•The Glasgow Coma Scale is a tool that

healthcare
providers use toThe
consciousness. measure
scoresdecreases
from eachinsection of
the scale are useful for describing disruptions in
nervous system function and also help providers
track changes. It’s the most widely used tool for
measuring comas and decreases in
consciousness.

•The Glasgow Coma Scale (GCS) is a system to

“score” or measure how conscious you are. It
does that by giving numbered scores for how
awake you are, your level of awareness and how
you respond to basic instructions.
•Experts at the University of Glasgow in Scotland
developed the GCS in 1974. Despite “coma”
being part of the name, the GCS sees much
wider use in medicine today. It’s the most
commonly used scale for measuring decreases in
consciousness, including coma.
•The Glasgow Coma Scale helps medical providers
determine how conscious (or how deeply in a
coma) you are based on eye, speech and
movement responses.
What is consciousness?
In the medical context, consciousness has three requirements. To
be conscious, you have to be:
• Awake: This includes whether or not you have the ability to
wake up
because of voice or touch. That’s what makes a coma different
from
just being asleep.
• Alert: This is how responsive you are to people talking to you
and ifThis means you know who you are, where you’re at, what
• Oriented:
day ityou’re
is andable todetails
other understand what’s
related to thehappening in your immediate
here and now.
surroundings.
When is the Glasgow Coma Scale used?
•Healthcare providers can use the GCS as part of
a neurological exam. It’s also useful for any situation
where you might have a decrease in how conscious
you are. That includes injury-related conditions
like concussions and traumatic brain injuries.
•The scale also can help with conditions that don’t
involve injuries, such as low blood sugar
(hypoglycemia), poisoning or after a seizure.
What does the Glasgow Coma Scale measure?

A neurological exam looks for any problems with the

function of the two main parts of your nervous system.
Those
partsnervous
• Central are your:system: This consists
ofyour brain, brainstem, optic nerves (these link your brain to
the retinas at the back of your eyes) and spinal cord.
• Peripheral nervous system: This is all the nerves outside
your central nervous system.
of
The Glasgow Coma Scale has three categories that apply
to a neurological exam.
Most of them apply to your brain itself, but some can also
involve your spinal cord and nerves throughout your body:
• Eye response: This relates to how awake and alert you are.
• Motor response: This part is about how well your brain can
control muscle movement. It can also show if there are any
issues with the connections between your brain and the rest
of
your body.
• Verbal response: This tests how well certain brain abilities
work,
including thinking, memory, attention span and awareness
How does the Glasgow Coma Scale work?
•To get your Glasgow Coma Scale score, providers take
the scores from the three categories of the GCS and
add them together. A healthcare provider will test
each of the three categories in multiple ways. An
example of this is testing your verbal response by
asking you a few different questions, such as what day
of the week or date it is or what city you're in
currently.
 One of the best uses of the GCS is to track changes in your level
of consciousness. Healthcare providers will often repeat a
neurological
exam at regular intervals to check for and document any changes
in
your GCS score.
The scoring guidelines for the categories are as follows:
• Eye response
• Motor response
• Verbal response
• Pupil response
Eye response
•This is mainly about how awake you are. If
you’re unconscious, it measures the level of
unconsciousness by testing reflex responses to
pressure. Pressure here means something like a
pinch or a poke. It should be just enough to
cause minor, momentary discomfort but not
injury.
Eye response score Score meaning

You can open your eyes and keep them open on your
4
own.

You only open your eyes when someone tells you to

3
do so. Your eyes stay closed otherwise.

2 Your eyes only open in response to feeling pressure.

1 Your eyes don’t open for any reason.

Verbal response
 •A provider checks this by asking you questions
that test your memory, thinking ability and your
awareness of the world around you. Your
provider can also use this to see if there are any
brain or nerve problems affecting control of your
face and mouth.

Verbal response score Score meaning

 You’re oriented. You can correctly answer questions about
5
who you are, where you’re at, the day or year, etc.

You’re confused. You can answer questions, but your answers

4
show you’re not fully aware of what’s happening.

You can talk and others can understand words you say, but
3
your responses to questions don’t make sense.

2 You can’t talk and can only make sounds or noises.

1 You can't speak or make sounds.

Motor response
 •This part can reveal any issues with the
connections between your nerves, spinal cord
and brain. It also tests your brain’s ability to
control muscle movement and how well you can
understand and follow instructions.

Motor (movement) response score Score meaning

6 You follow instructions on how and when to move.

 You intentionally move away from something that presses
5
on you.

You only move away from something pressing on you as a

4
reflex.

3 You flex muscles (pull inward) in response to pressure.

You extend muscles (stretch outward) in response to

2
pressure.

1 You don’t move in response to pressure.

GCS-P(GCS score – Pupil size)

•In 2018, a team of experts — including one of
the original creators of the GCS — published an
updated version of the GCS called the “GCS-P.”
The P stands for “pupil,” as in the pupil of the
eye. This is a fourth number that providers
subtract from the standard GCS score.

Pupil reaction is important because it’s an indicator of

your brain function. When your pupils don’t react to
light, it’s
 a sign that a serious problem or injury is affecting your
brain.
The pupil score ranges from 0 to 2.
The pupil scores mean:
• 2: Neither pupil reacts to light.
• 1: One pupil doesn’t react to light.
• 0: Both pupils react to light.

•Subtracting the pupil reaction score from the GCS

 score means that the GCS-P score can range from 1 to
15. The GCS-P score still uses a score of 8 or fewer to
mean a coma.
•A GCS score of 3 and a pupil score of 2 is a GCS-P
score of 1. That means a very deep coma and no pupil
reaction in both eyes.

Does a neurological exam that uses the

Glasgow Coma Scale involve pain?
•Older descriptions of the GCS use the word
 “pain” to describe the sensation used to test
certain reflexes. Newer guidelines change that
word to “pressure.” The word change is more
accurate because it doesn’t involve an injury. It’s
also clearer because a provider isn’t actually
trying to cause pain or hurt your loved one.

•The original GCS guidelines were also vague on

where providers should press to test reflexes. In
1975, a year after the original publication of the
GCS, the experts who created the GCS published
specific guidance.
Points where a provider will put pressure include your:

• Nail beds: Your fingernails and toenails are pressure-

sensitive. Providers often push on one or more of them
during a neurological exam to test if your body reacts
reflexively to the pressure.
• Trapezius muscle: This muscle connects your shoulder to
the
center of your neck and back. It’s an easy-to-reach muscle to
• check for a pressure
Supraorbital reflex.
notch: This is a small groove in the bone of your
skull just above your eye and just below your eyebrow.
What type of results do you get, and what
do the results mean?
•The highest possible GCS score is 15, and the lowest is
3. A score of 15 means you’re fully awake, responsive
and have no problems with thinking ability or
memory. Generally, having a score of 8 or fewer
means you’re in a coma. The lower the score, the
deeper the coma is.
•Healthcare providers may abbreviate your GCS score
using letter/number combinations. A score of 15
would be “E4V5M6.” A score of 3 would be “E1V1M1.”

