Transcript Decision-Making and Delegation in the Dynamic Health Care

RN
LVN
UAP
Delegation and Decision Making
•Key to delegation is ability to make correct
decisions and think critically!
•What is decision-making in nursing?
•What are some examples of nursing decisions?
•What are the ethical principles involved?
•What is decision making in nursing?
•It’s a systematic cognitive process in which you:
•identify and evaluate alternatives, come to a
conclusion, and select an action
•As an RN you must make judgments and
decisions based upon education and experience
•What is Critical thinking?
•Systematic way to form and shape one’s thinking
•*Critical Thinking Def.- the ability to focus your
thinking so that you get the results you need.
NOT!!!
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Critical thinking skills are needed for
◦ Early detection of problems
◦ Interventions to prevent adverse occurrences
◦ Interventions to decrease mortality and morbidity
and failure to rescue rates
◦ Improving patient outcome rates
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Open minded
Systematic
Analytical
Inquisitive
Judicious
Truth seeking
Confident in reasoning
A. Authoritarian
B. Systematic
C. Laissez-faire
D. Ambitious
B. Systematic
Rationale: critical thinking dispositions include a
systematic & flexible approach.
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As new assistant charge nurse, you have
responsibility for scheduling employees assigned
to your unit. In the past, this has been done by one
individual without consultation from others. You
would like to try a group decision making process.
◦ What factors need to be considered in moving to
this process?
◦ What will be the benefits? Drawbacks?
◦ If you decide to go ahead with the plan how will
you structure it?
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Data gathering
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Analysis
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Establishing Goals/Outcomes/Strategies
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Implement chosen alternatives
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Evaluate Outcomes
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Resources
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Listing Pros and cons
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Algorithms
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Clinical pathways
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Thinking hats
Critical or Clinical Pathways
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Does the group have sufficient knowledge?
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Is there enough time?
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Is the group mature enough?
◦ Conflict
◦ Individual differences
Will management support the group?
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Consensus
◦ general agreement that members will support a
strategy even if not their chosen one
Majority Rule
◦ vote is taken and the most votes win
Brainstorming- time and expensive
Task force- group formed to discuss a certain problem.
Quality circles- people working in same area with common
concerns meet on a regular basis
Nominal group technique-manager selects members and
presents a problem. Each writes a solution and then all
solutions are discussed and ranked
Delphi- person selects members and polls them for
alternatives. Membership is anonymous so can’t influence
decisions
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Beneficence: do or bring about good (similar to
nonmaleficence – do no harm)
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Autonomy: each individual makes personal
decisions
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Justice: obligation to be fair to all people, nondiscrimatory. Pt. should be informed of wrongs.
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Fidelity: carry out the agreement and
responsibilities one has undertaken: faithful to the
clients- opposite of patient abandonment
Veracity: to tell the truth…
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Knowing- using
assessment skills and
knowledge base as well
as self-assessment
Facilitating- acquiring
pertinent information
and facilitating
communication
Guiding- have you
thought about? It
sounds to me…
Supporting ethical
decision making by
patient and families
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Delegation: When you authorize a competent
person to act for or in your stead while still
retaining accountability and using a UAP
What is a UAP?
The Registered Nurse is
empowered to make that decision
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There are 65 job titles for UAP
 There is no universal training
 There is no universal hiring
 Lack of consistent job descriptions
between different settings
in same facility
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1987 - NCSBN became concerned
about ability of nurse’s to delegate
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1990-1995 – conceptual papers
written.
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Defined delegation:
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Transferring to a competent
individual the authority to perform a
selected nursing task in a selected
situation. The nurse retains
accountability for this delegation.
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You must delegate if you want to deliver quality
care to all of your patients in a timely manner
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What is it?
It is giving someone authority and responsibility to
do something that is normally part of someone
else’s job.
It is not “dumping problems on someone else.
It is not abandonment. The “manager” retains
accountability and needs to supervise .
It is giving the employee appropriate authority to
act alone.
Why delegate?
