1 NRSG355 Clinical Integration Towards Profession.docx

1
NRSG355 Clinical Integration:
Towards Professional Practice
Module 4 – Professional Practice: Time Management,
delegation, scope of practice
Scope of Practice/ Delegation/Advocacy
Over the course of your undergraduate degree you have been
taught about your scope of practice as
a student and the scope of practice of registered nurses under
many different frameworks – legal,
ethical, practical and so on. It is now time to consider how the
change in your roles will influence
your scope of practice. Historically the scope of practice of
nurses was clearly defined. In the
current contemporary model of health practice the professional
boundaries between the health
professions is becoming increasing blurred (Fedoruk &
Hoffman, 2013 p24). The issue is further
compounded due to the scope of nursing practice expanding
with roles such as advanced practice
nurse, as well as the increase in semi-independent practitioners
in community settings.

In this time of transition you must be careful that you
understand the scope of practice of the role
you aspire to, that of an experienced practicing Registered
Nurse and the role you are about to
undertake that of new registered nurse. Benner describes the
new graduate as an advanced
beginner one who is competent but relies on the rules they have
been taught to guide them in their
practice. Advanced beginners are seen as nurses who have a
wide theory base of practice but are
still developing the ability to make content dependant
judgements (Benner, 1984 p 21-22). This
means that you should not set the bar too high for yourselves
and realise that you are still learning
and developing the clinical judgement skills that can only come
from exposure to clinical situations,
known as experiential learning. If we take Benner at her word
then it takes at least 2-3 years of
clinical experience following registration as a registered nurse
to be deemed competent and even
then she says the competent nurse will lack speed and efficiency
(Benner, 1984 p 26-27).
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ACTIVITY 1
Access the following summary of Benner’s stage of clinical
competence and consider these along
with the NMBA competencies and decision making tools. Then,
consider what your priorities for your

final semester are and consider what skills you need to
consolidate that will assist in you making the
transition from student to registered nurse.
Reading:
Benner’s stages of clinical competence
Reading:
NMBA Nursing Standards for practice (2016)
Nursing and Midwifery Board of Australia. (2013). A national
framework for the development of
decision-making tools for nursing and midwifery practice.
Role of delegation
The ability to delegate is an important skill that all nurses need
to understand whether you are a
CEO or a newly registered nurse. Delegation is about
understanding your own and others time
management, prioritisation issues and your own scope of
practice. It must be clearly noted that
delegation is not about someone getting rid of work, the process
should be mutually supportive and
have clear aims to improve outcomes (Pearce, 2006). You must
also remember that while you can
delegate tasks that you are the person who remains accountable
for the outcome. So you must fully
understand the scope of practice of the person you are
delegating too.
Access the following journal article which outline 10 steps to
effective delegation and consider as a

newly registered nurse who you might delegate too, most likely
they will not be junior staff, but
more senior staff or team members. As a registered nurse you
will often need to delegate to
Division 2 nurses or AIN’s who may have been working longer
than you. How would you approach
these nurses and how would you ensure that all tasks are
completed.
ACTIVITY 2:
While you are out on placement, observe how other staff
delegate, who delegates and what forms
of communication they use to effectively delegate. As basis for
this observation please read:
Reading:
Pearce, C. (2006). Leadership resources. Ten steps to effective
delegation. Nursing Management,
UK, 13(8), 19.
http://www.health.nsw.gov.au/nursing/projects/Documents/novi
ce-expert-benner.pdf
http://www.health.nsw.gov.au/nursing/projects/Documents/novi
ce-expert-benner.pdf
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-
Statements/Professional-standards.aspx
http://www.nursingmidwiferyboard.gov.au/documents/default.as
px?record=WD10%2f3341&dbid=AP&chksum=3SWDivwEVX
M4K6MsMHxTmw%3d%3d

http://www.nursingmidwiferyboard.gov.au/documents/default.as
px?record=WD10%2f3341&dbid=AP&chksum=3SWDivwEVX
M4K6MsMHxTmw%3d%3d
http://ezproxy.acu.edu.au/login?url=https://search.ebscohost.co
m/login.aspx?direct=true&db=ccm&AN=2009361739&site=ehos
t-live
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Role of Advocacy
Nursing as defined by the ICN:
Nursing encompasses autonomous and collaborative care of
individuals of all ages, families,
groups and communities, sick or well and in all settings.
Nursing includes the promotion of
health, prevention of illness, and the care of ill, disabled and
dying people. Advocacy, promotion
of a safe environment, research, participation in shaping health
policy and in patient and health
systems management, and education are also key nursing roles
(ICN 2010).
The term advocacy presents the newly registered nurse with a
number of conflicting issues. What is
advocacy? Are we talking advocacy for individual patient’s
rights, nurse’s rights, or advocacy for the
wider community on issues of public health, advocacy for
equity of health care access? You have
looked at the term advocacy throughout your undergraduate
education in both clinical and ethical
context.

Point 2.4 of the National competency standard for registered
nurse (2006) state that nurses should
“advocate for individuals/groups and their rights for nursing
and health care within organisational
and management structures”. This clearly states that the role of
advocacy can take many forms and
encompasses an individual’s right to advocacy as well as
advocacy for the broader community.
Further 2.4.3 goes on to express that nurses have a duty to
advocate for individuals to ensure that
individuals are given information that facilitates informed
decisions (ANMC, 2006).
The next time you are out on clinical placement during your
final semester consider how you
advocate for your patients. Make a note of your interactions for
a day and consider did you
advocate for your patients. Did you just allow them to rest for
half hour by negotiating with other
health care team members, did you intervene on their behalf
with medical doctor to clarify point of
care, did you encourage your patient to speak up and ask the
important questions or did you just
listen to them. Advocacy does not have to be all bells and
whistles and you will be surprised on
completion of this exercise how often you act as an advocate for
your patients.
ACTIVITY 3:
Readings:
Read the following articles to further your understanding of
advocacy.
Choi, PP. (2015). Patient advocacy: the role of the nurse,

Nursing Standard, 29 (41) 52-58.
While the following article is dated 2002, it still contains
information that is relevant and pertinent to
your role in understanding patient advocacy.
Schwartz, L. (2002). Is there an advocate in the house? The role
of health care professionals in
patient advocacy. Journal of Medical Ethics, 28(1), 37-40.
http://ezproxy.acu.edu.au/login?url=https://search.proquest.com
/docview/1785223099?accountid=8194
http://ezproxy.acu.edu.au/login?url=http://dx.doi.org/10.1136/j
me.28.1.37
me.28.1.37
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Professional Boundaries
Another important consideration in understanding scope of
practice and delegation is an
understanding of professional boundaries within practice. It is
difficult sometimes when nurses are
fulfilling their role of duty of care to see where the boundaries
are. The following guide by the
Australian Nursing and Midwifery Council (ANMC) 2010
includes a flow chart and guide on
professional boundaries. Please read these carefully.

Australian Nursing and Midwifery Council (ANMC). (2010).
Professional boundaries for
nurses
Whilst this resource is American it provides a clear explanation
of professional boundaries with
examples in a simple language which is easy to understand.
National Council of State Boards (2014) A nurse’s guide to
professional boundaries.
* e-Portfolio Assessment Re-cap
As part of this module please undertake the following activity
and upload your answer into your e-
Portfolio. Please remember that this forms part of your
assessment for this unit.
You are a Registered Nurse on the afternoon shift on a short-
stay (24 hours) surgical ward. One
other RN, an EN and three AINs are also on duty. The NUM is
off sick and the other RN is acting as
NUM as well as taking a patient load. The ward is full: there are
22 patients, 14 of whom went to
surgery in the morning, and 8 are going on your shift. Half of
these patients have intravenous access
and require antibiotics at some time during your shift.
ACTIVITY:

Using your knowledge and experience of various patient
allocation models (e.g. total patient
care, team nursing and task allocation), outline how you would
allocate the staff to the
patients. Include in your discussion your rationale for the model
of allocation chosen and the
scope of practice of the various staff.
https://www.ncsbn.org/ProfessionalBoundaries_Complete.pdf
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References: Module 4
Australian Nursing and Midwifery Council (ANMC). (2010).
Professional boundaries for nurses
Retrievedfrom:http://www.nursingmidwiferyboard.gov.au/Codes
-
GuidelinesStatements/Professional-standards.aspx
Benner, P. (1984). From novice to expert: excellence and power
in clinical nursing practice. Menlo
Park Ca: Addison-Wesley.
Choi, PP. (2015). Patient advocacy: the role of the nurse,
Nursing Standard, 29 (41) 52-58.