GCS ranges for head injuries

When providers use the GCS in connection with a
head injury, they tend to apply scoring ranges to
describe how severe the injury is. The ranges are:
•13 to 15: Mild traumatic brain injury (mTBI). Also
known as a concussion.
•9 to 12: Moderate TBI.
•3 to 8: Severe TBI.

What should I know about my loved one’s

GCS score?
•Generally, your family or close loved ones will
be
the ones to talk to your healthcare provider
about your score(s). Some things you should
know about the GCS and how healthcare
providers use it include:
 •The results of the test are much more complex than
just a number. A GCS score doesn’t include details
about the results of the test. There’s a lot more to a
neurological exam than just a number. While the
number is generally easier to understand, it’s best to
talk to your loved one’s provider to understand your
loved one’s condition better.

•The GCS has its limits. It may not be possible to

use the GCS in some situations, such as when
someone is on a ventilator or doesn’t speak the
same language as their healthcare provider. It
also isn’t useful for people with conditions or
injuries affecting body parts or systems the GCS
relies on, such as vision or hearing loss.
•The GCS isn’t the only thing providers use to
make a prognosis. Healthcare providers
commonly use the GCS to predict likely
outcomes, but it isn’t the only factor they
consider. Ask your loved one’s provider about
the score and what it might mean long term.
• The Glasgow Coma Scale is the most common tool
healthcare providers use to measure decreases in
consciousness and comas. Since its creation almost 50 years
ago, experts have studied the scale extensively and found
that it continues to be a useful diagnostic tool. (They’ve even
improved it along the way.) Using this tool also helps
providers track changes in brain function. That helps guide
treatment and improve care for people with conditions that
affect their level of consciousness.
• Critical care nurses provide expert, specialist care to the
most severely ill or injured patients in intensive care units
and the wider hospital. They are highly trained and skilled
safety-critical professionals working as part of a
multidisciplinary team. Critical care is classified using four
levels of patient acuity.
• Updated guidelines for the provision of intensive
care
services (Faculty of Intensive Care Medicine, 2019)
 recommend that level-3 patients should have a minimum
registered nurse–patient ratio of 1:1 and level-2 patients
must have a minimum nurse–patient ratio of 1:2.

•
critical-care-nursing-18-10-2021/
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is-
• To deliver highly skilled care, critical care nurses
undertake
postgraduate study and ongoing training. The Step
Competency Framework underpins critical care nurse
education; it recognizes that, to be able to deliver high-
quality care to patients, staff need the knowledge and skills
so they can work at the highest level, with standardization
across all critical care units.
Managing organ dysfunction
• Admission to a critical care unit is usually because of organ
dysfunction or organ failure. Respiratory failure alone leads
to around 100,000 annual admissions to critical care in the
UK (FICM, 2019). The goal is to correct or provide support to
these dysfunctional organs.
• Technological and medical advances over the past few
decades have meant significant growth in treatments and
interventions, and more-effective management of patients
who need organ support.
• The interventions most commonly used include mechanical
ventilators, infusion devices and renal replacement therapy.
Table 2 outlines the interventions used for different
physiological systems.
Patient monitoring and documentation
• It is crucial to gather accurate data on physiological
parameters – such as oxygen saturation (SpO2), heart rate
and fluid balance – at the bedside of the patient who is
critically ill.
• Typically, each patient will have their own monitor that
will
display a range of clinical factors (Box 1) and provide real-
time feedback to help evaluate critical care interventions,
and detect any deterioration or emergency situations
promptly.
Box 1. Clinical factors recorded by bedside monitors
•Heart rhythm
•Heart rate
•Oxygen saturation
•Respiratory rate
•Exhaled carbon dioxide concentration/partial pressure
•Non-invasive blood pressure
•Arterial blood pressure
•Central venous pressure
•Temperature
Critical care nurses need technical skill and knowledge to
effectively use and interpret bedside monitors. A further
common
technical resource is the clinical information system (CIS), which
can
record and process large amounts of data, such as:
• Patient physiological observations;
• Care or interventions delivered;
• Medication plans.
• The FICM (2019) highlights how a CIS can not only improve
efficiency,
Psychosocial care
•Holistic patient-centred care – as outlined by Jasemi
et al (2017) – is vital in critical care, with effective
psychosocial care, and cultural, spiritual and family
care being of particular significance. Immediately on
admission to a critical care setting, patients are
subjected to an onslaught of physical and psychosocial
stressors including:
• Physical pain;
• An unfamiliar environment; equipment and treatments;
• Sensory disturbances;
• Isolation from family;
• Loss of autonomy;
• Impaired communication;
• Fear for their life (Kiekkas et al, 2010).
•It can lead to severe emotional distress and the
development of delirium, anxiety, depression and
post-traumatic stress disorder (PTSD) (Hatch et al,
2018) – all of which may persist long after the
patient’s physical recovery and discharge from
hospital (Ewens et al, 2018).
• Psychosocial care is often considered the touchstone to person-
centred care and, in this setting, refers to supportive interventions
that may mitigate the stressors associated with critical illness.
Evidence-based measures that may all help include:
• Providing information and explanations;
• Regularly orientating the patient to date, time and place;
• Reassurance;
• Empathetic touch;
• Early mobilisation;
• Family visits;
• Maintaining clear night and day routines;
• Minimising noise (Bani Younis et al, 2021; Alaparthi et al,
2020; Parsons and Walters, 2019).
•Delirium is of particular concern in patients who are
critically ill, and has an incidence range of 45-87%
(Cavallazzi et al, 2012). It is characterised by the acute
onset of cerebral dysfunction, with a change or
fluctuation in baseline mental status, inattention,
disorganised thinking or an altered level of
consciousness (NICE, 2019).
•Delirium is associated with significant increases in
mortality, morbidity and hospital stay, as well as
having long-term ramifications such as cognitive
impairment, PTSD, anxiety and depression (Cavallazzi
et al, 2012) so the prevention, early recognition and
effective management of it is of paramount
importance. The ABCDEF bundle of care may help:
• Assessment, prevention and management of pain;
• Awakening the patient and doing a spontaneous Breathing
trial;
• Choice of sedation and analgesia;
• Assessment, prevention and management of Delirium;
• Early mobilisation;
• Family engagement (Marra et al, 2017) .
Cultural and spiritual care
•A patient’s cultural and spiritual background
influences many aspects of nursing in critical care,
such as patient and family roles, communication,
nutrition, values and beliefs towards health, care and
treatments, and end-of-life care.
• Careful assessment of the patients’ health beliefs,
communication needs, social networks and family dynamics,
dietary requirements, religious practices and values, is
essential to plan and deliver culturally sensitive and spiritual
care that contributes to the quality of life, care and
satisfaction of patients as well as their families (Willemse et
al, 2020).
Family care
• Family members of patients who are critically ill can play an
important part – often acting as surrogate decision makers –
and be essential in providing emotional and social support.
• However, relatives may experience extreme stress, fear and
anxiety, both during and after the patient’s admission.
Relatives are also vulnerable to ongoing psychological
illnesses such as PTSD, anxiety and depression (Johnson et al,
2019).
•Nurses need to develop a collaborative
relationship
with them to effectively identify and address their
immediate needs, as well as prepare them to cope
with their loved one’s discharge and ongoing
rehabilitation. Families need honest and timely
information, assurance, proximity, comfort and
support (Scott et al, 2019).
Rehabilitation
• Critical illness can cause significant long-term physical and
non-physical problems for patients, and rehabilitation is
important to improve recovery.
• National guidelines, such as those by the FICM (2019) and
the National Institute for Health and Care Excellence (2017),
have supported this, with the aim of improving these
patients’ physical, psychological and cognitive outcomes.
 Patients should be assessed at the following key stages:
• Within four days of admission to a critical care unit, or
earlier
if being discharged;
• Just before discharge to ward-based care;
• When
• Before receiving
discharge ward-based
to their home or care;
community care;
• Two to three months after discharge from the critical care
unit.
• Rehabilitation should be patient centred, involve the whole
multidisciplinary team and occur throughout the patient
pathway, with plans updated as the patient’s condition
changes (FICM, 2019).
• Physiotherapists, occupational therapists, dieticians,
speech
and language therapists, critical care nurses and doctors, as
well as patients and their families, all have a role.
• Short clinical assessments should be done with all patients
in
critical care to identify their risk of physical and non- physical
morbidity. A short clinical assessment is applicable for
patients who are expected to recover quickly, despite
requiring initial level-3 care, and should assess a range of
factors (Box 2).
•If the patient is deemed at risk, a comprehensive
clinical assessment should be undertaken; this will
also assess physical and non-physical risk (Box 3).
•Box 2. Short clinical assessment
•The following may indicate that the patient is at risk of
physical/non-physical morbidity and needs further
assessment:
 Physical
• Unable to get out of bed independently
• Anticipated long duration of critical care stay
• Obvious significant physical or neurological injury
• Lack of cognitive functioning to continue exercise independently
• Unable to self-ventilate on 35% of oxygen or less
• Presence of pre-morbid respiratory or mobility problems
• Unable to mobilize independently over short distances
• Non-physical
• Recurrent nightmares, particularly if the patient reports trying
to
stay awake to avoid them
• Intrusive memories of traumatic events that occurred before
admission (for example, road traffic accidents) or during their
critical care stay (for example, delusion experiences or
• flashbacks)
New or recurrent anxiety or panic attacks
• Expressing a wish not to talk about their illness or changing
the
subject quickly
• Box 3. Comprehensive clinical assessment
• This assessment should be undertaken for all patients
identified as being at risk of physical or non-physical
morbidity.
• Physical issues
• Physical
• Fatigue
• Breathlessness
• Tracheostomy
• Ventilated
• Artificial airway
• Swallowing issues
• Poor nutritional state
 • Activities of daily living
• Minor assistance needed
• Major assistance needed
• Full assistance needed
• Sensory
• Visual changes
• Hearing changes
• Altered sensations
• Sedated/pain
•Communication
• Difficulties in speech
• Changes in voice quality
• Difficulty writing
•Miscellaneous
• Hair loss
• Poor wound healing
•Non-physical
issues
 •Anxiety or depression (new or recurrent
symptoms)
• Palpitations, irritability or sweating
• Hallucinations, delusions
• Nightmares
• Flashbacks, withdrawal, traumatic memories of
critical
care
•Cognitive
• Loss of memory
• Attention deficit
• Sequencing problems
• Lack of organisational skills
• Confusion
• Disinhibition
•Miscellaneous
• Low self-esteem
• Low self-image
• Relationship difficulties
• Difficulty sleeping
 • During the assessment of these patients, a range of tools
may be used including the following:
• Hospital Anxiety and Depression Score (Zigmond and
1983);
Snaith,
• Barthel Activities of Daily Living Index (Wade and Colin,
1988);

