mean the same thing in all cultures.

B. Cultural communication patterns.

  • Willingness to share their thoughts and feelings.
  • Use and meaning of touch between family, friends, same sex, opposite sex, with health-care provider.
  • Personal space: meaning of distance and physical proximity.
  • Eye contact: special meaning for staring (rude, “evil eye”); for avoidance of eye contact (e.g., not caring, not listening, not trustworthy); variation of eye contact among family, friends, strangers, and socioeconomic groups.
  • Facial expression: how emotions are shown (or not) in facial expressions; use and meaning of smiles.
  • Standing, greeting strangers: what is acceptable.

C. Concept of time: past, present, or future oriented; social time vs. clock time

D. Names: expected greetings by health-care providers


focus topic: Safe, Effective Care Environment

A. Gender roles: patriarchal or egalitarian; change in perceived head of household during different life stages; male/female norms (e.g., stoic, modest)

B. Prescriptive (should do), restrictive (should not do), taboo behaviors for children and adolescents

  • Prescriptive (e.g., “Fat children are healthy”).
  • Restrictive practices (e.g., silence, not anger, at parents).
  • Taboo (e.g., discussion of sexuality).

C. Family roles and priorities

  • Family goals and priorities (family needs may have priority over individual health needs).
  • Developmental tasks.
  • Aged: status and role.
  • Extended family (biological and nonbiological): role and importance.
  • How social status is gained: through heritage? Educational accomplishments?

D. Alternative lifestyles

  • Nontraditional families: single parents, blended families, communal families, same-sex families.


focus topic: Safe, Effective Care Environment

A. Variations in color of skin and biological variations

1. Skin color: special problems/concerns: assessment of jaundice, “mongolian” spots, and blood/oxygenation levels in dark skin. Considerations for health care:

  • Assessment of anemia: examine oral mucosa and nail bed capillary refill.
  • Assessment of jaundice (e.g., in Asian people): look at sclera.
  • Assessment of rashes: palpate.
  • Get a baseline of skin color from family.
  • Use direct sunlight.
  • Look at areas with least amount of pigmentation.
  • Compare skin in corresponding areas.

2. Biological variations in body, size, shape, and structure: long bones, width of hips and shoulders, flat nose bridges (relevance for fitting eyeglasses), shorter builds (at variance with normative growth curves); mandibular and palatine dimensions (relevance for fitting dentures); teeth (peg, extra, natal, large size); ears (free, floppy, attached); eyelids (epicanthic folds).

3. Diseases and health conditions:

  • Specific risk factors related to climate, topography (e.g., air pollution, mosquito-infested tropical areas).
  • At-risk groups for endemic diseases (those that occur continuously in a specific ethnic group): e.g., malaria, liver and renal impairment, infectious blindness and scleral infections, otitis media, respiratory diseases (e.g., tuberculosis, coccidioidomycosis).
  • Increased genetic susceptibility for diseases and health conditions (e.g., diabetes, dwarfism, muscular dystrophy, cystic fibrosis, myopia, keloid formation, gout, cancer of stomach is more prevalent in blood type O, sickle cell anemia, Tay- Sachs disease).

4. Variations in drug metabolism (e.g., cardiovascular effects of propranolol in Chinese; peripheral neuropathy in Native Americans on isoniazid).

5. Variations in blood groups (e.g., Native Americans usually are type O and no type B; Rh-negative nonexistent in Eskimos, more often in Caucasians); twinning (dizygote) is highest among African Americans.


focus topic: Safe, Effective Care Environment

  • Use of alcohol, tobacco, recreational drugs
  • Level of physical activity; increased calorie consumption
  • Use of safety measures (e.g., seat belts and helmets and safe-driving practices)
  • Self-care using folk and magicoreligious practices before seeking professional care


focus topic: Safe, Effective Care Environment

A. Meaning of food: symbolic, socialization role; denotes caring and closeness and kinship, and expression of love and anger

B. Common foods and rituals

  • Major ingredients commonly used (high sodium, fat, spices).
  • Preparation practices (e.g., kosher does not mix meat with dairy in cooking, eating, serving).
  • Afternoon tea (British), morning coffee (American).
  • Fasting (e.g., Muslims, Catholics, Jews).
  • Foods not allowed (e.g., no shellfish or pork in kosher diet).