International Council of Nurses (2014). Retrieved from:
http://www.icn.ch/
National Council of State Boards (2014) A nurse’s guide to
professional boundaries. Retrieved from:
Pearce, C. (2006). Leadership resources. Ten steps to effective
delegation. Nursing Management UK,
13(8), 19.
Schwartz, L. (2002). Is there an advocate in the house? The role
of health care professionals in
patient advocacy. Journal of Medical Ethics, 28(1), 37-40.
Image:
ANMC sign retrieved from:
https://www.library.uq.edu.au/blogs/hsl/2010/05/26/australian-
nursing-
and-midwifery-council
Novice to expert retrieved from:
http://zoerosedaviesphotography.wordpress.com/2013/01/06/fro
m-novice-to-expert/
http://journals.rcni.com/doi/pdfplus/10.7748/ns.29.41.52.e9772

me.28.1.37
me.28.1.37
nursing-and-midwifery-council
nursing-and-midwifery-council
http://zoerosedaviesphotography.wordpress.com/2013/01/06/fro
m-novice-to-expert/Professional Boundaries
Final Term Project
Directions: Read the following Case andanswer all the
questions. Please submit your work to the Dropbox by midnight
Sunday CT.
Following is a portfolio consisting of 50 bonds with a market
value of $ 99,999,999 as of April 29, 2011:
Table 1: 50-bond Portfolio
Identifier
Description
Sector
Market Value
003723AA
ABN AMRO BANK NV
Corp. Financials
1,422,596
251591AY
DEVELOPERS DIVERS REALTY
Corp. Financials
644,344
381427AA
GOLDMAN SACHS CAPITAL II
Corp. Financials
2,761,546
58551TAA
MELLON CAPITAL IV

Corp. Financials
3,102,915
912810PW
US TREASURY BONDS
Treasury
804,588
912810QA
US TREASURY BONDS
Treasury
7,505,533
912810QK
US TREASURY BONDS
Treasury
4,048,097
912828PA
US TREASURY NOTES
Treasury
3,378,751
912828PF
US TREASURY NOTES
Treasury
20,596,365
00104BAC
AES EASTERN ENERGY
Corp. Utilities
1,206,446
02360XAL
AMERENENERGY GENERATING
Corp. Utilities
737,343
165167BS
CHESAPEAKE ENERGY CORP
Corp. Utilities
880,013
125896BG
CMS ENERGY

Corp. Utilities
1,337,697
665772CE
NORTHERN STATES PWR MINN
Corp. Utilities
907,113
797440BM
SAN DIEGO GAS & ELECTRIC
Corp. Utilities
856,840
FGB08000
FHLM Gold Guar Single F. 30yr
MBS Agency
3,040,911
FGB07001
MBS Agency
780,262
FGB06402
MBS Agency
1,004,579
FGB07002
MBS Agency
4,235,068
FGB05403
MBS Agency
1,531,707
FGB06003
MBS Agency
1,537,027
FGB06004

MBS Agency
700,545
FGB05011
MBS Agency
690,585
FNA07098
FNMA Conventional Long T. 30yr
MBS Agency
1,014,899
FNA08000
MBS Agency
1,883,297
FNA05402
MBS Agency
1,854,853
FNA06402
MBS Agency
1,311,433
FNA07002
MBS Agency
2,563,939
FNA05003
MBS Agency
684,085
FNA05403
MBS Agency
3,469,103
FNA06003

MBS Agency
1,715,870
FNA05010
MBS Agency
843,855
FNA05011
MBS Agency
1,173,465
GNB04411
GNMA II Single Family 30yr
MBS Agency
2,509,580
91311QAD
UNITED UTILITES PLC
Corp. Industrials
848,272
02051PAC
ALON REFINING KROTZ
Corp. Industrials
630,655
101137AD
BOSTON SCIENTIFC
Corp. Industrials
1,656,030
12527GAA
CF INDUSTRIES INC
Corp. Industrials
1,499,778
582834AM
MEAD CORP
Corp. Industrials
787,191
651715AF
NEWPAGE CORP

Corp. Industrials
1,603,501
723787AG
PIONEER NATURAL RESOURCES
Corp. Industrials
1,045,275
749685AQ
RPM INTERNATIONAL INC
Corp. Industrials
642,823
784635AM
SPX CORPORATION
Corp. Industrials
766,621
915436AF
UPM-KYMMENE CORP
Corp. Industrials
648,265
962166AV
WEYERHAEUSER CO
Corp. Industrials
871,588
45950KBJ
INTL FINANCE CORPORATION
Gov. Related
1,198,808
45905CAA
INTERNATL BANK RECON DEV-GLOBA
Gov. Related
1,200,080
46513E5Y
ISRAEL STATE OF-GLOBAL
Gov. Related
1,911,761
500769BR
KREDIT FUER WIEDERAUFBAU-GLOBA

Gov. Related
1,012,672
500769CH
KREDIT FUER WIEDERAUFBAU-GLOBA
Gov. Related
941,429
Table 2: Asset Class
The benchmark for the manager who has constructed this
portfolio is a composite index consisting of one-third each of
the Barclays Capital U.S. Treasury index, Barclays Capital U.S.
Credit Index, and Barclays Capital U.S. MBS index. First, in
regards to the Barclays Capital U.S. Treasury index, this index
measures the performance of U.S. Treasury securities. Second,
in regards to the Barclays Capital U.S. Credit Index, this index
includes both corporate and non-corporate sectors where the
corporate sectors are industrial, utility, and finance that include
both U.S. and non-U.S. corporations. The non-corporate sectors
are sovereign, supranational, foreign agency, and foreign local
government. The index is calculated monthly on price-only and
total-return basis. All returns are market value-weighted
inclusive of accrued interest. Third, in regards to the Barclays
Capital U.S. MBS index, this index measures the performance
of investment grade fixed-rate mortgage-backed pass-through
securities of GNMA, FNMA, and FHLMC.
Asset Class
Portfolio
Benchmark
Total
100.0
100.0
Treasury
?
33.3
Government Related
?
6.8

Corporate Industrials
?
13.9
Corporate Utilities
?
2.9
Corporate Financials
?
9.7
MBS Agency
?
33.3
Table 3.1: Analytics for the 50-bond Portfolio and the
Benchmark
Table 3.1 provides information about the relative exposure to
interest rate risk as measured by duration, spread risk as
measured by spread duration, and call/prepayment risk as
measured by vega, as well as the convexity.
Analytics
Portfolio
Benchmark
Difference
Duration
6.87
5.37
1.50
Spread Duration
6.77
5.27
1.50
Convexity
0.47
0.00
0.47
Vega

0.01
0.03
0.02
Spread(bps)
355
55
300.00
Table 3.2: Contribution to Duration by Asset Class for the 50-
bond Portfolio
Table 3.2 provides information about the portfolio’s relative
risk exposure to interest rate risk.
Duration Contribution
Portfolio
Benchmark
Difference
Total
6.87
5.37
1.50
Treasury
3.62
1.78
1.84
Government Related
0.92
0.41
0.51
Corporate
1.10
1.74
–0.63
Securitized
1.23
1.45
–0.22
Table 4: Monthly Tracking Error for Risk Factors

Risk Factor Categories
Isolated Risk/Tracking Error
Curve
40.8
Swap Spreads
2.5
Volatility
2.8
Spread Government Related
5.3
Spread Corporate
30.6
Spread Securitized
5.8
Table 5: Volatility table.
This table provides the breakdown of the standard deviation of
the returns for the portfolio and the benchmark
Volatility
Portfolio
Benchmark
Tracking Error
Systematic
141.9
117.4
37.9
Idiosyncratic
19.3
4.8
18.7
Total
143.2
?
?
Duration Beta

?
Table 6: Detailed Monthly Tracking Error for the 50-Bond
Portfolio by Risk Factor Group
The “risk factor group” table provides information about the
portfolio risk across the different categories of risk factors.
Shown are the systematic risk and the idiosyncratic risk and six
components of systematic risk. The “contribution to TEV”
column shows the isolated tracking error. The contribution to
tracking error for each group of risk factor is shown in the
“liquidation effect on TEV” column.
Risk Factor Group
Isolated TEV
Contribution to TEV
Liquidation Effect on TEV
TEV Elasticity (%)
Total
42.3
42.3
–42.3
1.0
Systematic Risk
37.9
33.2
–22.4
0.8
Curve
40.8
23.4
–4.3
0.5
Swap Spreads
2.5
0.2
–0.1
0.0