2013).
• Chelsea Critical Care Physical Assessment Tool (Corner et al,

2013).
• Many critical care units provide follow-up services for
patients after discharge, giving them access to a range of
health professionals, including critical care nurses, to assess
physical and non-physical recovery (NICE, 2017). If these are
not available, patients can be directed to ICU Steps
(www.icusteps.org), which can help to support patients and
families affected by critical illness.
Essential critical care
skills 2:
assessing the patient
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critical-care-skills-2-
assessing-the-patient.pdf
NursingTimes.net
In this article...
• ● The importance of systematic and structured patient
assessment
• ● Use of the airway, breathing, circulation, disability
and
exposure (ABCDE) approach
• ● Red flags that indicate deterioration
Key points
•Critical care is a complex and multifaceted
clinical
environment
•Comprehensive and careful assessment is vital to
monitor for signs of clinical deterioration
•Early recognition of deterioration, along with a
structured response and appropriate escalation, can
reduce patient harm and the risk of adverse events
•The airway, breathing, circulation, disability and
exposure approach enables life-threatening
problems to be prioritised to reduce patient
harm
•Holistic assessment of patients’ physical,
psychological and social care needs is essential
for ongoing clinical decisions, care and planned
discharge
•A structured, systematic assessment of a patient
who is critically ill is fundamental to good patient
care, management and experience. The
assessment process must include a
comprehensive review of the patient’s
physiological, sociological, psychological and
spiritual needs to identify and prioritise
problems (Baid et al, 2016
•The airway, breathing, circulation, disability and
exposure (ABCDE) approach (Bit. ly/RCUK_ABCDE) is a
well-established, reliable assessment tool used in the
systematic assessment of critically ill patients to
prioritise and treat life-threatening clinical problems.
Information from this should be communicated,
escalated, and actioned as appropriate (Baid et al,

