Nursing Management: Delegation, Staffing & Quality - Cheat Sheet
Your last-minute revision companion for Chapter 6. This rapid-fire reference covers the Five Rights of Delegation, staffing metrics, prioritization frameworks, conflict resolution, change theory, and quality improvement tools. Master these concepts in 30 minutes before the exam.
Delegation: The Five Rights
Important facts
- Delegation does NOT transfer accountability — the RN remains responsible for ensuring the task is done safely and well.
- Never delegate assessment, nursing diagnosis, planning, evaluation, or health teaching — these require professional nursing judgment and are RN-only.
- Never delegate care of an unstable patient, complex tasks, or situations with unpredictable outcomes.
- Unlicensed Assistive Personnel (UAP)/nursing aides can do: bathing, grooming, feeding (stable patient), ambulation, positioning, hygiene, vital signs (stable), I&O, catheter care, simple recording, toileting, dressing.
- Licensed Practical Nurses (LPN) scope is broader than UAP — may perform many skills RN can do but not complex judgment-based care.
- Delegation is NOT abdication — RN must remain vigilant, follow up, and address problems immediately.
- Under RA 9173 (Philippine Nursing Practice Act), the RN is the one accountable for safe care delegation and patient outcomes.
Key definitions
Delegation
Example
RN assigns vital-sign monitoring on stable patients to a nursing aide but remains accountable if a complication is missed.
Transfer of responsibility for task performance from one person to another; the delegator retains ACCOUNTABILITY for the outcome.
Right Task
Example
Bathing, feeding stable patient, ambulation, recording intake/output — YES. IV medication, complex wound assessment — NO.
Task is delegable, routine, standardized, stable, and within the delegatee's job description and legal scope.
Right Circumstance
Example
Delegate vital signs on stable post-op day 3 patient; DO NOT delegate on day 1 post-op or if patient is deteriorating.
Patient is stable and setting is appropriate; avoid delegation in emergency, unstable, or unpredictable situations.
Right Person
Example
Assign catheter care to trained nursing aide; do NOT assign to housekeeping staff or to an aide untrained in that facility's protocol.
Delegatee has valid license (if required), training, demonstrated competence, and authority for the task.
Right Direction/Communication
Example
NOT 'Monitor the patient.' INSTEAD: 'Check BP every 4 hours on Mr. Santos in Bed 5, systolic should stay 110–140; report if above 180 or below 90 or patient complains of headache.'
Clear, concise, specific instructions: task description, expected outcome, limits, timeline, and when to report back.
Right Supervision/Evaluation
Example
Check that vital signs were recorded correctly; observe aide's technique; praise if done well; correct if not; evaluate patient outcome.
Appropriate monitoring, follow-up, feedback, and evaluation of the task outcome; RN observes and assesses results.
Diagrams to know
- The Five Rights framework (task, circumstance, person, direction, supervision) — visualize as a checklist.
- Delegation decision tree: 'Is this a nursing-judgment step?' If YES → do not delegate. If NO and patient is stable → check Five Rights.
Prioritization: ABCs and Maslow
Important facts
- ACUTE > CHRONIC: See the post-op patient with sudden bleeding before the chronic diabetic patient with a routine dressing change.
- ACTUAL > POTENTIAL: Address the patient who IS hypoxic before teaching one about smoking cessation (prevention).
- UNSTABLE > STABLE: Prioritize the patient whose condition is deteriorating, unexpected, or life-threatening over the stable patient.
- See the MOST UNSTABLE PATIENT FIRST: This is the #1 prioritization rule on NLE questions.
- Physiologic needs always rank above psychosocial: A patient in pain (physiologic) takes priority over one with existential worry.
- Triage model: EMERGENT (life-threatening, treat NOW) → URGENT (needs prompt care) → NON-URGENT (can wait).
- When deciding between tasks: TIME-CRITICAL + RN-ONLY tasks first (IV starts, assessments); routine stable tasks later.
- Re-prioritize continuously as patient conditions change — what was stable may become unstable.
Key definitions
Prioritization
Example
On rounds: patient with altered respiratory rate → see FIRST; patient asking for pain meds 2 hours early → see after.
The process of deciding the order in which to address patient needs and tasks based on urgency, acuity, and safety.