C. Nutritional deficiencies and food limitations

  • Enzyme deficiencies (e.g., in glucose-6-phosphate dehydrogenase deficiency, fava bean can cause hemolysis and acute anemic crisis).
  • Food intolerances (e.g., lactose deficiency).
  • Significant nutritional deficiencies, such as calcium (Southeast Asian immigrants).
  • Native food limitations that may cause special health difficulties, such as poor intake of lysine and other amino acids (Hindu).

D. Use of food for health promotion, to treat illness, and in disease prevention

  • “Hot and cold” theories.


focus topic: Safe, Effective Care Environment

A. Fertility and views toward pregnancy, contraception, and abortion

B. Prescriptive, restrictive, and taboo practices related to pregnancy, birthing practices, and postpartum period

  • Pregnancy: foods, exercise, intercourse, and avoiding weather-related conditions.
  • Birthing process: reactions during labor, presence of men, position for delivery, preferred types of health-care practitioners, place for delivery.
  • Postpartum period: bathing, cord care, exercise, foods, role of men.


focus topic: Safe, Effective Care Environment

A. Death rituals and expectations

  • Cultural expectations of response to death and grief.
  • Meaning of death, dying, and afterlife.
  • Euthanasia.
  • Autopsies.

B. Purpose of death rituals and mourning practices

C. Specific burial practices (e.g., cremation)


focus topic: Safe, Effective Care Environment

  • Use of prayer, meditation, or symbols
  • Meaning of life and individual sources of strength
  • Relationship between spiritual beliefs and health practices


focus topic: Safe, Effective Care Environment

A. Health-seeking beliefs and behaviors

1. Beliefs that influence health-care practices.

  • Perception of illness (e.g., punishment for sin, work of persons who are malevolent).

2. Health promotion and prevention practices.

  • Acupuncture.
  • Yin and yang:

(1) Increased yin results in nervous, digestive disorders.
(2) Increased yang results in dehydration, fever, irritability.

B. Responsibility for health care

  • Acute care: curative or fatalistic.
  • Who assumes responsibility for health care?
  • Role of health insurance.
  • Use of over-the-counter medications.

C. Folklore practices

  •  Combination of folklore, magicoreligious beliefs, and traditional beliefs that influence health-care behaviors.

D. Barriers to health care (e.g., language, economics, geography)

E. Cultural responses to health and illness

  • Beliefs and responses to pain that influence interventions.
  • Special meaning of pain.
  • Beliefs and views about mental illness/mental health care.
  • Therapies must include extended families as opposed to individuals or nuclear families.
  • Cultural and racial as well as individual components must be considered when assessing precipitating or predisposing causes of illness (e.g., need to atone for sins).
  • Values may conflict: for example, individualism versus concern for family or social interactions; self-actualization versus survival needs.
  • Some ethnic groups do not value or possess qualities required for some psychiatric therapies, such as verbal skills, introspection, ability to delay gratification, and ability to discuss personal problems with strangers.
  • Therapy resources may not be accessible or considered useful or relevant for members of some ethnic groups.
  • Common feelings and behavior patterns may be shared by many “minority” groups:

(1)Feelings of inferiority and inadequacy, often a result of prejudice and racism.

(2) Incompetent behavior as an outcome of feeling inferior and inadequate.

(3)Suppressed anger, resulting in displaced hostility and paranoid ideas.

(4)Withholding and withdrawal; not comfortable with sharing feelings or experiences.

(5) Selective inattention; may block out or deny frustration or insults.

(6)Overcompensation in some areas to make up for denied opportunities in other areas.

