[Sharon]

How does the CNO three-factor framework support decisions in your practice area? Provide an example of how it is used for making patient care decisions.

[Jacqueline]

When I worked in Hemodialysis in the hospital setting, most clients that came into the unit were outpatients. Patients that were in hospital if critically unwell would have a dialysis nurse assigned to them directly. This was 1-1 care with the ICU nurse and doctor overseeing all aspects during those treatments. In this scenario it was only RN’s that were scheduled for on call or in-patient cases. All other patients seen in the Dialysis clinic were mapped out 3-1 care with both RN and RPN to support. It was very team based in the clinic; you were never working alone. The setting itself allowed for open sight lines and support when needed. A dialysis patient can deteriorate in seconds, some with warning and some without. I was always encouraged by the team atmosphere and level of respect for all nurses working in the unit. As with most settings you would have different levels of competence for different tasks such as difficult fistulas to needle or different strategies for fluid removal to profile or not, and different nurses to call on for those supports.

[John-paul]

Hi Jacqueline,

It really sounds like there was some excellent collaboration on this unit! Open sight-lines like you mentioned, provide an excellent environment for this collaborative practice and if nurse (RPN) did not have the knowledge, skill and judgment in a particular case due to the client’s condition being beyond their scope, there was enough support from RN colleagues to manage these scenarios.

Thanks for your post an great example of the three factor framework being used in practice.

[Alison]

I love how well defined the roles are in your practice setting . I enjoy organization and predictability.

[Jaclyn]

In my current role as a Clinical Supervisor for practical nursing students, I use the 3 factor framework as a guide when assigning appropriate patients to my students. In my job I can have 3 different level of clinical groups, students in their first clinical in long term care, students in their first hospital placement and finally students in their third clinical and in an acute care area. Each clinical group has different levels of knowledge and skill. Therefore, I first look at the current level of education of my students, what knowledge and skills have they learned in lecture and lab therefore what is their current ‘scope’. I then look at the individual student, what is their level of confidence, competence, how much support will they need from me to carry out this patient’s needs? I also take into consideration what nurse is assigned to the patient to determine what kind of leadership and support my student will have and what role modeling will they witness. I factor all this in so that the patient receives the most competent and safe care.

[John-paul]

Hi Jaclyn,
Great example! I’ve never really thought about it, however the three-factor framework plays such a huge roll in deciding what patient to assign each student. Thanks for the insight and for your post!

[Jacqueline]

This definitely gives you a fresh perspective on how the assignments are made and how much thought really should go into it. This was a great post.

[Josephine]

As the only Registered staff in the Retirement care setting, I utilize the three-factor framework by being accountable to my own decisions and actions to promote the best possible outcomes for a resident. I implement the framework through nursing assessment, planning, implementation, and evaluation of a resident’s care plan. In the event a resident’s complexities are not beyond the level of care of a retirement setting, I collaborate with external care providers i.e. Home and Community Care, Simcoe Palliative Care Network, Specialized Geriatric team etc. Moreover, I arrange to have an inter-professional meeting to re-evaluate the care plan in place. At times, we may also have open discussions about alternative care environments i.e. Long Term Care, rehabilitation, hospitalization, or another Retirement home.

Equally important, working primarily with Resident Attendants/Personal Support Workers (unregulated health care professionals) my role heavily entails teaching, supervising, and assigning unregulated care providers tasks and roles to carry out the resident’s care plan. One thing I have learned and always keep in mind when creating a care plan or accepting a new resident move-in is just how well my team will be able to cope with and manage the complexities of the resident care needs. For example minimal assistance vs. total care.

[John-paul]

Hi Josephine,
Being the only registered staff, it’s great to hear that you are aware of and are confident collaborating with so many external partners while caring for your patients! In a less predictable environment where you are the only registered staff, I feel that there would be such a need for this.
I like how you mentioned working collaboratively with un-regulated care providers as well. This is a piece of the environment that requires a lot of through as you must ensure that those you are collaborating with are doing so safely.
Thanks for your discussion post and thoughts this week!

[Veronica]

As a homecare nurse I use the 3 factor framework in my decision-making whether I take on a client or not. Before I accept a client I have to read his/her care plan I want to know everything about the client condition, what type of care is needed , any risks I need to anticipate then I will ask myself am I competent to do the task? If I am confident that I can do the task required then I will accept. There were cases I declined to service a client because I honestly have no experience in the type of care that needs to be delivered. It is easier to learn and practice the skills if you work in a hospital or long term care facilities where you can work directly with other nurses, you can collaborate and share your ideas and even learn from each other. But in home care you are on your own its just you and the client.

[John-paul]

Hi Veronica,

Great example! It is so important to assess these things and consider the three factor-framework when working in the community as the environment is very unpredictable and there are as many resources readily available in comparison to other care settings.
I’m glad you feel confident in knowing when a patient is beyond your ability to provide safe-care and that you are able to complete this assessment before arriving at your clients home to save our precious healthcare resources!

Thanks for your post this week!

[Alison]

In my practice setting, LTC, most of the time the patients are considered stable. The environment is very controlled and consistent. I have worked in this setting for 14.5 years so I am competent. Should a patient encounter an acute situation, one of more RN is consulted. They do not necessarily take over care of that patient but assess, call the doctor, offer suggestions and instructions for care.
For example, I administer a person’s medications daily, blood pressure and thyroid medication. I check their blood pressure weekly and document. One day this patient states she feels dizzy, looks pale and her blood pressure is 182/108. Although the next step is to call her doctor for instructions, I call the RN to assess this patient first in case I have missed something. I await instructions from the RN and we continue to work together to treat this patient.

[Author]

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