2016).
•Early recognition of a deteriorating
patient,
together with
appropriate a structured
escalation, canresponse and harm
reduce patient
and the risk of adverse events (Massey et al,
2017). The critical care nurse makes a systematic
assessment of the patient on admission, after
shift handover and in response to clinical
deterioration (Baid et al, 2016).
•This article – the second in a seven-part
series
on critical care – will outline how to make a
systematic assessment of a patient who is
critically ill, using the ABCDE approach.
Airway
•Once personal and patient safety is established, an
airway assessment is the first stage in the ABCDE
systematic approach. This is to assess airway patency,
checking for signs of full or partial airway obstruction
(Cathala and Moorley, 2020). A patient who can talk in
a normal voice and full sentences has an airway that is
patent. Box 1 lists causes of airway obstruction.
Causes of airway obstruction:
● Respiratory secretions
● Foreign body, such as food
● Direct trauma
● Pharyngeal swelling due to infection or
oedema
● Bronchospasm (spasm of the airways)
 •● Laryngospasm (spasm of the vocal cords)
•● Central nervous system depression due to loss of
airway patency and protective reflexes
•● Vomit or blood
•● Epiglottitis (inflammation and swelling of the
epiglottis)
•● Blocked tracheostomy or endotracheal tube
•Physical assessment of an airway involves the
‘look, listen and feel’ approach. Appropriate
infection control measures should be followed to
reduce the risk of contamination, for example,
when caring for patients with Covid-19.
 The clinical signs of a partial airway obstruction include:
● ‘See-saw’ respirations, seen as paradoxical chest and abdominal
movements;
● Decreased air entry on chest auscultation using a stethoscope;
● Abnormal breath sounds (noisy breathing such as a stridor
involving a
high-pitched sound, wheezing or snoring);
● Use
● Inability toof accessory muscles;
speak;
 Altered respiratory effort

• With complete airway obstruction, there is no air entry

on
chest auscultation or breath sounds at the nose and the
mouth (Baid et al, 2016). A complete or partial airway
obstruction is a medical emergency and, initially, can be
• managed using simple
● Head tilt-chin airway
lift or jaw manoeuvres,
thrust to open thesuch as: (Fig 1);
airway
● Application of high-flow oxygen using a mask with oxygen
reservoir;
• Insertion of a simple airway adjunct (such as an
oropharyngeal or nasopharyngeal airway) until further help
arrives (Bit.ly/RCUK_ABCDE). In a critical care unit, patients
may have an endotracheal or tracheostomy tube in place to
maintain their airway and help deliver mechanical
ventilation. Positioned in the trachea, endotracheal and
tracheostomy tubes are artificial airways that have an
inflatable cuff at the end of the tube to create a closed
system, which reduces the risk of aspiration or an air leak.
The patency of the airway is assessed through:
 •● Visual assessment of chest movement;
•● Chest auscultation with a stethoscope to detect air
entry;
•● Tracheal suctioning if required;
•● Continuous end-tidal carbon dioxide (EtCO2)
monitoring;
•● Review of mechanical ventilation parameters.
•EtCO2 monitoring is a non-invasive method of
measuring exhaled carbon dioxide. It is a
standard monitoring tool in patients who are
mechanically ventilated, as it can detect a
misplaced endotracheal and tracheostomy tube,
and aid in the monitoring of respiratory function
(Kerslake and Kelly, 2017).
 •As part of the airway assessment, the critical care
nurse does several safety checks when caring for a
patient with an endotracheal or tracheostomy tube to
reduce the risk of patient complication and harm.
Tables 1 and 2 list these checks and the reasons for
doing them.

Table 1. Key checks for endotracheal tubes

 Check :
Endotracheal tube is secured with appropriate tape or
securement device
Reduce the risk of dislodgement Position of endotracheal
tube relating to pressure damage at the mouth or lips – the
tube can be moved by an experienced critical care
practitioner to avoid pressure ulceration Reduce the risk of
pressure damage
IV Access in Emergency
•Intravenous (IV) access is a critical part of emergency
care, as it's required for delivering fluids, medications,
blood products, and contrast injections. In fact, more
than half of emergency department (ED) patients
require an IV. However, establishing IV access can be
challenging, especially for patients with difficult
intravenous access (DIVA).
Here are some tips for establishing IV access
in an emergency:
•Choose the right vein: Select a straight, non-branched
vein in the upper extremity. Veins in the upper
extremities are less likely to cause phlebitis and
interfere with mobility.
•Use a larger gauge catheter: For emergencies, use the
largest-gauge catheter that fits the vein.
 • Use a tourniquet: Place a tourniquet above the IV site
to
make the vein more prominent. The vein should feel
spongy and not pulsatile.
• Use ultrasound guidance: Ultrasound guidance can
help
• Use a net bandage: Cover the entire distal extremity with
locate
a the vein and insert the catheter.
other hand toFor
net bandage. prevent
youngthem fromyou
children, removing thebandage
can also IV. the
•
 •DIVA is common in the ED and can be
associated
with complications, longer wait times, and lower
patient satisfaction. Some patients with DIVA
may require more advanced procedures, such as
central venous access devices (CVADs).

•In general, it is advisable to select the smallest

 gauge of catheter that can still be effectively
used to deliver the prescribed therapy; this will
minimize the risk of damage to the vessel intima
and ensure adequate blood flow around the
catheter, which reduces the risk of phlebitis.

•However, if the situation is an emergency or if

 the patient is expected to require large volumes
infused over a short period of time, the largest-
gauge and shortest catheter that is likely to fit
the chosen vein should be used.

•Veins with high internal pressure become

 engorged and are easier to access. The use of
venous tourniquets, dependent positioning,
“pumping” via muscle contraction, and the local
application of heat or nitroglycerin ointment can
contribute to venous engorgement.

•The superficial veins of the upper extremities are

preferred to those of the lower extremities for
peripheral venous access because cannulation of
upper-extremity veins interferes less with
patient mobility and poses a lower risk for
phlebitis.
•It is easier to insert a venous catheter
where two tributaries merge into a Y-
shaped form. It is recommended to choose
a straight portion of a vein to minimize the
chance of hitting valves.
Indications:
Indications for IV cannulation include the following:
• Repeated blood sampling
• IV administration of fluid
• IV administration of medications
• IV administration of chemotherapeutic agents
• IV nutritional support
• IV administration of blood or blood products
 IV administration of radiologic contrast agents for computed tomography
(CT), magnetic resonance imaging (MRI), or nuclear imaging

Contraindications:
• No absolute contraindications for IV cannulation exist.
• Peripheral venous access in an injured, infected, or burned
extremity should be avoided if possible.
• Some vesicant and irritant solutions (pH < 5, pH >9, or osmolarity
>600 mOsm/L) can cause blistering and tissue necrosis if they leak
into the tissue, including sclerosing solutions, some
chemotherapeutic agents, and vasopressors. These solutions are
 more safely infused into a central vein. They should only be given
through a peripheral vein in emergency situations or when a central
venous access is not readily available.