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Why RN’s don’t delegate
Shortage of RN’s
Cost containment
Sicker patients
Shorter length of stay
Increased number of
UAP’s
Time management
Encourages team
building
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The Do's and Dont's of
Delegation
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Fear
Lack of knowledge
Lack of communication
skills
Loss of control
They can do it better
Lack of confidence in
their staff
Unclear job
descriptions
Might lose license
Don’t have time
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Assignment – dividing workload to be done:
describes entire set of tasks and responsibilities
given to an individual Also refers to workload given
to licensed staff
Delegation – giving authority to unlicensed person
for specific task in a specific situation
Right
Task
Right
Circumstances
Right
Person
Right
Direction/
Communi
cation
Right
Supervision/
Evaluation
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Right task – Nurse Practice Act, Job Descriptions
Right circumstances – What are the circumstances
of patient at this time?
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Right Person- Who is competent to perform task?
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Right Directions/Communication
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Right Supervision/Evaluation
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Evaluation
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Feedback
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There is no blanket delegation of tasks
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Delegation will never occur in isolation
◦ There will be:
 Internal Forces
 External Forces
◦ Most “Peer Review” incidents occurred as a result of
distractions.
 Rushed
 Poor systems or infrastructures
 Taking short cuts with policies and procedures
 What went wrong?
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What is the task or job to be delegated?
Are the expected results predictable?
Does the task require on-going nursing
assessment?
To whom shall the task be delegated?- skill level
and time
Does the task involve critical thinking or nursing
judgment?
If the delegatee needs help, am I available to help?
Delegation Resource
RULES AND REGULATIONS related to
PROFESSIONAL NURSE EDUCATION,
LICENSURE AND PRACTICE
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Rule 224-Delegation of Nursing Tasks by
Registered Professional Nurses to Unlicensed
Personal for Clients with Acute Conditions or
in Acute Care Environments
Rule 225 – RN Delegation to Unlicensed
Personnel and Tasks not Requiring Delegation
in Independent Living Environments for
Clients with Stable and Predictable Conditions
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224.2 Exclusions from Chapter
 (A) Supervise or instruct others in the gratuitous
nursing care of the sick
 (B) Qualified nursing faculty or preceptors directly
supervising or instructing nursing students…
 (C) Instruct/Supervise a UAP in the performance of
nursing tasks as a part of an educational…
 (D) Assign tasks to or to supervise LVNs or other
licensed practitioners practicing within the scope of
their licenses
1. As an RN you assign the LVN on your team to provide care for a
group of 6 patients
No, does not apply, do not delegate to LVN; have own practice act;
only make assignments to them
2. As an RN you work with a nursing student in an externship and
supervise the student while he/she gives IV push medications
Yes, does apply, exclusion in 224.2
3. As an RN you assign the CA to check intake and outputs for patients
in room 1-10
No, this is delegation according to 224 should be in an acute care
setting environment where nursing services are continuously
available; can delegate to UAP
4. As an RN you provide complicated wound care for a neighbor; you
refuse compensation
Yes, exclusion in 224.2
◦ (1) RN must make an assessment of the clients
nursing care needs prior to delegating
◦ (2) nursing task must be one that a reasonable and
prudent RN would find is within the scope of sound
nursing judgment 5 rights
◦ (3) can be properly and safely performed by the
UAP, not jeopardizing client’s welfare
◦ (4) requires no professional judgment
◦ (5) adequate identification by individual training,
education and/certification, experience/ permit etc.
◦ (6) RN shall either instruct the UAP in the
delegated task or verify UAP’s competency
◦ (7) RN must adequately supervise
◦ (8) if the delegation continues over time, the RN
must periodically evaluate the delegation of
tasks
◦ (2) RN or equally qualified RN shall be available in person or by
telecommunication
 (A) acute care, long term care RN’s presence required to provide nursing services of client
whose health status is changing and/or to evaluate the client’s
health status
 the RN must be readily available to supervise the UAP in the
performance of delegated tasks
 (B)nursing care provided in the client’s residence
 When the client’s status is unstable and unpredictable, RN
required to assess, plan intervene, and evaluate the client’s
unstable and unpredictable status and need for skilled nursing
service
 RN makes supervisory visits at least every 14 calendar days.
group homes, foster homes
Sue, RN, has provided careful instructions to Ted a UAP that she has
worked with on many occasions and has had instructions on the task
assigned. He is to feed a patient with some history of swallowing
difficulties.
a. Allow Ted to do his assigned task
No.224.7 states that an RN’s presence and supervision is required
b. Work side by side with Ted
No.The task can be delegated; Ted has the experience and training; this
is unnecessary.
c. Do not assign task to Ted as the patient is unstable
No.The task can be delegated; patient is not unstable at this time; Ted
has experience and training in feeding
d. Check with Ted throughout the day
Yes. 224.7 requires that an RN’s presence and supervision is required;
Ted has training and experience; your best answer.