ABCs (Airway, Breathing, Circulation)
Example
Patient with stridor (airway at risk) takes precedence over patient with mild back pain.
The cardinal rule: always address life-threatening respiratory or cardiovascular problems first, before all other needs.
Maslow's Hierarchy Applied to Nursing
Example
Assist patient with difficulty breathing (physiologic) before addressing anxiety about surgery (psychological).
Physiologic needs (O₂, elimination, nutrition, rest) first; then safety; then social, esteem, and self-actualization.
Diagrams to know
- Maslow's Hierarchy pyramid (physiologic base → safety → love/belonging → esteem → self-actualization).
- Triage priority decision tree (life-threatening? YES → emergent; urgent? YES → urgent; else non-urgent).
- Prioritization flowchart: ABCs → Maslow → acute/actual/unstable → RN-only tasks → time-critical → routine.
Staffing & Scheduling: Metrics and Models
Formulas
Nursing Care Hours per Patient Day (NCH/PPD) = Total Nursing Hours Available ÷ Patient Census
Meaning
Total Nursing Hours = sum of all RN, LPN, and UAP hours available in a shift or day; Patient Census = number of patients on the unit.
Watch out
Remember to use AVAILABLE hours (scheduled), not billed or actual; account for breaks, meetings, orientation time. A common mistake is forgetting to convert part-time hours to full-time equivalent.
When to use
When calculating the average nursing hours each patient receives; used to match staffing to acuity and demand.
Full-Time Equivalent (FTE) = Part-Time Hours ÷ Full-Time Hours per Week
Meaning
FTE measures staffing in units of full-time positions; one FTE = 40 hours/week (or facility standard); 0.5 FTE = 20 hrs/week.
Watch out
Different facilities define a full-time week differently (may be 36, 40, or 42 hours); always confirm the facility's standard. A common error is mixing FTE with actual shift hours.
When to use
When budgeting staff, planning workforce, comparing staffing levels across units, or calculating total payroll.
Nurse-to-Patient Ratio = Total Number of Patients ÷ Number of Nurses Assigned
Meaning
Expresses the workload — how many patients each nurse cares for; varies by acuity and setting (ICU 1:1–1:2, med-surg 1:5–1:6).
Watch out
A 'better' ratio (lower number, e.g., 1:2) means fewer patients per nurse and safer care. High ratios (1:10+) are associated with poor outcomes. Do NOT confuse ratio direction; 1:6 is NOT better than 1:4.
When to use
When determining safe staffing levels, assigning patient loads, or comparing staffing adequacy across units.
Common values
Value
4–6 hours/patient/day
Symbol
NCH/PPD (med-surg)
Quantity
Typical NCH/PPD, Medical-Surgical Unit
Value
8–14 hours/patient/day
Symbol
NCH/PPD (ICU)
Quantity
Typical NCH/PPD, ICU
Value
40 hours/week (may vary: 36–42 per facility)
Symbol
1.0 FTE
Quantity
Standard Full-Time Equivalent
Value
1:5 to 1:6 patients per nurse
Symbol
1:5–1:6
Quantity
Typical Nurse-to-Patient Ratio, Med-Surg
Value
1:1 to 1:2 patients per nurse
Symbol
1:1–1:2
Quantity
Typical Nurse-to-Patient Ratio, ICU
Important facts
- Patient Classification (acuity) systems match staffing to real patient need — a unit with 5 minimal-care and 5 intensive-care patients needs more staff than one with 10 minimal-care patients.
- NCH/PPD is a core staffing metric: typical range 4–8 hours/patient/day for med-surg; 8–14 for ICU.
- FTE is used for budgeting and workforce planning; one FTE = one full-time position (typically 40 hrs/week).
- Higher RN skill mix (more RN:UAP ratio) → fewer medication errors, lower CAUTI/fall rates, better patient satisfaction; cost-effective long-term.
- Nurse-to-patient ratio varies: ICU 1:1 or 1:2 (critical); med-surg 1:5–1:6; psychiatric 1:6–1:8. Know the typical ratios for each setting.
- Scheduling types: CENTRALIZED (done by admin, consistent but inflexible) → DECENTRALIZED/unit-based (done by unit manager, responsive) → SELF-SCHEDULING (staff coordinate own shifts, high morale but risky if unmanaged).
