1.7 Managing the Nursing Team

Managing the Nursing Team

Managing care provided by the nursing team is an important skill of nurse leaders to ensure safe, quality, client-centered care in complex and often challenging health care environments. While many nursing students focus on developing clinical skills and knowledge during their educational journey, the importance of learning management and leadership skills should not be minimized. Newly licensed nurses in clinical practice often find themselves in situations requiring effective nursing leadership and management skills.

Nurses must first have a good understanding of the Nurse Practice Act (NPA) in the state in which they are employed to know their legal scope of practice, as well as the scope of practice of other members on the nursing team. The NPA contains regulations established by the state legislature that are enforced by the Board of Nursing. The Board of Nursing (BON) is the state-specific licensing and regulatory body that sets standards for safe nursing care and issues nursing licenses to qualified candidates. A good understanding of the state NPA ensures adherence to legal standards of care when performing, assigning, and delegating nursing responsibilities. Additionally, a clear understanding of the scope of each team member’s role promotes an efficient and well-coordinated approach to client care.

Wisconsin Nurse Practice Act

Let’s examine the roles and scope of practice for members of the nursing team according to the state-specific regulations in the Wisconsin Nurse Practice Act (NPA).

According to the NPA, a registered nurse (RN) “utilizes the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness, or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation.”[1]

The role of the licensed practical/vocational nurse (LPN/VN) is defined as the “performance of acts in basic patient situations.”[2] In the performance of acts in basic patient situations, the LPN/VN shall, under the general supervision of an RN or the direction of a provider, do the following[3]:

  • Accept only patient care assignments which the LPN/VN is competent to perform.
  • Provide basic nursing care.
  • Record nursing care given and report to the appropriate person changes in the condition of a patient.
  • Consult with a provider in cases where an LPN/VN knows or should know a delegated act may harm a patient.
  • Perform the following other acts when applicable:
    • Assist with the collection of data.
    • Assist with the development and revision of a nursing care plan.
    • Reinforce the teaching provided by an RN provider and provide basic health care instruction.
    • Participate with other health team members in meeting basic patient needs.

Basic Nursing Care

In this description of the LPN/VN role and standards of care, basic nursing care is defined as “care that can be performed following a defined nursing procedure with minimal modification in which the responses of the patient to the nursing care are predictable.” A basic patient situation is defined as a situation “determined by an RN, physician, podiatrist, dentist, or optometrist that meets the following three conditions[4]:

  • The patient’s clinical condition is predictable.
  • Medical or nursing orders are not changing frequently and do not contain complex modifications.
  • The patient’s clinical condition requires only basic nursing care.

Review an example of basic nursing care in the following box.

Example of “Basic Nursing Care” in a “Basic Patient Situation”

In a long-term care facility, an LPN/VN is responsible for providing care to a resident named Mrs. Anderson, who has been diagnosed with type 2 diabetes. Mrs. Anderson’s diabetes is well-managed and stable, with no recent fluctuations in her blood sugar levels. Her medication regimen consists of oral medications taken daily, and her diet plan is consistent.

The LPN/VN’s role in Mrs. Anderson’s “basic nursing care” involves administering her daily medications, measuring and recording her blood sugar levels prior to meals, and ensuring she follows her prescribed diet.

Complex Patient Situation

The Wisconsin NPA further states that in the performance of acts in complex patient situations, the LPN/VN shall meet these previously defined standards, as well as perform delegated acts beyond basic nursing care under the direct supervision of an RN or provider. Direct supervision is defined as “immediate availability to continually coordinate, direct, and inspect at first hand the practice of another.”

A complex patient situation is defined as, “an act determined by an RN, physician, podiatrist, dentist, or optometrist where one or more of the following conditions exist in a given situation[5]:

  • The patient’s clinical condition is not predictable.
  • Medical or nursing orders are likely to involve frequent changes or complex modifications.
  • The patient’s clinical condition indicates care that is likely to require modification of nursing procedures in which the responses of the patient to the nursing care are not predictable.

Review an example of how a “basic patient situation” becomes a “complex patient situation” in the following box.

Example of a “Complex Patient Situation”

In a long-term care facility, an LPN/VN is responsible for providing care to Mrs. Anderson, a resident with type 2 diabetes. Over the past week, Mrs. Anderson has been experiencing frequent and unexpected fluctuations in her blood sugar levels. Her physician has modified her medication regimen several times over the past few days to better control her condition. Additionally, Mrs. Anderson’s clinical condition now requires modifications to the standard nursing procedures because her responses to the care provided are not predictable.

In this “complex patient situation,” the LPN/VN collaborates closely with the RN and the health care provider to adjust Mrs. Anderson’s care plan in real-time based on her changing clinical condition. The LPN/VN administers medications, monitors blood sugar levels, and adjusts her diet plan per the updated medical orders. The LPN/VN works under the direct supervision of the RN or health care provider to ensure that Mrs. Anderson receives the necessary and responsive care to manage her complex diabetes condition effectively.

Scope of Practice in Wisconsin

See Table 1.7a for a summary of educational preparation and scope of practice for RNs and LPN/VNs according to Wisconsin’s Nurse Practice Act, as well as an overview of tasks performed by certified nursing assistants (CNAs), a type of unlicensed assistive personnel (UAP).