Volatility
2.8
0.5
–0.4
0.0
Spread Government Related
5.3
0.0
0.3
0.0
Spread Corporate
30.6
10.0
0.8
0.2
Spread Securitized
5.8
–0.8
1.1
0.0
Idiosyncratic Risk
18.7
9.1
–4.2
0.2
Questions
The purpose of this project is to describe in detail the risk
characteristics of the 50-bond Portfolio. Your instructor drew
up the following list of questions that should be covered to be
able to discuss the portfolio’s risk relative to the benchmark. In
your analysis, be sure to discuss where it seems like the
manager is taking views on the market.
1. Use the data in Table 1 to calculate the missing weights for
each class asset that appear in Table 2. After completing the
missing weights, start your analysis of table 2 by comparing the

portfolio to that of benchmark in terms of the allocation to the
major sectors of the benchmark (i.e.,
overweighting/underweighting). Discuss your results.
2. Do you think the portfolio manager can use the percentage
allocation to each sector (i.e., Asset class table) to evaluate the
portfolio’s exposure to various risk factors? Explain?
3. Use the data in Table 3.1 and 3.2 to assess the portfolio risk
relative to the benchmark? Make sure to discuss the sources of
risk (i.e., interest rate risk, spread risk, and call & prepayment
risk). Before starting your analysis, explain the differences
among interest rate risk, spread risk, and call & repayment risk.
4. What is tracking error? What is meant by tracking error due
to systematic risk factors? What is meant by isolated tracking
error? Briefly explain what is meant by yield curve risk, swap
spread risk, volatility risk, government-related spread risk,
corporate spread risk, and securitized spread that are listed in
table 4 and the (monthly) volatility of these risk factor
categories?
5. Compute the isolated systematic tracking error for the
portfolio given the monthly tracking error for each risk factor
exposure in Table 4? Discuss the implications of your results
for the risk exposure of this portfolio. Make sure to assume a
zero correlation between any pair of risk factors when
calculating the portfolio isolated systematic tracking error.
6. Why is the tracking error more important than portfolio
variance of returns when a portfolio manager’s performance is
measured versus a benchmark?
7. You are reviewing table 5 that indicates that a portfolio
tracking error is 143.2 basis points. It is also reported that the
tracking error due to systematic risk is 141.9 basis points and
the tracking error due to non-systematic risk is 19.3 basis
points. Why doesn’t the sum of these two tracking error
components total up to 161.2 basis points?
8. Calculate the total risk for the benchmark using the values in

the “volatility” Table (i.e., Table 5) and portfolio tracking error
(volatility of net position). Complete the related blank in Table
5.
9. How can a multi-factor risk model be used to monitor and
control portfolio risk? Explain whether you agree or disagree
with the following statement “It is the tracking error not the
idiosyncratic risk (as measured by the standard deviation of the
idiosyncratic returns) that the manager must consider in
portfolio construction and monitoring”. Use Table 5 to support
your argument.
10. Compute the duration beta using the values in the
“analytics” table (Table 3.1). Complete the related blank in
Table 5. Explain your answer.
11. Based on the information given in Table 6, what are the
major risk exposures of the 50-bond portfolio? Explain your
answer.
1
Module 3 – Provision and Coordination of Care

Assessment and problem solving
From our work with the Clinical Reasoning Cycle during the
intensives you should now be
recognising that a large part of clinical reasoning is the
gathering of patient data or clinical cues. As a
result the information that you gather, whether it is subjective
or objective, is significant in the
overall provision and coordination of care.
You have learnt through the past two and a half years how to
obtain the required data. This can
range from HLSC 110 where you learnt to interview and
communicate with a patient to NRSG 354
where you learnt more advanced and complex patient
assessment skills. You have also learnt the
relevant disease processes so now is the time to develop skills
to link this knowledge altogether.
Every interaction you have with people allows you an
opportunity to collect cues whether you
formally acknowledge this or not. In the healthcare setting the
information can come from several
different areas. Your initial collection of cues commences from
handover. During handover a nurse
will identify if the patient is independent and self-caring or if
they are of higher acuity. This is similar
to the simulation class you had during the intensives. When
you were given the patient handover
and then commenced the allocation of staff to patients you were
using the cues you had collected
from handover to determine what would be an appropriate
patient allocation without even seeing

the patients. This is some of the information a charge nurse
will allocate patients each shift.
During handover nurses will often start to question the cues
they are getting about their patient that
might influence the provision and coordination of care. Eg you
receive handover and collect the cue
that your patient is mildly hypotensive with an epidural. This
information guides your priority post
handover to complete a focused physical assessment of this
patient first as opposed to the patient
that is due for discharge in one hour who has been ambulant and
self caring.
2
This activity demonstrates how you have started collecting cues
during handover.
After handover as graduate nurses you will most likely develop
a care plan. The development of a
care plan is a way of processing the information that you have
collected during handover to ensure
you adequately manage your time in relation to the care you
think you will need to provide. It is
important to acknowledge that this care plan can often change,
as you need to reprioritise care,
which is similar to the second activity we undertook in the
“ward for a day” simulation.

Whilst you start to process information you will also start to
think about cues that you are missing
and where you can gather this information. Assessing the
patient’s chart, communicating with the
patient and their family or even increasing your patient
assessment are some of the ways in which
you will achieve this. During the phase of processing
information you are also starting to work out
what is relevant information as opposed to information that is
irrelevant to the situation.
The Clinical Reasoning Cycle can provide a framework for you
structure your thought processes and
ensure you can link the knowledge that you have obtained
during your undergraduate degree to the
clinical context in which you will be working as a graduate
nurse.
ACTIVITY 1
You are working on the morning shift on the ward, and receive
a patient from ED. The ED nurse
provides you with the following handover, using the ISBAR
format. Further information about the
ISBAR format can be found on page 7 of this module.
Please click on the handover link in LEO within Module 3
section, titled: ‘Module 3 Activity 2 Verbal
Handover’. Listen to this recording, and then please answer the
following:
1. What further questions will you need to ask the nurse?
2. List specifically what further assessments you would
complete when the patient arrives

onto the ward
3. Upload the above answers to your e-Portfolio on LEO. This
forms part of your assessment
for this unit.
ACTIVITY 2
To understand more about the Clinical Reasoning Cycle please
read chapter 1 of the prescribed
text. Whilst reading this chapter identify ways that you can
incorporate the Clinical Reasoning Cycle
into your clinical placement.
Levett-Jones, T. (2013) Clinical Reasoning: Learning
to think like a nurse, Frenchs Forests, NSW:
Pearson.
Please read the article by Felton (2012). While you read the
article take particular note of how
important it is to take accurate vital obs, and how your thorough
assessment can have a major
impact on the patient’s prognosis.
Felton, M. (2012). Recognising signs and symptoms of patient
deterioration. Emergency Nurse,
20(8), 23-27.
Activity 2 : continued

t-live
3
Development, implementation and evaluation of planned care
based on assessment findings
Once you have completed all your assessments, it is then time
to re-evaluate a plan of care for your
patient. Most nurses will have a patient load of 4 or more
patients, and it is essential you learn how
to prioritise your time effectively in order to provide safe and
quality care.
Things change quickly in healthcare environments, and you
need to learn how to be flexible.
Therefore, the ability to prioritise and delegate are essential
skills for nurses, and with time and
experience you start to improve these skills. Student and
graduate nurses can quickly feel
overwhelmed and overloaded when they are required to care for
a full patient load, and their time
management may suffer as they learn how to juggle different
tasks and responsibilities.
Wentworth (2003, p. 438) also speaks of the “personal
inadequacy” one feels when they cannot
manage their time – from personal experience, most nurses can
tell you that they certainly felt
incompetent when they started their graduate years; as most
want to do everything for their

patients but can not understand why it is not possible. Most
graduate nurses think that no one else
feels this way and often feel judged as inept when they hand
over to the next shift nurse. It takes a
while, but you will finally learn that nursing is a 24/7 job, and
you are not expected to do EVERY
thing for your patients. You can leave tasks for the next shift if
it does not compromise the care you
provide.
Initially, novice nurses will need help with prioritising their
work, and Siviter (2013) has created the
ABCD system to help with organising and prioritising your
nursing tasks:
A - Absolutely must get
done
• Tasks that must be done at a certain time. Eg. medications,
dressings, medical rounds
• You will be interrupted to do a particular task if it is not done
soon
• Waiting will cause a patient avoidable distress. Eg.
Administering
analgesia
• A risk or hazard is present
• Documentation and paperwork.
B - Better sooner than
later

• Can wait, but not too long
• Must be done today or on this shift. Eg. ADLs
•
C - Can wait until later • Things that do not have any time
frame attached. Eg. Changing
During clinical placement choose a patient that is of interest to
you. Perhaps a patient that you
found challenging in terms of linking the theory together. Fill
in the Clinical Reasoning Cycle
Worksheet that can be found on the LEO page to assist with
your understanding of that patient’s
condition and how the Clinical Reasoning Cycle can be of
benefit to you.
Upload the worksheet to your e-Portfolio on LEO. This forms
part of your assessment for this
unit.
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• Getting things that will be needed later in the day.
D - Do not worry about it
• These are tasks that are beneficial, but if left undone will not
affect patients or their care.