- Good scheduling balances: patient safety, coverage, fairness, staff preference, fatigue prevention, and cost.
- Team nursing is the MOST COMMON model in Philippine hospitals and the most tested on NLE.
- Primary nursing offers the best continuity but is expensive; used selectively (ICU, high-acuity units).
- Case management is increasingly used in DRG/managed-care settings to control length of stay and cost while maintaining quality.
Key definitions
Patient Classification System (PCS) / Acuity Classification
Example
Category I (minimal care): alert, independent; needs 2 NCH/PPD. Category IV (intensive care): critical, unstable; needs 8+ NCH/PPD.
A system that groups patients by the level of care and nursing intensity they require, translating that into nursing-hours needed.
Skill Mix
Example
Skill mix 80% RN + 20% UAP is safer than 50% RN + 50% UAP.
The ratio of professional (RN) to non-professional (LPN, UAP) staff on a unit; higher RN skill mix is associated with better patient outcomes and fewer errors.
Functional Nursing
Example
One nurse does meds for 20 patients; another does wound care for all; communication and continuity are weak.
Task-oriented care delivery: each staff member does one specific task (e.g., all vital signs, all medications) for all patients — efficient but fragmented.
Team Nursing
Example
RN assess, plan, complex meds; LPN gives stable meds, does wound care; UAP does hygiene, vital signs, I&O for 8 patients.
An RN-led team (RN, LPN, UAP) cares for a group of patients; work is delegated by skill level; most common ward model in Philippine hospitals.
Primary Nursing
Example
Ms. Cruz is the primary nurse for Mr. Santos from Day 1 post-op through discharge; she leads his care plan and follows all decisions.
One RN has 24-hour accountability for planning and coordinating a patient's care from admission to discharge; high continuity but labor-intensive.
Modular Nursing
Example
Module A (4 patients, 1 RN + 1 UAP); Module B (4 patients, 1 RN + 1 UAP) — reduces travel, improves communication.
A variant of team nursing organized by geographic zones; teams care for patients in specific areas of the unit.
Case Management
Example
A case manager coordinates a hip-fracture patient's pre-op work-up, surgery, post-op rehab, and discharge-home plan to ensure timely, cost-effective care.
Coordinating and integrating care across the care continuum (hospital, home, community) against a timeline using clinical pathways to control cost and quality.
Diagrams to know
- Acuity classification ladder: minimal → moderate → total → intensive care (tied to NCH/PPD increase).
- Care delivery model spectrum: Functional (task) → Team (RN-led) → Primary (RN dedicated) → Case Management (across continuum).
- Staffing calculation flow: census + acuity PCS → NCH/PPD needed → multiply by hours → divide by FTE hours → number of FTEs required.
Conflict Resolution: Thomas–Kilmann Modes
Important facts
- COMPETING is ONLY appropriate in emergencies or when a quick, unpopular decision is essential (e.g., triage during mass casualty).
- ACCOMMODATING is useful when the issue matters more to the other party or when preserving the relationship is critical; overuse breeds resentment.
- AVOIDING should NEVER be used to dodge real problems or important issues — it allows conflicts to fester and morale to collapse.
- COMPROMISING is a practical middle ground when time is limited or both parties have equal power; it prevents deadlock but satisfies no one fully.
- COLLABORATING is the GOLD STANDARD and preferred approach in nursing management — it solves the root issue and builds trust and team cohesion.
- Effective conflict resolution: address conflict EARLY and DIRECTLY, focus on the ISSUE (not the person), listen ACTIVELY, identify SHARED GOALS, seek MUTUALLY ACCEPTABLE solutions.
- Assertive (not aggressive or passive) communication is the manager's core tool — state needs clearly, listen to the other party's perspective, work toward a solution.
- Aggressive communication alienates; passive communication breeds resentment and non-compliance; assertive communication builds respect.
Key definitions
Conflict
Example
RN and physician disagree about discharge timing for a patient (conflict); resolved collaboratively, it leads to a better plan.
A clash of interests, values, goals, or priorities between individuals or groups; not inherently bad — when managed well, it drives improvement.
Competing (Win/Lose)
Example
In an emergency, the charge nurse orders 'Stat IV access NOW' — no time for negotiation; competing style is appropriate here.