Table 1.7a. Roles and Responsibilities of Nursing Team Members in Wisconsin[6],[7]

Registered Nurse (RN) Licensed Practical Nurse (LPN) Certified Nursing Assistant (CNA)
Education and Licensure or Certification  Completes an accredited nursing program (diploma, associate degree, or bachelor’s degree) and successfully passes the NCLEX-RN. Completes a state-approved practical nursing program and successfully passes the NCLEX-PN. Completes a state-approved nursing assistant training program and successfully passes the state competency evaluation.
Scope of Practice
  • Provides comprehensive nursing care according to the standards of the nursing process, including complex situations where the client’s condition is not predictable.
  • Assesses and analyzes clients’ health status, including laboratory and diagnostic results.
  • Develops, implements, and revises nursing care plans.
  • Administers medications (all routes).
  • Administers blood transfusions.
  • Assigns and delegates tasks to LPN/VNs and UAPs under defined conditions with appropriate supervision.
  • Advocates for client rights and overall well-being with the interprofessional health care team.
  • Ensures compliance with legal and ethical standards.
  • Plans and provides client health teaching and health promotion.
  • Provides therapeutic communication.
  • Provides basic nursing care in basic patient situations to clients with predictable clinical conditions.
  • Provides nursing care in complex patient situations under the direct supervision of an RN or provider.
  • Assists with the collection of client data.
  • Assists with the development and revision of a nursing care plan.
  • Reinforces the teaching provided by an RN and provides basic health care instruction.
  • Participates with other health team members in meeting basic client needs.
  • Administers medications under supervision (generally including the routes of oral, topical, and injections).
  • Provides wound care and dressing changes.
  • Provides therapeutic communication.
  • Collects and documents vital signs and other routine measurements, such as input/output.
  • Assists with activities of daily living (bathing, dressing, grooming, feeding, toileting).
  • Repositions and transfers clients from bed to chair.
  • Assists with mobility and ambulation.
  • Documents client observations.
  • Assists in maintaining a clean and safe environment.
  • Provides emotional support to clients.
  • Assists in postmortem care.
  • Follows infection control protocols.
  • Recognizes and reports changes in client condition to the nurse.

When making assignments and delegating tasks to nursing team members, it is essential for a nurse leader to keep in mind specific tasks that can and cannot be delegated to other nursing team members based on federal and/or state regulations. For example, in Wisconsin the NPA states, “In the supervision and direction of delegated acts, an RN shall do all of the following:

(a) Delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised.
(b) Provide direction and assistance to those supervised.
(c) Observe and monitor the activities of those supervised.
(d) Evaluate the effectiveness of acts performed under supervision.”

Examples of tasks that generally cannot be delegated are described in Table 1.7b.

Table 1.7b. Examples of Tasks Outside the Scope of Practice of Nursing Team Members

Nursing Team Member Tasks That Cannot Be Delegated

 
LPN/VN
  • Cannot create nursing care plans, analyze client assessment data, establish nursing diagnoses or expected outcomes, or evaluate the effectiveness of a nursing care plan. (However, LPN/VNs can collect data and contribute to the development and revision of a client’s nursing care plan in collaboration with the RN.)
  • Cannot administer high-risk medications (such as heparin and chemotherapeutic medications).
  • Cannot titrate medications. (Titrate refers to adjusting the dosage of medication until the desired effects are achieved.)
  • Cannot independently provide client education. (However, they can implement client education that has been planned by the RN.)
  • Cannot perform admission assessments or initial postoperative assessments.
  • Cannot discharge clients.
Unlicensed Assistive Personnel (UAP)
  • Cannot complete tasks requiring clinical judgement and/or professional knowledge. For example, a nursing assessment of a client’s skin cannot be delegated to UAP. However, UAP are encouraged to report concerns about skin breakdown and other potential signs and symptoms to a licensed nurse.
  • Cannot delegate tasks.
  • Cannot provide client education but can reinforce education previously provided. For example, UAP can encourage a client to keep their nasal cannula in place while eating.
  • Cannot complete tasks that require clinical expertise unless advanced training has been received and written agency policy allows, such as[8]:
    • Administering medications and injections
    • Inserting Foley catheters
    • Administering tube feedings
    • Performing wound care or dressing changes

As always, refer to the state Nurse Practice Act and other state regulations for specific details about nursing team members’ scope of practice in which one is employed.

Find Nurse Practice Acts and other nursing regulatory information around the world at the NSCBN’s Global Regulatory Atlas web page.

Read more about the Wisconsin’s Nurse Practice Act and the standards and scope of practice for RNs and LPNs at Wisconsin’s Legislative Code Chapter N 6 PDF.

Read more about scope of practice, skills, and practices of nurse aides in Wisconsin at DHS 129.07 Standards for Nurse Aide Training Programs web page.

Managing Client Care as a Member of the Interprofessional Health Care Team

Collaboration with other interprofessional team members is a key aspect of managing nursing care. Nurses work closely with physicians, therapists, social workers, and other health care professionals to develop and implement comprehensive care plans. Effective communication, coordination, and teamwork are essential to ensure that all members of the health care team are aligned in their efforts and contribute their expertise for the best possible outcomes for clients.

Nurses and charge nurses may participate in interprofessional team conferences where they contribute their insights, advocate for clients, and ensure that their needs are met holistically. They may also serve as liaisons when establishing community resources for clients being discharged home, ensuring a smooth transition and continuity of care.

  1. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf ↵
  2. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf ↵
  3. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf ↵
  4. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf ↵
  5. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf ↵
  6. Wisconsin Administrative Code. (2018). Chapter N 6 standards of practice for registered nurses and licensed practical nurses. https://docs.legis.wisconsin.gov/code/admin_code/n/6.pdf ↵
  7. Wisconsin State Legislature. (2023). Chapter DHS129. https://docs.legis.wisconsin.gov/code/admin_code/dhs/110/129/ii/07 ↵
  8. State of Wisconsin Department of Health Services. (2018). Medication administration by unlicensed assistive personnel (UAP): Guidelines for registered nurses delegating medication administration to unlicensed assistive personnel. https://www.dhs.wisconsin.gov/publications/p01908.pdf ↵
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