Equipment
Equipment used for intravenous (IV) cannulation includes the
following:
• Nonsterile gloves
• Tourniquet
• Antiseptic solution (2% chlorhexidine in 70% isopropyl alcohol)
 Local anesthetic solution
1-mL syringe with a 30-gauge needle
2 × 2 in. gauze

•Venous access device

•Vacuum collection tubes and adaptor
•Saline or heparin lock
•Saline or heparin solution
•Transparent dressing
•Paper tape
Patient Preparation
Anesthesia
•Both intradermal injection of a topical anesthetic
agent just prior to IV insertion [5] and topical
application of a local anesthetic cream [6] about 30
minutes prior to IV insertion have been shown to
achieve significant reduction of the pain associated
with the procedure. Both should be used unless the
situation is an emergency.
 Positioning
• Make sure that there is adequate light and that the room
is
warm enough to encourage vasodilation. Adjust the height
or position ofand
comfortable theto
bed or chair
prevent to make sure
unnecessary you areMake sure
bending.
the patient is in a comfortable position, and place a pillow or
a rolled towel under the patient’s extended arm.
• The patient’s skin should be washed with soap and water if it
is visibly dirty.
Intravenous Cannulation Technique
The practice of Emergency Medicine frequently
requires access to a patient's venous circulation.
Venous access allows sampling of blood as well
as administration of medications, nutritional
support, and blood products. Devices such as
cardiac pacing wires and pulmonary artery
catheters can be introduced into the patient's
central venous circulatory system.
•Percutaneous, as opposed to surgical, venous
access is usually rapid, safe, and well tolerated.
An understanding of the various techniques
available, the venous anatomy, and the
indications for the procedure allows the
Emergency Physician to choose the appropriate
site and method of venous access.
•Veins, like arteries, have a three-layered wall
composed of an internal endothelium surrounded
by a layer of muscle then a layer of connective
tissue.
•The muscular layer of a vein is much smaller than
that of an artery. While veins can dilate and
constrict somewhat on their own, they do so
mostly in response to the pressure within them.
•Veins with high pressures become engorged and
are easier to access. The use of venous tourniquets,
dependent positioning, “pumping” via muscle
contraction, and the local application of heat or
nitroglycerin ointment all contribute to venous
engorgement.2 These maneuvers can be used to aid
in the identification of a peripheral

vein.
• Comparative anatomy of an artery and a vein. A. The generic blood vessel. B. A
muscular artery. C. A vein. Note the vein's thinner wall with fewer myocytes and elastic
fibers. This is indicative of the lower pressure within veins compared to arteries.
•The connective tissue surrounding veins can be a
help or a hindrance during attempts at peripheral
venous access. Deficient connective tissue
permits the vein to “roll” from side to side and
evade the needle. Tough connective tissue can
impede the entry of a flexible catheter through
the soft tissues and into the vein. This tissue also
serves to stabilize the vein and prevent its
collapse.

•Venous valves are an important aspect of

peripheral venous anatomy (Figure 47-2).1 They
encourage unidirectional flow of blood back
toward the heart. Venous valves prevent blood
from pooling in the dependent portions of the
extremities due to gravitational forces. Valves can
impede the passage of a catheter through and into
a vein.

• Forcing a catheter past venous valves may damage them and

contribute to later venous insufficiency. Valves are more
numerous at the points where tributaries join larger veins and in
the lower extremities. Valves are almost totally absent within the
large central veins, the veins of the head, and the veins of the
neck.
 • Venous valves. Cross-section of converging veins demonstrating the
valve
leaflets that only permit forward flow, proximally, toward the right heart.
The arrows represent the directional flow of blood.

Insertion of an intravenous (IV) cannula involves connecting a

tube into a patient's vein so that infusions can be inserted directly
into
the patient’s bloodstream. Cannulas (also known as venflons) are
available in various colours, each of which correspond to the size
• Whatofwill
thebe infused, for example: colloid, crystalloid, blood products
tube. The required size depends on:
or medications.
• Or, at the rate the infusion is to run.