Assertive, uncooperative; one side 'wins' at the other's expense — quick but leaves resentment.
Accommodating (Lose/Win)
Example
Staff member wants a specific shift; manager accommodates because the person has seniority and the staffing still works.
Unassertive, cooperative; yielding; one side gives in to preserve harmony or because the issue matters more to the other party.
Avoiding (Lose/Lose)
Example
Two nurses aren't speaking after a disagreement about patient care; manager ignores it hoping it goes away — BAD. Should address it.
Unassertive, uncooperative; sidestepping or postponing; useful for trivial issues or cool-downs but harmful if used to dodge real problems.
Compromising (Middle Ground)
Example
Two departments want different meeting times; they agree to meet bi-weekly (one half-hour each).
Moderate assertiveness and cooperation; each side gives up something; a workable solution under time pressure but not optimal.
Collaborating (Win/Win)
Example
RN and aide disagree on work assignments; they sit down, listen, identify that aide wants fewer patient transfers → redistribute workload; both satisfied.
Assertive, cooperative; problem-solving to find a solution that satisfies both parties' core interests — the IDEAL approach when time allows.
Diagrams to know
- Thomas–Kilmann conflict modes grid: X-axis (assertiveness low to high) × Y-axis (cooperativeness low to high); five modes plotted in the quadrants.
- Conflict resolution process: Recognize conflict → Address early and directly → Focus on issue, not person → Listen actively → Identify shared goals → Collaborate on solution.
Change Theory: Lewin's Three-Stage Model
Important facts
- Lewin's three-stage model (Unfreeze → Move → Refreeze) is the CLASSIC, MOST-TESTED change framework on NLE.
- Resistance to change is NORMAL and EXPECTED — do not assume staff will simply accept new protocols.
- Effective strategies to reduce resistance: COMMUNICATE (why change is needed, benefits, expectations), PARTICIPATE (involve staff in planning), EDUCATE (train thoroughly), SUPPORT (provide resources, coaching, time), BUILD TRUST (show that change benefits patients and staff).
- Force-field analysis identifies WHERE to focus effort: strengthen drivers (data, incentives, leadership support) and weaken resisters (training, involvement, time, reassurance).
- Refreezing is CRITICAL — without it, old habits return within weeks. Reinforce the change through audits, feedback, rewards, and making it part of standard procedure.
- Change takes TIME — expect 3–6 months minimum for new protocols to become habit; ongoing reinforcement prevents backsliding.
- Managers are KEY to change success — model the new behavior, provide visible support, remove barriers, celebrate wins.
Key definitions
Unfreezing
Example
Incident report shows high fall rate. Manager presents data, explains new fall-prevention protocol, explains why current practice isn't working — unfreezing staff to accept change.
The first stage: creating awareness of the need to change and reducing resistance by motivating people to let go of the status quo.
Moving (Changing)
Example
Staff are trained on new fall-prevention protocol, practice new steps, ask questions, get feedback; manager observes and coaches.
The second stage: implementing the new process; providing information, support, training, and reinforcement as people adopt new behaviors.
Refreezing
Example
After 2 weeks of new protocol, audits show compliance; manager celebrates success, rewards adherence, integrates new protocol into standard procedure.
The third stage: stabilizing and reinforcing the change so it becomes the new norm and does not slip back to old habits.
Force-Field Analysis
Example
Drivers: high fall rate (data), pressure from admin, nursing desire for safer practice. Resisters: staff fear, extra work, habit. Strategy: emphasize safety (strengthen driver), train thoroughly (weaken resistor).
A method to frame change as a balance between DRIVING FORCES (pushing toward change) and RESTRAINING FORCES (resisting it); change succeeds by strengthening drivers and weakening resisters.
Resistance to Change
Example
New charting system: staff resist because they fear losing jobs to automation, are unsure about the new software, don't trust management's assurance that jobs are safe.
Expected opposition to change; sources include fear of the unknown, loss of control, comfort with status quo, lack of trust, perceived threat to job security.
Diagrams to know
- Lewin's three-stage model: Unfreezing (awareness, motivation) → Moving/Changing (implement, train, support) → Refreezing (stabilize, reinforce, normalize).
- Force-field analysis diagram: current state in center; above (driving forces — data, pressure, desire); below (restraining forces — fear, habit, inertia).