• These things should get done, but no one will be hurt if they
are
not.
Once you assess your patient and ascertain what they need and
the tasks you need to complete, rate
them as either A, B, C or D. Do all the A tasks first, then B etc,
and where possible combine tasks to
increase efficiency.
Sometimes (if not all the time), your plans will change, and this
may mean that you will need to re-
prioritise. The doctor may have decided that Mr. Smith in bed 2
is ready for discharge this morning,
and you will find that completing his discharge paperwork and
education has now become your main
priority.
It is normal to realise that sometimes you cannot do everything,
even when you have prioritised. In
this case, ensure you ask for help and delegate where possible.
It is difficult for students to
delegate, as you feel you are the most junior member, but you
need to be able to speak up and ask
for help. At the end of the day, your priority is your patients,
and you need to ensure they receive
the best care.
To be able to develop professional nursing practice, you need to
learn how to prioritise and manage
your time. With practice and experience, this will become
second nature but in the meantime,
remember to practice, practice, practice!
ACTIVITY 3

You have been allocated 4 patients this afternoon shift
commencing at 1300hrs. You have
received handover for the following patients:
Bed 1: A 45 year old female presented to ED with a
haemothorax, and had an ICC inserted. She
arrived on the ward at 1230hrs. She has an IVC in-situ in her
left antecubital, and currently has
100ml/hr of NaCl 0.9% running. She has a morphine PCA which
she is using appropriately, and it has
kept her settled and pain-free. She is on 3 doses of prophylactic
cephazolin 8 hourly, and she has
received a dose in ED at 1200 hrs. There is an IDC in-situ,
which is draining 35ml/hr, the urine
appears cloudy. She will require a CXR in the morning, physio
assessment, as well as a pain review by
the medical team. Diet and fluids as tolerated.
Bed 2: A 23 year old male has been admitted with suspected
cholecystectomy, and has been placed
on the evening emergency theatre list. He is complaining of
severe abdominal pain with a numerical
pain score of 8/10. He has been fasting for 8 hours since he
came to the ward this morning. He has
no IV inserted, and has been prescribed PRN oral paracetamol
and oxycodone for pain.
Bed 3: A 17 year old male who is Day 4 following a
laparoscopic appendectomy with perforation, and
is ready to be discharged home. He has been on PRN
paracetamol and oxycodone, and has been
prescribed amoxicillin and lactulose for use at home. His
parents will pick him up at 1700hrs, once

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they have finished work.
Bed 4: Dirty bed. A new patient is to come up from ED in 1
hour with abdominal pain of unknown
origin. She has no relevant past medical history, and has been
booked in for an abdominal
ultrasound at 1600 hrs. She is fasting and has not yet been
prescribed any analgesia.
Communication of assessment, planned care and evaluation of
planned care – handover and documentation
Central to the nurse’s role is the diagnosis, treatment, and
evaluation of patient responses to actual
&/or potential health problems (Campbell, Gilbert & Laustse,
2010). However, this is not done in
isolation; but as a member of a team. The ability to
communicate a patient’s condition, response to
therapy, and plan of action is a foundation stone on which
effective team-work is built. This
communication can be between the nurse and other nurses, the
patient, the patient’s family, and
other members of the multidisciplinary team (Campbell et al.,
2010).
According to the Department of Human Services (2006),

ineffective communication between staff is
ranked as the second most common factor contributing to
sentinel events in the Victorian
healthcare setting. Therefore different strategies for
communication are necessary in order to
facilitate effective communication depending on the setting, the
issue, and the participants.
The importance of effective clinical communication cannot be
overstated, and if successful, can lead
to:
• Improved safety.
• Improved quality of care and patient outcomes.
• Decreased length of patient stay.
• Improved patient and family satisfaction.
• Enhanced staff morale and job satisfaction
(The Joint Commission, as cited in Department of Health, 2010,
p. 5)
This module will now explore two major forms of clinical
communication – the verbal handover, and
documentation of patient care.
Now that you have received a handover, please complete the
following tasks:
1. Assess your patient’s needs and decide what tasks or nursing
care needs to be
done
2. Draw up a shift planner with an hourly plan.
3. Prioritise these hourly tasks by rating it A, B, C or D – do the

most important
first.
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Handover
The practice of clinical handover at the change of shift can vary
drastically between practitioners.
While it may appear to be a simple task of “handing over” or
“updating” the care of your patient, it is
in fact a complex issue. There are a number of articles that
identify ineffective handover as a source
of adverse patient events – please read the articles which are
linked below:
ACTIVITY 4
1. Scovell, S. (2010). Role of the nurse-to-nurse handover in
patient care. Nursing Standard,
24(20), 35-39.
Scovell (2010) identifies that handover assumes an almost
religious significance in a nurse’s day
before going on to describe the various roles that handover
assumes in nursing culture. Therefore,
apart from being a simple information sharing event, handover
has a significant influence on the
day-to-day, shift-to shift experience of nurses.

2. Street, M., Eustace, P., Livingston, P.M., Craike, M.J., Kent,
B. & Patterson, D.
(2011). Communication at the bedside to enhance patient care:
A survey of nurses’
experience and perspective of handover. International Journal of
Nursing Practice, 17, 133-
140.
According to Street et al. (2011), the primary purpose of
handover is “to provide accurate, up-to-
date information about the patient’s care, treatment, use of
services, current condition, and any
anticipated changes in that condition” (p. 134). However
dangers to effective handover include
omission of vital information, inclusion of irrelevant &/or
speculative information, and poor
handover technique.
Please read the Scovell and Street articles by clicking on the
link. You may not look at handover the
same way again after realising what a significant event it is.
Take note of the practices you may
have experienced already as a student and consider how these
two articles can help you to be
more effective when giving your own handover now and in the
future.
Now that you have a better understanding of the importance of
handover, you need to work out
how to provide an effective handover to your colleague. Every
facility will have their own processes,
but you need to remember to incorporate the standards outlined
above, and be SYSTEMATIC.

There is a greater movement towards using the ISBAR clinical
handover tool, which you would have
learnt and practiced in previous units. This is an effective tool
which ensures that your handover
provides relevant and vital information, and is well organised.
Remember, this is a guide only, and
you will need to ensure you individualise this!
I – Identify
S – Situation
B – Background
A – Assessment
R - Recommendation
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1440-172X.2011.01918.x
1440-172X.2011.01918.x
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Documentation
Documentation includes end-of-shift progress notes, charting
and any assessment findings. It is
essential that you document in a timely manner, and remember
that unless it has been documented
properly, it has NOT happened. We tend to fall into bad habits
over time, such as writing vital signs
on a piece of paper and transcribing it “later”, several hours on.

Ask yourself this: If your patient was
to arrest and a MET was called, and there was nothing charted
for the last few hours, do you think
that your crumpled up piece of paper with random numbers will
hold up in court?
When you complete your documentation, try to follow the
standards of effective documentation, as
outlined below:
Complete • Try and prevent interruptions – once you start, don’t
stop until you are
done
Concise • Include only relevant statements and avoid
unnecessary repetition
Accurate
• Use words which are considered. Facts and figures need to be
accurate
• If you have not witnessed an event, ensure you communicate
that. Eg.
Mrs. Jones stated she had eaten breakfast in the hospital
cafeteria this
morning.
Clear
• Short and familiar words are used to construct effective and
understandable messages

• Avoid jargon, patronising or discriminatory language
• Don’t use abbreviations unless legally acceptable. Here is a
list of
acceptable abbreviations you can use.
• Please note that you still need to follow the policy and
procedures of
the facility when using abbreviations
Timely
• Relay and document information in a timely manner – don’t
delay!
• Remember – if it hasn’t been documented or charted, it has not
been
done!
(VPSR, 2013)
Summary
To enable you to practice in a safe and professional manner you
can try reflecting on the experience
of your current placement in addition to the information
presented in this module. Reflect on these
activities in the context of your clinical experience. Practicing
these skills within the safe context of
student status will aid your transition to RN role.
Complete Activity 1 and 2, and upload your answers onto your
e-Portfolio. Please remember that
this forms part of your assessment for this unit.

http://nursing.flinders.edu.au/students/studyaids/clinicalcommu
nication/page_glossary.php?id=13
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Aitken, L., Chaboyer, W. & Elliot. (2102). Scope of Critical
care Practice. In ACCCN’s Critical Care
Nursing 2nd Ed. Elsevier, Sydney.
Campbell, L., Gilbert, M. & Laustsen, G. (2010). Clinical coach
for nursing excellence. Imprint:
Philadelphia, Pa.
http://ezproxy.acu.edu.au/login?url=http://ACU.eblib.com/patro
n/FullRecord.aspx?p=474457
Department of Human Services (2006). Sentinel event program:
Annual report 2005-06. Department
of Human Services, State of Victoria: Victorian Government of
Human Services, Melbourne.
http://docs.health.vic.gov.au/docs/doc/55C19FCE805F1AA2CA
2578FE0016B49B/$FILE/Sentinel-
event-program-0506.pdf
Department of Health (2010). Promoting effective
communication among healthcare professionals to
improve patient safety and quality of care. Department of