• In addition, the patients veins may dictate the size to use, for
example
you may only be able to insert a blue (small) cannula into an elderly
patient's vein.
 Organizing,
Staffing,
Scheduling,
Directing and
Delegating
• Effective nursing management is crucial for
ensuring high-quality patient care and
maintaining a harmonious work environment.
This involves several key concepts, including
organizing, delegation, motivation, supervision,
coordination, and conflict management.
• Organizing
• Organizing is a crucial management function that
ensures tasks are logically identified, assigned,
and grouped. It determines who is responsible for
each task, establishes clear lines of reporting, and
facilitates decision-making. At its core, organizing
defines roles and relationships within the
organization, clarifying each staff member’s
functions to execute the organizational plan
effectively.
• Organizing Process
• The process of organizing involves the following:
1.Identifying and Defining Tasks.
Determine the basic tasks that need to be accomplished.
2.Delegating Authority and Assigning Responsibility.
Allocate authority and assign responsibilities to
appropriate individuals.
3.Establishing Relationships.
Create a structure that separates activities, arranges
them hierarchically, and fosters efficient teamwork.
• Three Forms of Authority
• Authority within an organization can be categorized into three
primary forms:
• Line Authority
• Line authority is the direct supervisory authority that flows
from a supervisor to their subordinates. It represents the clear,
direct chain of command where decisions and instructions are
passed down the hierarchy. For example, a nurse manager has
direct supervisory authority over a team of registered nurses
(RNs) on a hospital ward. The nurse manager delegates tasks,
oversees patient care, and evaluates the performance of the
nursing staff, ensuring that the ward operates smoothly.
• Staff Authority
• Staff authority is based on expertise and typically involves
providing advice and support to line managers. Staff
authority does not entail direct command over other
employees but focuses on specialized knowledge and
guidance. For example, a clinical nurse specialist (CNS)
provides expert advice to the nursing staff and line
managers on best practices for patient care. Although the
CNS does not have direct supervisory control, they influence
decisions through their specialized knowledge in areas such
as wound care, pain management, or diabetes education.
• Team Authority
• Granted to committees or work teams involved in daily
operations, team authority empowers groups of employees
who share a common vision, goals, and objectives. These
teams are responsible for collaborative decision-making and
achieving specific outcomes. For example, in a hospital
setting, the chain of command starts with the Chief Nursing
Officer (CNO) at the top, followed by nurse directors, nurse
managers, charge nurses, and finally the staff nurses. This
hierarchy ensures that decisions and instructions are passed
down systematically and that issues can be escalated
appropriately.
Additional concepts related to
authority include:
• Chain of Command. This is an unbroken line of reporting
relationships that extends through the entire organization,
defining the formal decision-making structure and ensuring
clarity in the flow of authority.
• Unity of Command. This principle states that each person in
the organization should take orders from and report to only
one supervisor, preventing confusion and overlapping
directives.
• Span of Control. This refers to the optimal number of
employees that one leader-manager can effectively supervise.
A well-defined span of control ensures efficient management
and communication within the organization.
• Organizational Chart
• An organizational chart is a visual representation that
illustrates the structure of an organization. It shows how
different parts of the organization are linked,
highlighting formal relationships, areas of responsibility,
accountability, and communication channels.
• Organizational Structure
• The chart clearly depicts roles and expectations, as well
as the arrangement of positions and working
relationships within the organization.
Lines of Authority
In an organizational chart, various lines are used to represent
different types of authority and relationships within the organization:
•Dotted Line. Represents staff positions or staff authority,
indicating advisory roles to line managers.
•Solid Horizontal Line. Represents positions of equal status but
different functions.
•Solid Vertical Line. Indicates the chain of command, showing
direct authority from supervisors to subordinates (line authority).
•Centrality. Refers to the position on the chart where frequent and
diverse communication occurs. Positions with smaller organizational
distance, closer to the center, receive more information compared
to those located more peripherally.
Managerial Levels
In an organization, managerial roles are divided into different
levels, each with distinct responsibilities and scope of influence:
•Top-Level Managers. Make strategic decisions with minimal
guidelines or structure. Coordinate both internal and external
influences. Examples include: CEO, President, Vice President, Chief
Nursing Officer
•Middle-Level Managers. Oversee day-to-day operations while
also engaging in long-term planning and policy-making. Examples
include: Head Nurse, Department Head, Unit Supervisor/Manager
•First-Level Managers. Focus on specific unit workflows and
address immediate, day-to-day issues. Examples: charge Nurse,
Team Leader, Primary Nurse, Staff Nurse
Patterns of Organizational
Structure
• Organizational structures define how tasks,
responsibilities, and authority are
distributed within an organization. Different
structures cater to various organizational
needs and scales, each with distinct
characteristics and implications for
communication and management. These
may include:
Tall or Centralized Structure
Tall or centralized structures are
characterized by a narrow span of control,
where supervisors are responsible for only a few
subordinates. Due to its vertical nature, this
structure involves many levels of
communication. Communication can be
difficult, and messages often fail to reach the
top effectively. Workers tend to be boss-
oriented due to close supervision.
Flat or Decentralized Structure
Flat or decentralized structures feature few
levels and a broad span of control, making
communication easy and direct. This structure
shortens the administrative distance between
top and lower levels, facilitates fast problem-
solving and response, and encourages workers
to develop their abilities and autonomy.
However, it is impractical for large
organizations.
Types of Organizational
Structure
Organizational structures can vary
significantly, each designed to meet specific
operational needs and management styles.
Understanding the different types helps in
selecting the most appropriate structure for
a given organization.
1.Line Organization/Bureaucratic/Pyramidal. In a line organization,
there is a clearly defined superior-subordinate relationship. Authority and
power are concentrated at the top.
2.Flat/Horizontal Organization. A decentralized type, flat organizations
are applicable in small organizations. Nurses become more productive and
directly involved in decision-making processes, leading to greater worker
satisfaction.
3.Functional Organization. This structure allows specialists to assist line
positions within a limited and clearly defined scope of authority.
4.Ad Hoc Organization. An ad hoc organization is a modification of the
bureaucratic structure, often created for specific projects or purposes.
5.Matrix Structure. The matrix structure focuses on both products and
functions, making it the most complex type. It incorporates both vertical
and horizontal chains of command and lines of communication.
Staffing
Staffing is the process of assigning
competent individuals to fulfill the roles
designated within an organizational
structure. This involves recruitment,
selection, development, induction, and
orientation of new staff to align with the
organization’s goals, vision, mission, and
philosophy.
Staffing Process
Staffing involves a systematic approach to ensuring the
organization has the right number and type of personnel to achieve
its goals. The following steps outline the key stages in the staffing
process:
1.Preparing to Recruit. This initial step involves determining the
types and number of personnel required to meet the organization’s
needs.
2.Attracting Staff. Formal advertisements and outreach efforts
are used to attract potential candidates.
3.Recruiting and Selecting Staff. This phase includes conducting
interviews, induction, orientation, job orders, pre-employment
testing, and signing contracts to onboard new employees.
Staffing Pattern