Quality Improvement: Frameworks and Tools
Important facts
- QA is inspective, retrospective; CQI/TQM is proactive, continuous, process-focused — CQI/TQM is the modern, preferred approach.
- Deming's principle: DO NOT blame the person; analyze the PROCESS. Most errors (85%+) stem from poor processes, not poor people.
- Donabedian's three dimensions: Structure (inputs/resources) → Process (what we do) → Outcome (results). All three matter; improve structure and process to improve outcome.
- PDSA/PDCA cycle is CONTINUOUS — not a one-time event. Once a change is adopted, begin planning the next improvement.
- RCA is RETROSPECTIVE (after sentinel event); FMEA is PROSPECTIVE (before failure). Both are essential: fix past problems, prevent future ones.
- Nursing-sensitive indicators include fall rate, CAUTI rate, CLABSI rate, HAI (hospital-acquired infection) rate, medication errors, pressure injuries, staffing ratios, patient satisfaction.
- Just culture is CRITICAL to quality improvement — staff must feel safe reporting errors and near-misses, or the system stays blind to problems.
- Standards and indicators must be MEASURABLE and TRACKED regularly (monthly, quarterly) to detect trends.
- Audits (concurrent or retrospective) are tools to monitor adherence to standards and identify gaps needing improvement.
- Under RA 9173 and PRC Board of Nursing standards, RN accountability includes contributing to quality and safety improvement initiatives.
Key definitions
Quality Assurance (QA)
Example
Audit of 30 charts to check if pain was assessed per protocol; identifies non-compliance; corrects individuals.
Traditional, inspection-focused approach; evaluates whether standards are met; often retrospective and looks for 'who erred' — focused on detection and correction.
Continuous Quality Improvement (CQI) / Total Quality Management (TQM)
Example
Fall rate is high. Instead of blaming nurses, analyze the PROCESS: are bed rails adequate? Is footwear protocol clear? Is staff trained? Fix the process → prevent falls.
Proactive, ongoing, team-based, process-focused approach; assumes most errors stem from PROCESSES, not people (Deming); culture of continuous improvement.
Structure (Donabedian Framework)
Example
Having adequate RN staffing (1:5 ratio), modern beds with side rails, fall-prevention protocols, and training = good structure.
The setting and resources: staffing levels, equipment, facilities, policies, budgets, nursing hours, qualifications.
Process (Donabedian Framework)
Example
Nurses assess fall risk on admission, document findings, implement precautions, communicate with team, reassess regularly = good process.
What is actually done in giving care: adherence to standards, protocols, procedures, clinical judgment, communication.
Outcome (Donabedian Framework)
Example
Fall rate is 0.5 per 1000 patient-days (low = good outcome); patient satisfaction is 4.5/5; 30-day readmission rate 8% (acceptable).
The results of care: patient recovery, complication rates (CAUTI, CLABSI, hospital-acquired infections), mortality, patient satisfaction, length of stay.
PDSA / PDCA Cycle
Example
Problem: high medication errors. Plan: bedside verification protocol. Do: test on 1 unit for 1 week. Study: compare error rates before/after. Act: adopt hospital-wide, monitor.
The engine of continuous improvement: Plan (identify problem, test change) → Do (implement on small scale) → Study/Check (analyze results) → Act (adopt, adjust, or abandon; standardize if successful). Repeat continuously.
Root Cause Analysis (RCA)
Example
A wrong-site surgery occurred. RCA identifies: lack of clear marking, no nurse verification, communication breakdown. Fix: implement WHO surgical safety checklist.
A retrospective, systematic method to find the UNDERLYING CAUSE of a SENTINEL EVENT (unexpected, involving death or serious harm); aimed at SYSTEM FIXES, not individual blame.
Failure Mode and Effects Analysis (FMEA)
Example
Before implementing a new medication system, identify failure points: barcode scanner malfunction (effect: wrong med), staff not trained (effect: errors). Prevent by backup scanner, mandatory training.
A PROSPECTIVE method to identify where a process COULD FAIL before it does; used to prevent problems proactively.
Sentinel Event
Example
Patient falls and fractures hip; wrong-site surgery; medication error causing harm; hospital-acquired pressure injury grade 4.