Health, State of Victoria: Victorian
Government Department of Health
http://www.health.vic.gov.au/qualitycouncil/downloads/commun
ication_paper_120710.pdf
Felton, M. (2012). Recognising signs and symptoms of patient
deterioration. Emergency Nurse, 20(8),
23-27.
m/login.aspx?direct=true&db=ccm
&AN=2011787433&site=ehost-live
Jacox, L. & Cole. A. (2012). ISOBAR: Standardising nursing
handover. Retrieved 21 June, 2013,
from: http://yhhiec.org.uk/wp-content/uploads/2012/07/34.pdf
Levett-Jones, T. & (2013) Clinical Reasoning: Learning to think
like a nurse, Frenchs Forests,
NSW: Pearson.
Scovell, S. (2010). Role of the nurse-to-nurse handover in
patient care. Nursing Standard, 24(20), 35-
39.
Siviter, B. (2013). Effective time management for nurses.
Retrieved 21 June, 2013, from
http://nursingstandard.rcnpublishing.co.uk/students/from-
student-to-qualified-

nurse/effective-time-management-for-nurses
Street, M., Eustace, P., Livingston, P.M., Craike, M.J., Kent, B.
& Patterson, D. (2011). Communication
at the bedside to enhance patient care: A survey of nurses’
experience and perspective of
handover. International Journal of Nursing Practice, 17, 133-
140.
1440-172X.2011.01918.x
Virtual Simulated Patient Resource (VSPR) (2013). Standards
of effective communication. Retrieved
19 June, 2013, from
https://www.vspr.net.au/joomla/index.php?option=com_joomdle
&view=wrapper&moodle
_page_type=course&id=5&Itemid=
2578FE0016B49B/$FILE/Sentinel-event-program-0506.pdf
2578FE0016B49B/$FILE/Sentinel-event-program-0506.pdf
http://www.health.vic.gov.au/qualitycouncil/downloads/commun
ication_paper_120710.pdf

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1440-172X.2011.01918.x
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Wentworth, S. (2003). Time management strategies in nursing
practice. Journal of Advanced
Nursing, 43(5), 432-440.
Image:

MDT meeting at bedside retrieved from:
http://www.vernoncollege.edu/VocationalNursingTemplate.aspx
?ekfxmen_noscript=1&ekfx
mensel=e5a1dcbef_46_52&id=2149
Nurse with ventilator retrieved from:
http://www.vox.gi/index.php?category=3&pg=3
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entation
1
Module 2 – Collaborative and Therapeutic Practice
Introduction

Welcome to Module 2 for NRSG 355 Clinical Integration:
Transition to Professional Practice. This is
the second of the on-line modules and will focus on the areas of
Collaborative Practice, the Multi-
Disciplinary Health Care Team and Therapeutic Practice. This
relates very closely to the three other
modules: Critical Thinking, Professional Practice, and Provision
and Coordination of Care.
As you enter your final semester of your nursing degree the
content within this unit and the modules
will not be new to you. Although, the real test of knowledge is
in how we apply it. With that in mind,
each of the theoretical concepts within this module are only
briefly addressed. The bulk of the work
is how you apply it to some hypothetical clinical scenarios.
Collaborative Practice
Collaboration is when several health professionals work
together for a common goal. Collaboration
is not unique to health care but is also part of business and
community models for achieving success
in any project. In the case of health, success is defined in terms
of patient outcomes. A successful
outcome for the patient can only be achieved by implementing a
coordinated series of interventions
from a variety of health professionals and intrinsic to this is the
involvement of the patient and their
family. Collaboration is essential for such a group to keep the
patient as the central focus, ensure the
roles within the team are clear, ensure all aspects of the health
issue and its impacts are accounted
for and the care plan is aimed at achieving common goals (Crisp

& Taylor, 2009, pp 43).
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A collaborative approach to health care reflects the
multidimensional nature of illness. For the
individual, illness often impacts on several body systems as
well as having effects on family and
friends. The end result can be personal, social and occupational
malfunction. This pathological
complexity means that health care intervention requires a
complex response. In the course of your
studies you have been exposed to terms such as ‘holistic care’
to describe a series of interventions
aimed at treating physical, psychological, emotional and
spiritual care to describe this complex
response. Each member of the team contributes to the care but
merely having the same goals does
not guarantee a smooth process or successful outcomes. You
will all have had experience working in
groups within your studies, on clinical placements, at school
and with other group projects you may
have been involved with.

Multidisciplinary Health Care Team
The multidisciplinary healthcare team, by definition, includes
members from a variety of disciplines.
From your clinical experiences to date you should be familiar
with most of the common members of
a health care team. The most important and sometimes neglected
member of the health care team
is the patient and their family. While we acknowledge this as
health professionals it can sometimes
be lost in the pressure of delivering quality health care with a
finite resource base.
ACTIVITY 1
Reading:
Weller, J. (2012). Shedding new light on tribalism in health
care. Medical Education, 46,
132-142.
Please read this article and answer the following questions:
1. What does tribalism refer to?
2. How do tribalism and power inequities impact on information
sharing?
3. What are the five key dimensions for a well-functioning
health care team?

Reading:
Kalishman, S., Stoddard, H. & O’Sullivan, P. (2012). Don’t
manage the conflict: transform
it through collaboration. Medical Education, 46, 926-934.
Please read this article and answer the following question:
1. What benefits does the author suggest are there to conflict
within groups?
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Therapeutic Practice

The aim of any health intervention is to address the cause and
symptoms of illness. These
interventions are designed to deliver the best possible outcome
for the patient and their family. The
implementation of these interventions is what constitutes
therapeutic practice. Therapeutic practice
incorporates a range of nursing skills, knowledge,
communication skills and attitudes. A therapeutic
relationship is one based on mutual trust, respects
confidentiality and focuses on patient self-care
(Berman et al, 2008, pp 496). Therapeutic relationships have
been described as both a helping
relationship and an interpersonal relationship. During your
clinical practice you will have had the
opportunity develop therapeutic relationships with your patients
and engage in therapeutic practice
within your own scope of practice.
The real focus of this unit is about knowledge application so to
prepare you for your role as a
member of a health care team working collaboratively we have
developed a series of five (5)
theoretical scenarios for you to comment on.
While you need to work on all 5 case studies, please choose one
and upload the answers on your e-
Portfolio on LEO. This forms part of your assessment for this
unit.
CASE STUDY 1
Grant Thompson was a fit 37 year old man, a father of two
young children and married for
14 years to Georgina. Grant was a truck driver who was
involved in an MVA 6 months ago and

suffered extensive injuries to his leg and a mild head injury. His
recovery has been slow and he
relies heavily on the use of a wheelchair but can now walk for
short distances with the aid of a
walker. Georgina wants Grant to come home and rehabilitate
there. She has made some
modifications to their home, ramps put in, handrails in the
bathroom and toilet.
The health care team is meeting to discuss this option. The
team consists of the treating
doctor, physiotherapist, and occupational therapist, NUM of the
rehabilitation unit, social worker
and psychologist. There is disagreement among the team as to
whether Grant would be better to
stay in hospital a bit longer or go home. The physiotherapist
and the occupational therapist both
feel that Grant still requires intensive treatment which can only
be provided as an inpatient. The
psychologist and the social worker have noted that Grant’s
separation from his family and home
ACTIVITY 2
Reading:
The “MND Australia Fact Sheet on Multidisciplinary Teams”
outlines professional groups who
could make up a multidisciplinary health care team for a patient
with motor neurone disease
(MND).
Please read this fact sheet, answer the following questions, and
upload your answers on your
e-Portfolio on LEO. This forms part of your assessment for this
unit.

1. Identify factors that determine which healthcare professionals
are required to be
involved in a health care team?
2. Who should lead the health care team?
3. Who is the most important member of the health care team?
http://www.mndaust.asn.au/Get-informed/Information-
resources/Living_better_for_longer/WEB-MND-Australia-Fact-
Sheet-EB3-Multidisciplinary.aspx
4
environment has been having a negative effect on Grant,
Georgina and their children. The treating
doctor feels that we could treat Grant as an outpatient but it
would mean he has to attend regular
physiotherapy and occupational therapy sessions. You are the
team designated leader of the health
care team.
Discuss the following questions
1. What are the key issues in this dilemma?
2. What outcomes would be best for Grant and his family?
3. How would you guide the group in achieving this best
outcome?

CASE STUDY 2
Norma Ellis is a 76 year old widow who recently had a fall at
the nursing home she has
lived in for the past 7 years and fractured her hip. She has
subsequently had a hip replacement and
has been rehabilitating well and is now due for discharge back
to the nursing home. Norma has an
extensive medical history including postural hypotension,
rheumatoid arthritis and impaired
mobility. She mobilised within the nursing home using a
walker. Her son is demanding that his
mother be kept in the ward as an inpatient as he feels the
nursing home staff were negligent and
wants his mother to be placed elsewhere but has not arranged
this yet. The treating team consists

of the doctor, physiotherapist, NUM of the rehabilitation unit,
social worker and NUM of the
Norma’s wing at the nursing home she was in prior to the fall.
You are the designated team leader.
The doctor feels there is no need to have Mrs Ellis on the ward
as he feels that her rehabilitation
has been maximised, this is an opinion shared by the
physiotherapist. Norma wants to go back to
the nursing home as she has made many friends there and feels
at home there.
2. How would you deal with Norma’s son? Are his objections
warranted?
CASE STUDY 3
Robert Hughes is a 52 year old male who was injured in a
bicycle accident two months ago where
he suffered fractures to his (R) tibia/fibula and (R) radius.
Robert is intellectually impaired and was
living with his elderly mother until the accident. Robert has
been known to engage in verbally
aggressive outbursts towards staff and other patients. His
mother who is now 75 years of age feels
she can no longer look after Robert. You are the NUM of the
rehabilitation unit that is admitting
Robert for his ongoing rehabilitation. You are required to gather
together a health care team to
determine immediate and long term care options for Robert.