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(a) Tasks) Most Commonly Delegated….
◦ (1) non-invasive and non-sterile
treatments
◦ (2) the collecting, reporting, and
documentation of data (but not
interpreting it) including…
 Vital signs, height, weight, I&O, Glucose
monitoring; Environmental situations; Client or
family comments ….relating to client’s care
◦ (3) ambulation, positioning, and turning
◦ (4) transportation of patient in the facility
Tasks Which are Most Commonly
Delegated…
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◦ (5) personal hygiene and elimination,
including vaginal irrigations, sitz baths
and cleansing enemas
◦ (6) feeding- cutting up of food or
placing of meal trays
◦ (7) socialization activities
◦ (8) ADLs
◦ (9) reinforcement of health teaching
planned and/or provided by the RN
Yellow Light Tasks
Discretionary Delegation Tasks
◦ (2) nursing tasks not usually within the scope of sound
professional to delegate…
 (A) sterile procedure …a wound or an anatomical site which
potentially can become infected
 (B) non-sterile procedure , such as dressing or cleansing
penetrating wounds and deep burns
 (C) care of broken skin other than minor abrasions or cuts
generally classified as requiring only first aid treatment
Yellow Light Tasks
Discretionary Delegation Tasks
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(1) may be delegated to UAP if
 (A) RN delegating task is directly responsible for nursing care
given
 (B) Agency employing UAP follows current protocol for
training of UAP with input by RN
 (C) Protocol recognizes that what can be safely delegated in
ANY situation is within the specific scope of the RN’s
professional judgment. Most critical
Red Light Tasks
Nursing Tasks Prohibited from Delegation
◦ (1) physical, psychological and social assessment which
require professional nursing judgment, intervention,
referral, or follow-up
◦ (2) formulation of the NCP and evaluation of the client’s
response to the care rendered
◦ (3) specific tasks involved in the implementation of the
NCP which require professionals nursing judgment or
intervention
Red Light Tasks
Nursing Tasks Prohibited from Delegation
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◦ (4) the responsibility and accountability for client health
teaching and health counseling which promotes client
education and involves the client’s significant others…
 Remember the UAP can only reinforce health teaching!
◦ (5) administration of medication, except by medication
aides as permitted under 224.9
(a) RN may delegate to medication aides the
administration of medication to clients in long
term care facilities and home health agencies if:
◦ (1) medication aide holds valid permit
◦ (2) RN assures that the medication aide
functions in compliance with laws and
regulations of the agency issuing the permit
◦ (3) route of administration is oral, via
permanently placed feeding tube, sublingual
or topical including eye, ear or nose drops and
vagina or rectal suppositories
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(b) The following tasks may NOT be delegated to
medication aides (unless in compliance with
Chapter 225 (Independent Living Environments….)
◦ (1)calculation of any medication except for
measuring a prescribed amount of liquid
medication and breaking tablet that the RN has
calculated
◦ (2)Administration of the initial dose of a
medication
◦ (3)Administration of medications by an
injectable route (except administration of
insulin under 225.11 of this title)
(b) The following tasks may NOT be delegated to
medication aides (unless in compliance with
Chapter 225)
◦ (4) administration of medications used for
intermittent positive pressure breathing
…(225.10)
◦ (5) medications by way of a tube inserted in a
cavity of the body except as stated in 225.11
◦ (6) receiving verbal or telephone orders from
a physician, dentist
◦ (7) ordering a client’s medication from the
pharmacy
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1. The Medication Aide can do
all the following except:
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A. administer eye drops
B. administer an enema
C. administer insulin
D. administer first dose
of new medication
2. The home care patient that
the UAP is caring for has
run out of her medication
and needs to have her
medications re-ordered.