An unexpected occurrence involving death or serious injury (or risk thereof); triggers RCA; reportable to regulators and accrediting bodies.
Nursing-Sensitive Quality Indicators
Example
Unit tracked fall rate monthly: Jan 2.1/1000, Feb 1.8/1000 (improving) → identify driver: new mattress system working.
Outcome measures directly influenced by nursing care: fall rate, CAUTI (catheter-associated UTI) rate, CLABSI (central-line bloodstream infection) rate, medication-error rate, hospital-acquired infection rate, pressure-injury rate, patient satisfaction, nurse staffing adequacy.
Just Culture / Blame-Free Reporting
Example
Nurse reports a medication near-miss (caught before giving to patient); instead of punishment, team analyzes why the error almost happened and fixes the process.
An organizational culture where staff report errors and near-misses without fear of unfair punishment, so systems can be fixed and learning occurs.
Benchmarking
Example
Unit's fall rate is 3/1000; best practice is 1.5/1000; benchmarking goal: reduce to ≤1.5/1000 within 12 months.
Comparing an organization's (or unit's) performance against best-in-class standards or peer organizations to identify gaps and improvement targets.
Diagrams to know
- Donabedian framework: Structure (inputs) → Process (activities) → Outcome (results); improvement in process should lead to improvement in outcome.
- PDSA/PDCA cycle: Plan → Do → Study/Check → Act → repeat; shows continuous nature of improvement.
- RCA fishbone diagram: lists potential causes of error (communication, training, process, equipment, staffing) and identifies root cause.
- Nursing-sensitive quality indicators dashboard (tracked monthly): fall rate, CAUTI, CLABSI, HAI, med errors, pressure injuries, staffing ratio, patient satisfaction.
Must remember
- 1. DELEGATION: Transfer of TASK, NOT accountability. RN retains accountability. Use Five Rights: task, circumstance, person, direction, supervision. Never delegate assessment, diagnosis, planning, evaluation, health teaching, or care of unstable patient.
- 2. PRIORITIZATION: ABCs first (Airway, Breathing, Circulation). Maslow: physiologic needs before psychological. Acute > Chronic, Actual > Potential, Unstable > Stable. See the MOST UNSTABLE patient FIRST.
- 3. STAFFING METRICS: NCH/PPD = nursing hours ÷ patient census (tells average hours/patient). FTE = part-time hours ÷ full-time hours/week (for budgeting). Nurse-to-patient ratio varies by setting (ICU 1:1–1:2; med-surg 1:5–1:6).
- 4. SKILL MIX: Higher RN% (more RNs, fewer UAP) → fewer errors, better outcomes, higher cost. Balance is needed for both safety and cost-effectiveness.
- 5. TEAM NURSING: Most common care delivery model in Philippine hospitals. RN assesses/plans/complex care; delegates stable tasks by skill to LPN and UAP.
- 6. CONFLICT RESOLUTION: COLLABORATING (win/win) is the IDEAL approach when time allows. COMPETING is only for emergencies. Focus on ISSUE not PERSON. Use assertive communication, not aggressive or passive.
- 7. LEWIN'S CHANGE MODEL: Unfreeze (create awareness, motivate) → Move (implement, train, support) → Refreeze (stabilize, reinforce). Resistance is normal; reduce it via communication, participation, education, and support.
- 8. QUALITY IMPROVEMENT: CQI/TQM (modern, process-focused) assumes errors come from PROCESSES, not people. PDSA cycle: Plan → Do → Study → Act → repeat. Always ask 'What's wrong with the PROCESS?' not 'Who made the mistake?'
- 9. DONABEDIAN FRAMEWORK: Structure (resources) → Process (what we do) → Outcome (results). Improve structure and process to improve outcome. All three matter.
- 10. RCA vs FMEA: RCA is retrospective (after sentinel event, find root cause, fix system). FMEA is prospective (before failure, identify risks, prevent). Both support just culture and continuous improvement.
Last minute tips
- EXAM TIP 1 — Delegation Scenario Questions: Always ask yourself three questions: (1) Is this the nursing process (assessment, diagnosis, planning, evaluation, teaching)? If YES → RN only, do not delegate. (2) Is the patient stable? If NO → RN only. (3) Does the delegatee have training and authority? If NO → cannot delegate. If all are YES, check Five Rights.