Developing an effective staffing pattern is

essential for ensuring that an organization
has the right number of staff with the
appropriate skills to meet its needs. There
are two primary methods for creating a
staffing pattern:
Determining Nursing Care Hours
This method involves calculating the
number of nursing care hours required per
patient. For example, if each patient needs
an average of 6 hours of nursing care per day
and the unit has 20 patients, the total
nursing care hours needed per day would be
120 hours. This helps in determining the
number of nurses required per shift to meet
patient care needs effectively.
Calculating Full-Time
Equivalents (FTEs)
This approach measures the work
commitment of full-time employees. For
instance, 1.0 FTE represents a full-time
employee who works 5 days a week, 8 hours
a day, totaling 40 hours a week. Conversely,
0.5 FTE corresponds to a part-time
employee working 5 days every 2 weeks,
totaling 20 hours a week.
• Considerations in Staffing Pattern
• When developing a staffing pattern, several key
factors must be taken into account to ensure
optimal organizational performance and
compliance with regulations. The following
considerations are essential:
• Benchmarking. This management tool is used to seek out the
best practices within the healthcare industry to improve
performance. For instance, a hospital might compare its nurse-
to-patient ratio with top-performing hospitals. By measuring
their staffing practices and patient outcomes against these
benchmarks, the hospital can identify areas for improvement
and set realistic targets for nurse staffing levels.
• Regulatory Requirements. Staffing patterns must adhere to
mandated regulations, such as those outlined in relevant
legislative acts. For example, the laws regarding safe staffing in
certain regions mandates specific nurse-to-patient ratios that
must be maintained to ensure patient safety and care quality.
• Skill Mix.The skill mix refers to the percentage
or ratio of professionals to non-professionals
within the staff. For example, in a hospital unit
with 40 full-time equivalents (FTEs), if there are
20 registered nurses (RNs) and 20 nursing
assistants, the RN mix is 50%. This ratio ensures
a balanced team with the necessary expertise
and support staff, allowing RNs to focus on
complex patient care tasks while nursing
assistants handle more routine duties.
• Staff Support. Adequate staff support must be in place for the
operations of units or departments. For example, a nursing unit
might need administrative staff to handle scheduling, clerical
tasks, and patient records. This support allows nurses to dedicate
more time to patient care rather than administrative duties.
• Historical Information. Reviewing historical data on quality and
staff perceptions regarding the effectiveness of previous staffing
patterns is crucial. For example, a hospital may analyze past
staffing patterns during peak flu seasons to determine the
optimal number of nurses required to maintain patient care
standards. This historical review helps in planning and adjusting
staffing levels to meet future demands more effectively.
• Patient Classification System
• The term Patient Classification Systems refers to
measurement systems in nursing that reflect actual patient
care needs for staffing purposes. These systems, also known
as Acuity Systems, are used to articulate the nursing
workload for specific patients or groups of patients over a
defined period. While “Acuity” typically denotes the
unidimensional severity of illness in a medical context, the
nursing community prefers the broader term “Patient
Classification” to encompass the bio-psycho-social-spiritual
aspects of patient care. For this discussion, the term Patient
Classification/Acuity System is used.
• Patient Care Classification
• Patients are classified into different categories based on
their care needs:
1.Self-Care or Minimal Care. These patients are capable of
performing activities of daily living (ADLs) independently,
such as hygiene and meals. They require minimal assistance
from the nursing staff.
2.Intermediate or Moderate Care. Patients in this category
require some assistance from the nursing staff for special
treatments or specific aspects of personal care. Examples
include patients with IV fluids, catheters, or on respirators.
1.Total Care. These patients are bedridden and lack the strength or
mobility to perform ADLs. They require comprehensive nursing care.
Examples include patients on complete bed rest (CBR), those in the
immediate post-operative phase, or those with significant mobility
restrictions.
2.Intensive Care: Intensive care patients are critically ill and in
constant danger of death or serious injury. They require continuous
monitoring and specialized nursing care. Examples include comatose
patients or those with life-threatening conditions who are bedridden.
• By classifying patients according to their care needs, the Patient
Classification System ensures that nursing resources are
appropriately allocated, enhancing patient care and optimizing the
nursing workload.
• Scheduling
• Scheduling is the process of creating a timetable
that outlines the planned workdays and shifts for
nursing personnel. Effective scheduling takes into
account several key factors to ensure that staffing
meets patient care needs and maintains staff well-
being. Several key factors must be considered to
create an optimal schedule that meets both patient
needs and staff preferences. The following are some
issues to consider in scheduling staff:
• Patient Type and Acuity. Different patients require
varying levels of care, significantly impacting how staff is
allocated. For example, intensive care unit (ICU) patients
need constant monitoring and specialized care, requiring
more experienced nurses compared to patients in a general
ward.
• Number of Patients. The total patient count directly
influences the number of staff needed. A higher patient load
requires more nursing staff to ensure each patient receives
adequate attention and care. For instance, during peak flu
season, a hospital might need to increase its nursing staff to
handle the influx of patients.
• Experience of Staff. The skill and experience levels of the staff
should match the complexity of patient care required. For
example, a novice nurse might handle basic patient care tasks,
while a more experienced nurse might be assigned to complex
cases or critical care units.
• Support Available to the Staff. The availability of support
personnel, such as nursing assistants and administrative staff,
affects how nursing duties are distributed. For example, having
sufficient administrative support can allow nurses to focus more
on patient care rather than paperwork.
• Shifting Variations. Different shift patterns are utilized to meet
both patient care needs and staff preferences. These variations
can help in maintaining a balanced and effective workforce.
• Shifting Patterns
• To meet the diverse needs of patients and
preferences of nursing staff, various traditional
shifting patterns are utilized. Each pattern offers
unique benefits and challenges, helping to
ensure continuous and effective patient care.
• 3 Shift (8-hour shift). Commonly used to provide 24-
hour care, this pattern divides the day into three 8-hour
shifts. For instance, one nurse might work from 7 AM to 3
PM, another from 3 PM to 11 PM, and a third from 11 PM
to 7 AM.
• 12-hour Shift. This pattern involves longer shifts with
fewer workdays, often preferred by nurses who enjoy
having more consecutive days off. A nurse might work
from 7 AM to 7 PM, providing continuity of care for
patients but also requiring adequate rest between shifts
to prevent burnout.
• 10-hour Shift. Less common but offers a balance between 8 and
12-hour shifts. This pattern might involve a nurse working from 7
AM to 5 PM, allowing for extended care periods without the
intensity of a 12-hour shift.
• Weekend Option. Staff works primarily on weekends, which can
be ideal for nurses who prefer or need weekdays off. This option
helps in ensuring adequate coverage during weekends when
patient admissions might fluctuate.
• Rotating Work Shift. Shifts rotate between day, evening, and
night, allowing all staff to experience different times of day. This
can help in maintaining a fair distribution of shifts but requires
careful management to avoid disruption to staff routines and
circadian rhythms.
• Self-Scheduling. Staff members create their own schedules,
promoting autonomy and job satisfaction. For example, a nurse
might choose to work three consecutive days followed by four
days off, allowing flexibility in managing personal commitments.
• Permanent Work Shift. Staff work consistent shifts without
rotation, providing stability and predictability. For instance, a
nurse might always work the night shift, ensuring they can plan
their personal life around a steady work schedule.
• Floaters. Staff who are “on-call” to fill in as needed. Floaters
provide critical support during unexpected absences or
increased patient loads, ensuring that the unit remains
adequately staffed at all times.
 Organizing,
Staffing,
Scheduling,
Directing and
Delegating
Directing