1. What are the key issues in this situation?
2. Who would be included in the health care team and what role
would they play?
5
Your mandatory assessment requirements for module one
include

1. Complete Activity 2 and upload your answers onto your e-
Portfolio.
2. Choose one case study and upload your answers onto your e-
Portfolio.
Please remember that this forms part of your assessment for this
unit.
CASE STUDY 4
You are working in a health care team on a busy rehabilitation
unit. Team meetings and
patient reviews are conducted weekly. There has recently been a
turnover of staff in the
Physiotherapy department and a new representative from
physiotherapy has joined the health
care team. You notice although that this new member of the
team members is often absent, fails
to provide patient updates and when challenged on these issues
is exceptional confrontational.
This behaviour is not only impacting on the effectiveness of the
health care team but also on
patient outcomes. You are the designated team leader and need
to find a resolution.
2. What strategies would you employ to address this situation?
CASE STUDY 5
You are the NUM of a Mental Health Unit where case reviews

are conducted every 4
weeks. You are the designated team leader and the team
members include the medical officer,
resident psychiatrist, patient case manager, social worker and
employment officer. Several of the
team members approach you after the meetings and voice
concerns about how the meetings are
being dominated by the medical staff. The general feeling was
that the medical team dominated all
clinical care decisions and most of them felt they did not have a
voice at the team meetings. As the
designated team leader you are responsible for ensuring equity
exists in decisions about ongoing
care.
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Crisp, J. & Taylor, C. (Eds). (2009). Potter and Perry’s
fundamentals of nursing, 3rd edn. Elsevier,
Chatswood.
Berman, A., Snyder, S., Kozier, B., Erb, G., Levett-Jones, T.
Dwyer, T....& Stanley, D. (2010). Kozier and
Erb’s fundamentals of nursing, First Australian Edn. Pearson,

Frenchs Forest.
Kalishman, S., Stoddard, H. & O’Sullivan, P. (2012). Don’t
manage the conflict: transform it through
collaboration. Medical Education, 46, 926-934.
MND Australia (nd). Australia Fact Sheet on Multidisciplinary
Teams
resources/Living_better_for_longer/WEB-
MND-Australia-Fact-Sheet-EB3-Multidisciplinary.aspx
Weller, J. (2012). Shedding new light on tribalism in health
care. Medical Education, 46, 132-142.
Image:
Medical team conversation retrieved from:
http://www.gettyimages.com.au/detail/photo/hospital-
staff-discussing-patient-charts-royalty-free-image/132265940
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1
Module 1 – Critical thinking, clinical decision making
and professional development
Clinical decision making - problem solving and prioritising
This section is borrowed from a module prepared for the High
Dependency elective but is
relevant to all students approaching graduation and registration.
In the Australian College of Critical Care Nurses (ACCCN) text

on Critical Care Nursing, clinical
decision making is described as integral to critical care nursing
practice (Aitken, Chaboyer, Elliott,
2012). This observation is not only true for Critical Care, but is
pertinent for all nursing. Clinical
decision making is a cognitive process used to understand the
significance of patient data in order to
identify and diagnose actual and potential patient problems
before arriving at a clinical decision
regarding appropriate interventions to resolve the problem and
ensure optimal patient outcomes.
The foundation stones of clinical decision making are clinical
information and theoretical knowledge
(Aitken et al, 2012).
It might be tempting to see data collection as the simpler of the
two foundations of clinical decision
making; however, the complexity of some patients and the
overwhelming amount of data available
via various technologies brings its own challenges. In order to
attend to this complexity it is
necessary to draw on the basics of patient assessment and to be
systematic in the collection and
interpretation of data.
While monitoring and assessment of patients can include
technology, you already have the basic
skills required to assess your patients in any setting. It is
important to remember that at the core of
all clinical decision making is a full and thorough assessment of
the patient. To this end, recording
2

and interpreting basic vital signs is the first, crucial, foundation
step in patient assessment. Alysia
Coventry (from ACU) and Malcolm Elliott (ex-ACU lecturer)
have written an article on patient
assessment in critical care. Alysia and Malcolm propose that:
“Nurses have traditionally relied on five vital signs to assess
their patients: temperature,
pulse, blood pressure, respiratory rate and oxygen saturation.
However, as patients
hospitalised today are sicker than in the past, these vital signs
may not be adequate to
identify those who are clinically deteriorating” (Elliott &
Coventry, 2012).
Clinical decision making is a component of the clinical
reasoning process that the average nurse
performs 2-3 times per minute (Aitken et al, 2012). It takes
time, practice, and training to hone this
skill. As mentioned already, there is an abundance of
technology we can draw on to facilitate patient
monitoring and assessment. You might be feeling overwhelmed
at the prospect of patient
assessment and data collection in the acute care environment.
However, you have had plenty of
opportunity to practice patient assessment during your course so
far and will have ample
opportunity on your up-coming clinical placements. You will
also get plenty of opportunity to
observe and be involved in clinical decision making processes.
You already have the basics of clinical
reasoning as part of your professional repertoire. During the
intensives you will develop skills that

allow you to link your critical thinking using the framework of
the Clinical Reasoning Cycle (Levett-
Jones, 2013). Draw on these basics and learn from the
clinicians you work with during your
placements.
ACTIVITY 1
Reading:
Please read the article for Alysia Coventry and Malcolm Elliott.
While you read the article take
particular note of how traditional vital signs can be used to
assess the critically ill patient as well as
the role of the additional three “vital signs”: level of pain, level
of consciousness, and urine output.
Elliott, M. & Coventry, A. (2012). Critical care: the eight vital
signs of patient monitoring. British
Journal of Nursing, 21(10), 621-625.
Sharing assessment data & putting clinical decisions into action
The challenge
As mentioned above, a particular challenge associated with the
multidisciplinary team is the nurse-
physician relationship. The factors that contribute to this
challenge are also relevant to other
nurse/co-worker interactions. However, there is evidence that
suggests a positive relationship
between physicians and nurses contributes to improved patient
outcomes (Benner, Tanner, Chelsa,
2009).

t-live
3
It is important that you don’t get intimidated by physicians or
other health care practitioners; but,
that you recognise your limitations while ensuring appropriate,
professional communication
channels are maintained.
ACTIVITY 2
Reading:
Benner et al (2009) have dedicated a chapter to the nurse-
physician relationship. Follow this link
to “Expertise in practice; Caring, clinical judgement, and ethics
2nd Ed” by Benner et al, and then
click on Chapter 11: The nurse-physician relationship:
negotiating clinical knowledge.
The chapter is quite long and includes a number of clinical
scenarios that are used to illustrate
specific aspects of the nurse-physician relationship. There is
specific reference to junior nurses in
some of the scenarios.
Please take some time to identify the aspects of each scenario
that relate to the neophyte RN and
their place in this key clinical relationship including the pivotal
role of the RN as patient advocate.

The solution = Communication
Central to the nurse’s role is the diagnosis, treatment, and
evaluation of patient responses to actual
&/or potential health problems (Campbell, Gilbert, Laustsen,
2010). However, as alluded to already,
this is not done in isolation; but as a member of a team. The
ability to communicate a patient’s
condition, response to therapy, and plan of action is a
foundation stone on which effective team-
work is built. This communication can be between the nurse
and other nurses, the patient, the
patient’s family, and other members of the multidisciplinary
team (Campbell et al, 2010). Therefore
different strategies for communication are necessary in order to
facilitate effective communication
depending on the setting, the issue, and the participants. The
importance of effective clinical
communication cannot be overstated. In an investigation of
nursing handover practices, Street,
Eustace and Livingston et al (2011), report ineffective
communication as the most frequently cited
cause of sentinel (adverse) events in the U.S and Australian
hospitals. Handover will be explored in
more detail later in this module.
ACTIVITY 3
Reading:
Please read Chapter 7: Communication-mastering collaboration,
delegation and documentation

from Campbell, L., Gilbert, M. & Laustsen, G. (2010) Clinical
coach for nursing excellence:
When you read the chapter you can skip over the general
discussion of communication techniques if
time is short; however, please focus on the key aspects of the
rest of the chapter. In particular, pay
close attention to the sections on ISBAR, delegation and
documentation.
http://ezproxy.acu.edu.au/login?url=http://site.ebrary.com/lib/au
straliancathu/docDetail.action?docID=10281515
4
Reading:
Casey & Wallis, (2011) place nurses “at the heart of the
communication process”.
Please read the Casey & Wallis article by clicking on this link:
Please take particular note of the principles described under
documentation and reporting.
http://ezproxy.acu.edu.au/login?url=http://search.ebscohost.com

/login.aspx?direct=true&db=a9h&AN=60108115&site=ehost-
live
5
* e-Portfolio Assessment
and upload your answer into your e-
Portfolio. Please remember that this forms part of your
assessment for this unit.
On returning from your tea break you are met by several staff
members who relate the following
information to you concerning your patients.
i. Mrs Chew’s intravenous (IV) infusion has tissued, her IV
fluids are running behind and she has
missed her 14.00 hrs IV antibiotic.
ii. Mr Smith’s visitor has fainted.
iii. One of the staff toilets has blocked and is overflowing and
waste is pouring out rapidly.
iv. Mr Esposito is scheduled to leave the ward now for his
cardiac catheterisation and he has still
not received his preoperative medication.
v. One of the surgical consultants (VMO) is waiting to discuss a
medication error that happened

last week.
vi. As you are taking this handover, an elderly female post-
operative patient collapses to the floor
and is unconscious. She has had facial surgery.
The other RN is busy with NUM role. Staff currently available
on the ward to assist you in addressing
these issues include: the ward clerk, an Enrolled Nurse who is
currently undertaking her IV
cannulation certificate but is not yet competent, and an AIN.
ACTIVITY
Using the above scenario:
1: In order of priority, identify which tasks you yourself will
undertake and which tasks you will
delegate.
2: Document your rationales in detail.
6
Aitken, L., Chaboyer, W., Elliot, D. (2102). Scope of Critical
care Practice. In ACCCN’s Critical Care
Nursing, 2nd Ed. Sydney: Elsevier.