- EXAM TIP 2 — Prioritization (Most Tested Skill): The NLE LOVES asking 'Which patient do you see FIRST?' The answer is almost always the MOST UNSTABLE, ACUTE, or UNEXPECTED one. Use ABCs and Maslow; ignore fancy distractors. Unstable post-op patient with unexplained tachycardia BEATS stable chronic patient asking for pain meds early.
- EXAM TIP 3 — Staffing & Scheduling Questions: If asked about staffing adequacy or nurse-to-patient ratio, remember: higher RN skill mix (more RNs) and lower patient ratios (fewer patients per nurse) = safer care. An ICU with 1:2 ratio is better than 1:5. Med-surg 1:5 is typical and acceptable; 1:8+ is unsafe.
- EXAM TIP 4 — Conflict Style in Nurse Manager Scenario: Default to COLLABORATING unless the scenario screams emergency (then COMPETING is OK). If asked 'What should the manager do?' and the options include 'Meet with both parties, listen, find a solution both agree on' → that is COLLABORATING and almost always the BEST answer.
- EXAM TIP 5 — Quality Improvement Scenario: If asked 'A high medication-error rate was found. What should the manager do FIRST?' → Do NOT blame the nurse. Instead, analyze the PROCESS: Are meds labeled clearly? Is the new nurse trained on the system? Is there a double-check built in? Fix the PROCESS, not the person. This is CQI thinking and is heavily tested.
Comparison tables
Delegation: What CAN vs CANNOT Be Delegated
| Task Type | CAN Delegate to UAP/Aide | CANNOT Delegate (RN Only) | Can Delegate to LPN (if stable) |
|---|---|---|---|
| Vital Signs (Stable Patient) | ✓ Yes (routine, stable) | — | ✓ Yes |
| Patient Assessment | ✗ No | ✓ RN only (requires judgment) | ✗ No |
| Nursing Diagnosis | ✗ No | ✓ RN only (professional judgment) | ✗ No |
| Health Teaching / Patient Education | ✗ No | ✓ RN only (complex, judgment-based) | Limited (RN leads) |
| Bathing, Grooming, Hygiene (Stable Patient) | ✓ Yes | — | ✓ Yes |
| Medication Administration | ✗ No | ✓ RN/LPN (scope varies by state/facility) | ✓ Yes (many stable meds) |
| IV Start / IV Therapy | ✗ No | ✓ RN only (or trained paramedic) | LPN in some states |
| Catheter Care (Stable) | ✓ Yes (if trained) | — | ✓ Yes |
| Feeding (Stable Patient, No Swallowing Disorder) | ✓ Yes | — | ✓ Yes |
| Care of Unstable / Complex Patient | ✗ No | ✓ RN only (requires constant judgment) | ✗ No (RN leads) |
| Evaluation of Care Outcome | ✗ No | ✓ RN only (nursing judgment) | ✗ No |
| Intake & Output Recording | ✓ Yes (simple recording) | — | ✓ Yes |
Care Delivery Models Compared
| Model | Structure | RN Role | Advantages | Disadvantages |
|---|---|---|---|---|
| Functional Nursing | Task-oriented; staff divided by task, not patient | Does one task (e.g., all meds) for all patients | Efficient; easy to supervise and schedule | Fragmented; poor continuity; staff don't know patients; communication gaps |
| Team Nursing | RN-led team (RN, LPN, UAP) assigned to patient group | Leads team; assesses, plans, complex meds; delegates by skill | Good balance of continuity and efficiency; delegable; flexible; most common in hospitals | Requires strong RN leadership; quality depends on RN communication and delegation |
| Primary Nursing | One RN accountable for a patient 24 hours from admission to discharge | Direct care provider and care coordinator; full accountability for planning | Excellent continuity; high patient satisfaction; strong accountability | Labor-intensive; expensive; requires experienced RNs; hard to cover days off |
| Modular Nursing | Variant of team nursing; team assigned to geographic zone/module | Same as team nursing, but confined to one area | Reduces travel; improves communication; cost-effective | Still depends on team dynamics and RN leadership; limited to small units |
| Case Management | Coordinator (RN) manages patient care across care continuum using clinical pathway | Coordinates, integrates, and tracks care across settings (hospital, home, outpatient) to control cost and ensure quality | Improves coordination; reduces length of stay; cost control; better outcomes with chronic disease | Requires system infrastructure; RN must understand entire care continuum; coordination challenge if systems aren't integrated |
Conflict-Handling Modes: When to Use Each
| Mode | Attitude | Best Used When | Outcome | Pitfalls |
|---|---|---|---|---|