• Directing is the act of issuing orders,

assignments, and instructions to achieve
organizational goals and objectives. It
involves guiding and supervising staff to
ensure effective performance.
Elements of Directing
The following are the elements of directing:
•Communication. The exchange of ideas, thoughts, or
information through verbal speech, writing, and signals.
•Delegation. Assigning responsibility and authority to
subordinates.
•Motivation. Encouraging staff to achieve high performance
and job satisfaction.
•Coordination: Harmonizing efforts to ensure efficient
operations.
•Evaluation. Assessing performance to provide feedback and
improve outcomes.
Barriers in Communication
The following are the common barriers of communication:
1.Physical Barriers: Environmental factors that hinder
communication, such as distance and noise.
2.Social and Psychological Barriers: Judgments, emotions, and
social values that obstruct communication, such as stress, trust issues,
fear, and defensiveness. These include the internal climate (values,
feelings, temperament, and stress levels) and external climate
(weather, timing, temperature, and lack of message validation).
3.Semantics: Misunderstandings arising from words, figures, symbols,
penmanship, and the interpretation of messages through signs and
symbols.
4.Interpretations: Defects in communication skills, including
verbalizing, listening, writing, reading, and using telephony
Delegation
• Delegation involves assigning a portion of work
to someone else, along with the corresponding
authority, responsibility, and accountability.
According to the American Nurses Association (
ANA), it is the transfer of responsibilities, but
not of accountability, for the performance of a
task from one person to another. Much of a
manager’s work is accomplished by
transferring responsibilities to subordinates.
Common Errors in Delegation
• Managers often delegate routine tasks to free
themselves for more complex problems requiring
higher levels of expertise. Additionally, delegation
is beneficial when someone else is better prepared
or has greater expertise in solving specific
problems. However, some managers hesitate to
delegate due to a lack of trust in others, fear of
mistakes, fear of criticism, or doubt about their
own ability to delegate effectively. Here are the
three common errors involved in delegation:
Here are the three common
errors involved in delegation:
•Under Delegation
Managers may underdelegate due to the false assumption that
delegation might be seen as a lack of ability to do the job correctly.
For example, a charge nurse might feel that only they can correctly
handle patient assessments and may avoid delegating these tasks to
other nurses, leading to unnecessary workload and burnout.
•Over Delegation
This occurs when subordinates become overburdened, leading to
dissatisfaction and low productivity. For instance, a nurse manager
who delegates too many tasks to a single nurse, such as patient care
duties, administrative tasks, and training responsibilities, can cause
that nurse to become overwhelmed and reduce their effectiveness
and morale.
•Improper Delegation
Delegating tasks to the wrong person, at the
wrong time, or tasks beyond the subordinate’s
capability can lead to inefficiencies and errors. For
example, assigning a newly graduated nurse to
handle a critical care patient without adequate
supervision can lead to mistakes and compromise
patient safety.
Steps in Effective Delegating
Effective delegation involves a systematic approach to ensure tasks are
appropriately assigned and executed. Here are the steps to achieve
effective delegation:
Plan Ahead.
1.
Anticipate future needs and identify tasks that can be delegated. For
instance, a nurse manager can plan to delegate routine check-ups
during busy shifts.
Identify Necessary Skills and Levels.
2.
Determine the skills and experience required for the tasks. For
example, wound care should be delegated to a nurse with specialized
training.
Select the Most Capable Personnel.
3.
Choose individuals who are best suited for the tasks. A senior RN may
be chosen to oversee the orientation of new nurses.
4. Communicate Goals Clearly.
Ensure that the delegate understands the
objectives and expectations. For instance, clearly
explain the expected outcomes of a patient
discharge process.
5. Empower the Delegate.
Provide the necessary authority and resources for
the task. Ensure that the nurse has access to all
needed supplies and information.
6. Set Deadlines and Monitor Progress.
Establish timelines and check in regularly to ensure progress.
For example, set a deadline for completing patient
assessments and follow up to track progress.
7. Model the Role and Provide Guidance.
Demonstrate how to perform the task and offer support as
needed. Show a nurse how to use new medical equipment and
be available for questions.
8. Evaluate Performance.
Assess the delegate’s performance and provide feedback for
improvement. After delegating a task, review the outcomes
and discuss areas for improvement.
Key Concepts in Effective
Delegation
•Key Concepts in Effective Delegation
Effective nursing management and delegation involves
several key concepts that ensure high-quality patient care and
efficient team operations. Here are three essential concepts:
•Motivation
Motivation influences our choices and drives the direction,
intensity, and persistence of our behavior. In nursing,
motivation can come from personal fulfillment, professional
recognition, and the desire to provide excellent patient care.
For example, nurses might be motivated by positive
patient outcomes or career advancement opportunities.
Supervision
• Supervision entails guiding and directing work,
motivating staff, and encouraging participation in
activities that meet organizational goals while
fostering personal development. Effective
supervision in nursing includes regular check-ins,
feedback, and professional growth opportunities.
For instance, nurse managers might hold weekly
meetings to discuss challenges, celebrate
successes, and provide training on new
protocols.
Coordination
• Coordination involves arranging activities
to create harmony and facilitate success. In
nursing, effective coordination ensures
team members work together efficiently to
provide optimal patient care. This includes
coordinating schedules, assigning tasks
based on expertise, and ensuring clear
communication.
Conflict Management
• Conflict arises from internal and external
discord due to differences in ideas, values,
or feelings between two or more people. It
often stems from economic and
professional value differences and can
significantly impact workplace harmony
and productivity.
Conflict can either be competitive
or disruptive:
• Competitive Conflict. This occurs when two or more
groups vie for the same goal, but only one can attain it.
Management typically sets these goals, leading to a
competitive environment where each group strives to
outperform the others.
• Disruptive Conflict. This type of conflict happens in
environments filled with anger, fear, and stress. There
are no mutually acceptable rules, and each party’s goal
is to eliminate the opponent. This destructive form of
conflict can severely hinder cooperation and
productivity.
Conflict Resolution Strategies:
Effective conflict management involves employing
various strategies to address and resolve conflicts
constructively in the nursing field. Here are some
common approaches:
•1. Use of Dominance and Suppression. This win-
lose strategy involves one party imposing their will
on the other, often leading to anger and resentment.
For example, a head nurse might unilaterally decide
on a new scheduling system without consulting the
staff, leading to dissatisfaction and resistance.
• 2. Smoothing Behavior. This strategy involves
persuading the opponent diplomatically to maintain
harmony and avoid confrontation. For example, a nurse
manager might smooth over a conflict between two
nurses by diplomatically discussing their concerns and
finding a temporary compromise to ease tensions.
• 3. Avoidance Behavior. Both parties are aware of the
conflict but choose not to acknowledge or resolve it. For
example, two nurses who have a personal disagreement
might avoid discussing it, which can lead to unresolved
issues affecting teamwork and patient care.
• 4. Majority Rule. This approach relies on a
unanimous decision-making process. For instance,
when deciding on a new policy, the nursing team might
vote on the options, with the majority’s decision being
implemented.
• 5. Compromising. This consensus strategy involves
each side agreeing to solutions that partially satisfy
both parties, aiming for a middle ground. For example,
a nurse manager might compromise on shift
preferences to balance the needs of the staff and the
unit.
• 6. Interactive Problem-Solving. A constructive process
where the parties involved recognize the conflict, assist
each other, and openly work together to solve the problems.
For example, a nursing team might hold a meeting to
discuss and collaboratively find solutions to recurring
staffing issues.
• 7. Win-Win Strategy. This strategy focuses on goals and
attempts to meet the needs of both parties, fostering
cooperation and mutual satisfaction. For example, a head
nurse and a staff nurse might work together to develop a
new patient care protocol that improves efficiency and
meets both management and frontline needs.
• 8. Lose-Lose Strategy. In this approach, neither side wins,
often leading to a situation where both parties are dissatisfied.
For example, if a nurse manager enforces a policy change that
neither the administration nor the nursing staff fully support, it
may result in widespread dissatisfaction.
• 9. Confrontation. Considered the most effective means of
resolving conflict, confrontation involves addressing the issue
openly with knowledge and reason, seeking a solution through
direct communication. For example, a nurse manager might
directly address a conflict between two staff members by
facilitating a mediated discussion to resolve their differences.
• 10. Negotiation. This “give and take”
process involves both sides making
concessions to reach an agreement that
satisfies both parties to some extent. For
instance, during a staff meeting, nurses
and management might negotiate shift
schedules to balance personal preferences
and unit needs.
Summary
• Effective nursing management integrates crucial
concepts to create a well-functioning
healthcare environment. By organizing tasks and defining
roles, clarity and efficiency are ensured. Delegation allows
managers to focus on complex issues while empowering staff.
Motivation, supervision, and coordination are vital for
maintaining high performance and smooth operations. Conflict
management strategies, including competitive and disruptive
conflict resolution, ensure disputes are handled constructively,
fostering a positive work atmosphere. By applying these
principles, nursing managers can create a supportive and
efficient workplace, leading to improved patient outcomes
and higher staff satisfaction.