Benner, P., Tanner, C., Chelsa, C. (2009). Expertise in practice;
Caring, clinical judgement, and ethics
2nd Ed. Springer, NY.
Campbell, L., Gilbert, M., Laustsen, G. (2010). Clinical coach
for nursing excellence. Retrieved
from
Casey, A., Wallis, A. (2011) Effective communication:
Principle of nursing practice E. Nursing
Standard 25(32), 35-37. Retrieved from
Chaboyer, W., Hewson-Conroy. (2012). Quality and safety. In
ACCCN’s Critical Care Nursing, 2nd Ed.
Elsevier, Sydney.
Elliott, M. & Coventry, A. (2012). Critical care: the eight vital
signs of patient monitoring. British
Journal of Nursing, 21(10), 621-625. Retrieved from
Images:
Decision Making retrieved from:
http://www.mindwerx.com/articles/critical-thinking-decision-
making

Staff station retrieved from:
http://acanthajohnson.blog.com/2011/06/08/cna-training-
programs/
Thinking Statue retrieved from:
http://www.nyu.edu/classes/keefer/brain/cybermit.html
t-live
t-live
t-live
t-live
making
making
http://www.nyu.edu/classes/keefer/brain/cybermit.htmlClinical
decision making - problem solving and prioritisingThis section
is borrowed from a module prepared for the High Dependency
elective but is relevant to all students approaching graduation
and registration.Sharing assessment data & putting clinical
decisions into actionThe challengeThe solution =
Communication

www.mndaust.asn.au
Freecall 1800 777 175
1
Living Better for Longer: MND Australia Fact Sheet EB3
Multidisciplinary care team
What you should know
A multidisciplinary care team for people with motor neurone dis
ease usually includes a doctor, allied health
professionals (such as a dietitian, occupational therapist, physio
therapist, social worker and speech
pathologist) and local palliative and community care workers. O
ther team members who have particular
expertise are involved as needed, such as a respiratory specialist
.
You can live better for longer with motor neurone disease when
health professionals have a coordinated,
multidisciplinary approach to your care.
In many areas of Australia, the regional/care advisor from your
MND Association liaises with the team,
assisting you and the team get information, support and referral
to other services when needs change.

About the multidisciplinary care team
Multidisciplinary teams are also known as primary health care t
eams. Team members communicate with each
other about your care and help you get care from other members
of the team when you need it.
Professionals providing multidisciplinary care can be from the s
ame organisation, a range of organisations or
from private practice. They can work in the community, hospital
, clinic, residential and other care settings. Each
discipline‐specific team member enriches the knowledge‐base of
the team as a whole and, over time, the
multidisciplinary team composition can change to reflect change
s in the person’s needs (Mitchell et al 2008).
Multidisciplinary care and MND
Over the course of your disease progression you may find you n
eed to talk with a respiratory specialist about
breathing, an occupational therapist about equipment, a speech
pathologist about communication, a
physiotherapist about joint stiffness, a palliative care team abou
t support and your general practitioner and
neurologist for regular symptom review. You can live better for
longer with motor neurone disease when these
health professionals have a coordinated, multidisciplinary appro
ach to your care (Traynor et al 2003, Van den
Berg et al 2005).
Importantly, multidisciplinary care provides you with a direct li
nk to one person, who is a member of the team,
usually referred to as a key worker, case manager, care coordina
tor or team coordinator.
Yourmultidisciplinary care team key worker
Your key worker:
regular contact with you

effective and timely response when
your needs change
with other team members and services
regular case conferences and team
meetings.
Who your key worker is depends on:
you live in Australia
health and community care service
availability
professional interests of individual health
and community care professionals in your area.
Your key worker may be a:
manager
practitioner
occupational therapist, physiotherapist or
speech pathologist
clinic nurse
regional/care advisor
shared‐care worker
care professional
health or community care professional

with particular expertise in MND symptom
management.
© MND Australia 2012 EB3/201202
2
Members of a multidisciplinary care team
Community/aged care worker and case manager
Community/aged care workers provide general
household assistance, emotional support, care and
companionship to people in their homes. Case
managers assist people to access health and
community services.
Dietitian
Dietitians provide dietary and nutritional advice.
General practitioner
The general practitioner (GP) is a doctor providing
general medical care. GPs are usually your first
point of medical contact. The GP liaises with the
neurologist and other health and community care
providers.
MND Association regional/care advisor
MND Association regional/care advisors help
people with motor neurone disease connect to the
services they need. Regional/care advisors also
offer ongoing information to families and service

providers as questions arise or needs change.
Neurologist
The neurologist is a doctor who specialises in
disorders of the nervous system. The neurologist
coordinates the tests you need for diagnosis. The
neurologist also monitors the progress of the
disease and management of your symptoms.
Occupational therapist
An occupational therapist (OT) helps to maintain
mobility, function and independence. OTs provide
advice about home modification, different ways of
performing tasks and on selecting, acquiring and
adapting specialised equipment.
Palliative care team
The palliative care team specialises in interventions
that can improve quality of life for people with
eventually fatal conditions. Palliative care services
provide emotional support for people living with
MND and can assist you to plan your future care.
Physiotherapist
A physiotherapist helps you maintain physical
activity and mobility. Physiotherapists can also
show your family or carer how to safely help you
move from one position to another, for example,
moving from a chair to a bed.
Respiratory specialist
The respiratory specialist is a doctor who specialises
in disorders of the lungs and breathing. The
respiratory specialist provides information and
advice about breathing and motor neurone disease.

Registered nurse, MND nurse, clinical nurse
consultant or clinical nurse specialist
The role of the nurse is varied and can include
ongoing care and care coordination, often for
people in their own homes. Specialised MND nurses
usually work in MND clinics and have particular
expertise in motor neurone disease symptom
management.
Social worker, psychologist, or accredited
counsellor
A social worker, psychologist or accredited
counsellor provides counselling on the
psychological and emotional aspects of living with
motor neurone disease. In addition, a social worker
can provide information on community services
that may assist you with accommodation, legal,
financial and other issues.
Speech pathologist
A speech pathologist helps in the management of
communication and swallowing. They can advise
about communication aids and devices and also
about swallowing techniques and food consistency.
References
Mitchell GK, Tieman JJ, Shelby‐James TM 2008, 'Multidiscipli
nary care planning and teamwork in primary care', Med J Aust 1
88(8 Suppl).
Traynor BJ, Alexander M, Corr B, Frost E, Hardiman O 2003, 'E

ffect of a multidisciplinary amyotrophic lateral sclerosis (ALS)
clinic on ALS survival: a
population based study, 1996‐2000', J Neurol Neurosurg Psychi
atry 74(9).
van den Berg JP, Kalmijn S, Lindeman E, Veldink JH, de Visser
M, der Graaff MMV, Wokke JHJ, van den Berg LHV 2005, 'Mu
ltidisciplinary ALS care
improves quality of life in patients with ALS', Neurology 65(8).
Living Better for Longer: MND Australia evidence‐based fact s
heets
MND evidence‐based interventions ‐ an overview (EB1)
Multidisciplinary care (EB2)
care team (EB3)
Riluzole (EB4)
Breathing and motor neurone disease: an introduction (EB5)
Breathing and motor neurone disease: what you can do (EB6)
Breathing and motor neurone disease: medications and non‐inva
sive ventilation (EB7)
Considering gastrostomy ‐ PEG and RIG (EB8)
To find out about motor neurone
disease and other fact sheets in this
series contact the MND Association in
your state or territory
ph. 1800 777 175 or visit
www.mndaust.asn.au
**500 words (+/- 10%) each module

Module 1 - Critical Thinking, decision making and professional
development
This Module addresses issues such as problem solving,
prioritising and putting decisions into action through good
communication.
and upload your answer into your e- Portfolio. Please remember
that this forms part of your assessment for this unit.
On returning from your tea break you are met by several staff
members who relate the following information to you
concerning your patients.
i. Mrs Chew’s intravenous (IV) infusion has tissued, her IV
fluids are running behind and she has missed her 14.00 hrs IV
antibiotic.
ii. Mr Smith’s visitor has fainted.
iii. One of the staff toilets has blocked and is overflowing and
waste is pouring out rapidly.
iv. Mr Esposito is scheduled to leave the ward now for his
cardiac catheterisation and he has still not received his
preoperative medication.
v. One of the surgical consultants (VMO) is waiting to discuss a
medication error that happened last week.
vi. As you are taking this handover, an elderly female post-
operative patient collapses to the floor and is unconscious. She
has had facial surgery.
The other RN is busy with NUM role. Staff currently available
on the ward to assist you in addressing these issues include: the
ward clerk, an Enrolled Nurse who is currently undertaking her
IV cannulation certificate but is not yet competent, and an AIN.
ACTIVITY
Using the above scenario:
1: In order of priority, identify which tasks you yourself will
undertake and which tasks you will delegate.
2: Document your rationales in detail.