| Competing (Win/Lose) | Assertive, uncooperative | Emergency; quick decision essential; unpopular but necessary choice (e.g., triage) | Fast decision; one side gets what they want | Resentment if overused; damages relationships; blocks future collaboration |
| Accommodating (Lose/Win) | Unassertive, cooperative | Other party cares more about issue; preserving relationship is critical; not a major decision | Harmony maintained; other side satisfied | Overuse leads to feeling walked-over; staff lose respect if manager always yields |
| Avoiding (Lose/Lose) | Unassertive, uncooperative | Trivial issue; need cooling-off time; not the right moment to address | Temporary peace; issue postponed | RARELY appropriate; conflict festers; morale tanks; should NOT be default |
| Compromising (Split Difference) | Moderate both | Time pressure; equal power; both parties want faster solution than collaborating allows | Workable, fair-seeming solution; moves forward | No one fully satisfied; may not address root issue; temporary fix |
| Collaborating (Win/Win) | Assertive, cooperative | Time available; trust present; core interests matter; seeking best solution; relationship important | Root issue solved; both satisfied; strengthens relationship and team trust | Takes time; requires both parties willing to problem-solve; not possible in true emergency |
RCA vs FMEA: Retrospective vs Prospective Quality Improvement
| Aspect | Root Cause Analysis (RCA) | Failure Mode & Effects Analysis (FMEA) |
|---|---|---|
| Timing | RETROSPECTIVE — after a sentinel event has occurred | PROSPECTIVE — before a failure happens; proactive prevention |
| Trigger | Unexpected adverse event (patient harm, near-miss, death, wrong-site surgery, serious infection) | Process redesign; new system implementation; known risk areas; regulatory requirement |
| Focus | Why did THIS event happen? What systems/processes failed? | Where COULD the process fail? What are the risks? What preventive measures are needed? |
| Approach | Investigate the event, trace back through the process, identify contributing factors, find root cause (usually systemic, not individual error) | Analyze the process step-by-step, identify failure points, assess risk severity and likelihood, prioritize and plan preventive actions |
| Outcome | Identify what system needs fixing; prevent recurrence of THAT type of event | Prevent the identified failure modes; build robustness into process BEFORE harm occurs |
| Culture | Supports just culture: learn from mistakes, fix systems (not blame individuals) | Builds resilience: anticipate and prevent problems |
Diagrams
Delegation Decision Tree: Can This Task Be Delegated?
A flowchart to guide the RN through the delegation decision-making process, ensuring patient safety and appropriate task distribution. Use this to quickly evaluate whether a task can be safely delegated.
Prioritization Framework: Which Patient or Task FIRST?
A decision tree for prioritization that incorporates ABCs, Maslow's hierarchy, acuity, and time-sensitivity. Use this to quickly determine the order of patient visits and task completion on your shift.
Staffing Metrics & Formulas at a Glance
A mind map summarizing the key staffing metrics used to calculate and evaluate nurse staffing adequacy. Reference this to quickly recall formulas and typical values for different unit types.
Lewin's Three-Stage Change Model: From Status Quo to New Norm
A state diagram showing Lewin's change model stages and the transitions between them. Visualizes how change evolves from awareness to new normal, emphasizing the importance of refreezing to prevent regression.
PDSA Cycle: Continuous Quality Improvement Loop
The PDSA (Plan-Do-Study-Act) cycle, the engine of continuous quality improvement. Shows how changes are tested, evaluated, and standardized, and how the cycle repeats for ongoing improvement.
RCA vs FMEA: Two Approaches to Quality & Safety
A flowchart comparing RCA (retrospective, after an event) and FMEA (prospective, before failure), showing when to use each and how both support a just culture of continuous improvement.
Care Delivery Model Usage in Typical Hospital Settings
A pie chart showing the typical prevalence of different care delivery models in hospital settings. Team nursing dominates because it balances continuity, efficiency, and delegation. Note that combinations are common.