3. Different perception of mentally and physically handicapped.

4. Beliefs and practices related to chronic illness and rehabilitation.

5. Cultural perceptions of the sick role.

F. Acceptance of blood transfusions and organ donation


focus topic: Safe, Effective Care Environment

A. Traditional vs. biomedical care

  • Does the age of practitioner matter?
  • Does the gender of practitioner matter?

B. Status of health-care provider How different members of health-care practice see each other.


focus topic: Safe, Effective Care Environment

Religious and spiritual beliefs can have a major impact on health and illness. Each religion has its own rituals and traditions that must be observed, with the belief that if these are not followed, the outcomes may negatively affect the client’s well-being or their family.


focus topic: Safe, Effective Care Environment

  • Religion—an organized belief system in God or supernatural, using prayer, meditation, or symbols
  • Spirituality—encompasses more than religious beliefs; includes values, meaning, and purpose in life; can provide inspiration and sustain a person or group during crisis
  • Values clarification—aligns values and beliefs so that they are consistent with goals


focus topic: Safe, Effective Care Environment

  • Beliefs about birth and what follows death
  • Code of ethics about right and wrong
  • View of health, causes of illness, or what may be the cure for the problem
  • Dietary laws
  • Relationship of mind, body, and spirit
  • Importance of work and money as they relate to religion
  • Pain: purpose of, response to, treatment for
  • Importance of family
  • Meaning of life, individual sources of hope and strength
  • Religious practices that conflict with health practices and use of health services


focus topic: Safe, Effective Care Environment

  • Risk for spiritual distress related to prolonged pain; health-care choices that are in conflict with religious practices; anxiety and guilt due to violating religious beliefs; lashing out against the religion


focus topic: Safe, Effective Care Environment

A. Acknowledge client’s beliefs

  • Provide contact with clergy of choice.
  • Provide opportunity to carry out practices not detrimental to client’s health.

B. Do not impose beliefs and values of health-care system


  • Increased satisfaction related to medical care decision
  • Decrease in feelings of stress, guilt, depression, anger

 Safe, Effective Care Environment: NURSING ETHICS

focus topic: Safe, Effective Care Environment

Nursing ethics involves rules and principles to guide right conduct in terms of moral duties and obligations to protect the rights of human beings. In nursing, ethical codes provide professional standards and formal guidelines for nursing activities to protect both the nurse and the client.


focus topic: Safe, Effective Care Environment

—serves as a frame of reference when judging priorities or possible courses of action. Purposes:

  • To provide a basis for regulating relationships between nurse, client, coworkers, society, and profession.
  • To provide a standard for excluding unscrupulous nursing practitioners and for defending nurses unjustly accused.
  • To serve as a basis for nursing curricula.
  • To orient new nurses and the public to ethical professional conduct.

II. ANA CODE OF ETHICS FOR NURSES incorporates the following key elements of what the nurse needs to do*:

focus topic: Safe, Effective Care Environment

  • Demonstrate respect for human dignity and uniqueness of individual regardless of health problem or socioeconomic level
  • Maintain client’s right to privacy and confidentiality
  • Protect the client from incompetent, unethical, or illegal behavior of others
  • Accept responsibility for informed individual nursing judgment and behavior
  • Maintain competence through ongoing professional development and consultation
  • Maintain responsibility when delegating nursing care, based on competence/qualification criteria
  • Work on maintaining/improving standards of care in employment setting
  • Protect consumer from misinformation/ misrepresentation


focus topic: Safe, Effective Care Environment

—a philosophical field that applies ethical reasoning process for achieving clear and convincing resolutions to issues and dilemmas (conflicts between two obligations) in health care.†

A. Purpose of applying ethical reflection to nursing concerns:

  • Improve quality of professional nursing decisions.
  • Increase sensitivity to others.
  • Offer a sense of moral clarity enlightenment.

B. Framework for analyzing an ethical issue:

  • Who are the relevant participants in the situation?
  • What is the required action?
  • What are the probable and possible benefits and consequences of the action?
  • What is the range of alternative actions or choices?
  • What is the intent or purpose of the action?
  • What is the context of the action?