Module 2 - Collaborative and Therapeutic Practice This
module requires you to consider your communication with
various members of the multidisciplinary team using case
studies and scenarios provided.
Your mandatory assessment requirements for module one
include
1. Complete Activity 2 and upload your answers onto your e-
Portfolio.
2. Choose one case study and upload your answers onto your e-
Portfolio.
ACTIVITY 2
Reading:
The “MND Australia Fact Sheet on Multidisciplinary Teams”
outlines professional groups who could make up a
multidisciplinary health care team for a patient with motor
neurone disease (MND).
Please read this fact sheet, answer the following questions, and
upload your answers on your e-Portfolio on LEO. This forms
part of your assessment for this unit.
1. Identify factors that determine which healthcare professionals
are required to be involved in a health care team?
2. Who should lead the health care team?
3. Who is the most important member of the health care team?
CASE STUDY 1
Grant Thompson was a fit 37 year old man, a father of two
young children and married for 14 years to Georgina. Grant was
a truck driver who was involved in an MVA 6 months ago and
suffered extensive injuries to his leg and a mild head injury. His
recovery has been slow and he relies heavily on the use of a
wheelchair but can now walk for short distances with the aid of
a walker. Georgina wants Grant to come home and rehabilitate
there. She has made some modifications to their home, ramps
put in, handrails in the bathroom and toilet.
The health care team is meeting to discuss this option. The team

consists of the treating doctor, physiotherapist, and
occupational therapist, NUM of the rehabilitation unit, social
worker and psychologist. There is disagreement among the team
as to whether Grant would be better to stay in hospital a bit
longer or go home. The physiotherapist and the occupational
therapist both feel that Grant still requires intensive treatment
which can only be provided as an inpatient. The psychologist
and the social worker have noted that Grant’s separation from
his family and home environment has been having a negative
effect on Grant, Georgina and their children. The treating doctor
feels that we could treat Grant as an outpatient but it would
mean he has to attend regular physiotherapy and occupational
therapy sessions. You are the team designated leader of the
health care team.
2. What outcomes would be best for Grant and his family?
3. How would you guide the group in achieving this best
outcome?
CASE STUDY 2
Norma Ellis is a 76 year old widow who recently had a fall at
the nursing home she has lived in for the past 7 years and
fractured her hip. She has subsequently had a hip replacement
and has been rehabilitating well and is now due for discharge
back to the nursing home. Norma has an extensive medical
history including postural hypotension, rheumatoid arthritis and
impaired mobility. She mobilised within the nursing home using
a walker. Her son is demanding that his mother be kept in the
ward as an inpatient as he feels the nursing home staff were
negligent and wants his mother to be placed elsewhere but has
not arranged this yet. The treating team consists of the doctor,
physiotherapist, NUM of the rehabilitation unit, social worker
and NUM of the Norma’s wing at the nursing home she was in
prior to the fall. You are the designated team leader. The doctor
feels there is no need to have Mrs Ellis on the ward as he feels
that her rehabilitation has been maximised, this is an opinion

shared by the physiotherapist. Norma wants to go back to the
nursing home as she has made many friends there and feels at
home there.
2. How would you deal with Norma’s son? Are his objections
warranted?
CASE STUDY 3
Robert Hughes is a 52 year old male who was injured in a
bicycle accident two months ago where he suffered fractures to
his (R) tibia/fibula and (R) radius. Robert is intellectually
impaired and was living with his elderly mother until the
accident. Robert has been known to engage in verbally
aggressive outbursts towards staff and other patients. His
mother who is now 75 years of age feels she can no longer look
after Robert. You are the NUM of the rehabilitation unit that is
admitting Robert for his ongoing rehabilitation. You are
required to gather together a health care team to determine
immediate and long term care options for Robert.
2. Who would be included in the health care team and what role
would they play?
CASE STUDY 4
You are working in a health care team on a busy rehabilitation
unit. Team meetings and patient reviews are conducted weekly.
There has recently been a turnover of staff in the Physiotherapy
department and a new representative from physiotherapy has
joined the health care team. You notice although that this new
member of the team members is often absent, fails to provide
patient updates and when challenged on these issues is
exceptional confrontational. This behaviour is not only
impacting on the effectiveness of the health care team but also
on patient outcomes. You are the designated team leader and
need to find a resolution.

CASE STUDY 5
You are the NUM of a Mental Health Unit where case reviews
are conducted every 4 weeks. You are the designated team
leader and the team members include the medical officer,
resident psychiatrist, patient case manager, social worker and
employment officer. Several of the team members approach you
after the meetings and voice concerns about how the meetings
are being dominated by the medical staff. The general feeling
was that the medical team dominated all clinical care decisions
and most of them felt they did not have a voice at the team
meetings. As the designated team leader you are responsible for
ensuring equity exists in decisions about ongoing care.
Module 3 - Provision and Co-ordination of care This Module
looks at assessment and problem solving to care planning. You
will need to undertake pre-reading and preparation during
placement prior to submission.
Complete Activity 1
ACTIVITY 1
You are working on the morning shift on the ward, and receive
a patient from ED. The ED nurse provides you with the
following handover, using the ISBAR format. Further
information about the ISBAR format can be found on page 7 of
this module.
Please click on the handover link in LEO within Module 3
section, titled: ‘Module 3 Activity 2 Verbal Handover’. Listen
to this recording, and then please answer the following:
Hi I have got Mr. Jo Blocks. He is 92 year old male who is
coming to the ED with abdo pain and a 3kg weight lost in the
past week. He has chest cough for sputum production which

suspect a pneumonia. He has been on early obs down stairs. His
has got a history of gastric ulcer, CCF and CVA. He is currently
on 1.5 of oxygen via nasal prong. He has got a cannula on his
left hand and he has got IV antibiotics caphzolen and
zentromicin which were given as per drug chart. He is currently
NBM. He has got good urine output gone to the toilet twice
today. He has bowels open yesterday. You will need to please
start him on 50ml/hour of IV with normal saline. He needs to
have chest X-ray at 1600 hours today. And he will need also a
sputum test and repeat obs please.
1. What further questions will you need to ask the nurse?
2. List specifically what further assessments you would
complete when the patient arrives onto the ward
This activity demonstrates how you have started collecting cues
during handover.
After handover as graduate nurses you will most likely develop
a care plan. The development of a care plan is a way of
processing the information that you have collected during
handover to ensure you adequately manage your time in relation
to the care you think you will need to provide. It is important to
acknowledge that this care plan can often change, as you need
to reprioritise care, which is similar to the second activity we
undertook in the “ward for a day” simulation.
Whilst you start to process information you will also start to
think about cues that you are missing and where you can gather
this information. Assessing the patient’s chart, communicating
with the patient and their family or even increasing your patient
assessment are some of the ways in which you will achieve this.
During the phase of processing information you are also starting
to work out what is relevant information as opposed to
information that is irrelevant to the situation.
The Clinical Reasoning Cycle can provide a framework for you
structure your thought processes and ensure you can link the
knowledge that you have obtained during your undergraduate
degree to the clinical context in which you will be working as a
graduate nurse.

Module 4 - Professional Practice: Time management,
delegation, scope of practice This Module requires pre-
reading (prior to clinical) and then observation of, and
interaction with, the registered nurses on your clinical
placement. You will need to discuss delegation with the staff
and then make some decisions of your own using a case study.
It would also be very useful to discuss the scope of practice of
newly registered nurses with your facilitator or preceptor.
You are a Registered Nurse on the afternoon shift on a short-
stay (24 hours) surgical ward. One other RN, an EN and three
AINs are also on duty. The NUM is off sick and the other RN is
acting as NUM as well as taking a patient load. The ward is
full: there are 22 patients, 14 of whom went to surgery in the
morning, and 8 are going on your shift. Half of these patients
have intravenous access and require antibiotics at some time
during your shift.
ACTIVITY:
Using your knowledge and experience of various patient
allocation models (e.g. total patient care, team nursing and task
allocation), outline how you would allocate the staff to the
patients. Include in your discussion your rationale for the model
of allocation chosen and the scope of practice of the various
staff.

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