C. Principles of bioethics:

  • Autonomy—the right to make one’s own decisions.
  • Nonmal feasance—the intention to do no harm.
  • Beneficence—the principle of attempting to do things that benefit others.
  • Justice—the distribution, as fairly as possible, of benefits, resources, and burdens.
  • Veracity—the intention to tell the truth.
  • Confidentiality—the social contract guaranteeing another’s privacy.
  • Respect—acknowledge the rights of others.
  • Fidelity—keep promises and commitments.


focus topic: Safe, Effective Care Environment

A. Right to appropriate treatment that is most supportive and least restrictive to personal freedom.

B. Right to individualized treatment plan, subject to review and reassessment.

C. Right to active participation in treatment, with the risk, side effects, and benefits of all medication and treatment (and alternatives) to be discussed.

D. Right to give and withhold consent (exceptions: emergencies and when under conservatorship).

1. Advance directives: legal, written, or oral statements made by a person who is mentally competent about treatment preferences. In the event the person is unable to make these determinations, a designated surrogate decision maker can do so. Each state has own specific laws with restrictions.

  • Living will: legal document that specifically identifies treatment desires and states that the person does not wish to have extraordinary lifesaving measures (e.g., DNR) when not able to make decisions about own care.
  • Durable power of attorney (health care proxy): legal document giving designated person authority to make health-care decisions on client’s behalf when client is unable to do so.

E. Right to be free of experimentation unless following recommendations of the National Commission on Protection of Human Subjects (with informed, voluntary, written consent).

F. Right to be free of restraints and seclusion except in an emergency.

G. Right to humane environment with reasonable protection from harm and appropriate privacy.

H. Right to confidentiality of medical records.

I. Right of access to personal treatment record.

J. Right to as much freedom as possible to exercise constitutional rights of association (e.g., use of telephone, personal mail, having visitors) and expression.

K. Right to information about these rights in both written and oral form, presented in an understandable manner at outset and periodically thereafter.

L. Right to assert grievances through a grievance mechanism that includes the power to go to court.

M. Right to obtain advocacy assistance.

  • Definition: an advocate is a person who pleads for a cause or who acts on a client’s behalf.
  • Goals: help client gain greater self-determination and encourage freedom of choices; increase sensitivity and responsiveness of the health-care, social, political systems to the needs of the client.
  • Characteristics: assertiveness; willingness to speak out for or in support of client; ability to negotiate and obtain resources for positive outcomes; willingness to take risks, and take necessary measures in instances of incompetent, unethical, or illegal practice by others that may jeopardize client’s rights.

N. Right to criticize or complain about conditions or services without fear of retaliatory punishment or other reprisals.

O. Right to referral to complement the discharge plan.



focus topic: Safe, Effective Care Environment


A. Personal values versus professional duty—nurses have the right to refuse to participate in those areas of nursing practice that are against their personal values, as long as a client’s welfare is not jeopardized.
Example: therapeutic abortions.

B. Nurse versus agency—conflict may arise regarding whether or not to give out needed information to a client or to follow agency policy, which does not allow it. Example: a teenager who is emotionally upset asks a nurse about how to get an abortion, a discussion that is against agency policy.

C. Nurse versus colleagues—conflict may arise when determining whether to ignore or report others’ behavior. Examples: you see another nurse steal medications; you know that a peer is giving a false reason when requesting time off; or you observe a colleague who is intoxicated.

D. Nurse versus client/family—conflict may stem from knowledge of confidential information. Should you tell? Example: client or family member relates a
vital secret to the nurse.

E. Conflicting responsibilities—to whom is the nurse primarily responsible when needs of the agency and the client differ? Example: a physician asks a nurse not to list all supplies used for client care, because the client cannot afford to pay the bill.

F. Ethical dilemmas—stigma of diagnostic label (e.g., AIDS, schizophrenia, addict); involuntary psychiatric confinement; right to control individual freedom; right to suicide; right to privacy and confidentiality.




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