What action is appropriate?
 A. Contact the RN to
order the medication
 B. Have the UAP reorder the medications
 C. Have the patient reorder the medications
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As a new RN you have this patient assignment with
a UAP. It is 8 am. Determine, based upon the Nurse
Practice Act, which assignment should be given to
the UAP and why.
◦ a. Mr. C a 20 year post op ORIF
◦ b. Mr. Z. an 80 year old demanding that he wants
breakfast!
◦ c. Ms. F a 40 yr old male stating that she has
“heart burn” and wants breakfast to relieve the
discomfort.
◦ d. Mr. A a 70 yr old confused, incontinent male
◦ e. Ms. G. a first day post-op hernia repair who
needs to ambulate.
◦ f. Ms. R. who has discharge orders and demands
to go home
(a) Applies to …professional nurse who practices…with a
licensed practitioner who has delegated tasks to an UAP
over whom the RN has supervisory responsibilities. The
RN’s accountability to the BON, with respect to its
taking disciplinary action against the RN’S license is met
if the
RN:
◦ Verifies the training of the UAP
◦ Verifies that the UAP can properly perform the task
and not jeopardize the clients welfare…
◦ Adequately supervises the UAP
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(b) If the above not met…must communicate this fact to
the licensee who delegated the task
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BON of Texas
RN’s cannot “giveaway” accountability or
quality of care
◦ MD’s from the BME
 MD employs MA; Can
RN supervise the MA in
office situation?
 No. 224.10 “depends if RN
has ‘supervisory
responsibility over the
MA…and verify training of
the UAP, can verify task and
can supervise the UAP…”
◦ LVNs may not delegate
◦ RN’s do not delegate to
LVNs
◦ RN’s make assignments
to LVN’s
1. A nurse delegates a glucose finger stick to UAP who records a result of
40, but fails to notify the RN of the finding. Legal accountability for the
delayed intervention would be with the
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a. RN
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b. unit manager
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c. UAP
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d. hospital
2. Which statement to a UAP is MOST likely to accomplish the desired
result of getting a blood gas to the lab immediately?
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a. “This is stat!”
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b. “Take this specimen to the lab immediately. We need the
results now.”
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c. “Please do this as soon as possible!”
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d. “I need this in the lab now as the patient’s p02 is 84.”
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In an emergency situation,
Mary the RN requests Ed,
the UAP, to assist in
inserting a Foley catheter
into an uncooperative
patient. Ed had previous
training in the skill; Mary
directly supervises the
procedure.
◦ Is this delegation?
◦ No this is not
delegation: Mary is
directly assisting Ed in
the procedure. See
224.2
As a RN you have an eager
nursing student working as a CA
on your team. A NG tube needs
to be inserted. The CA /nursing
student wants the opportunity to
perform the skill. What is your
best response?
◦ A. Sure, go ahead.
◦ B. Have you ever done it
before?
◦ C. In your role as CA you
cannot insert an NG tube
◦ Your best answer…as a CA
your job description would not
include this role, though you
had training in nursing
program…might be permitted
to do this IF directly assisting
the RN in performing the
procedure. 224.2
Three levels of tasks
Activities of daily living (ADLs)
Health maintenance tasks
Nursing tasks
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Gate Keeping Criteria
◦ Independent Living Environment
◦ Client or client’s responsible adult (CRA) is willing
and able to participate in decisions
◦ Tasks are related to stable and predictable health
care conditions
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Six criteria
◦ Ability of client
◦ Support systems
◦ Tasks
◦ Client’s knowledge base
◦ Traditional and non-traditional methods for
communication
◦ Frequency of Assessment
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If RN determines criteria under 225.6 are adequate
in relation to
◦ Activities of daily living (ADLs)
◦ Health Maintenance Activities (HMAs)
RN may decide these tasks do not require
involvement of RN
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Task does not require nursing judgment
UAP experience/competency
Employer has policy re: Delegation is decision of
RN
Level of RN supervision
Five rights of delegation
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Amount of supervision based on:
◦ Client condition
◦ UAP competency
◦ Nature of task
◦ Availability of RN’s to UAP
◦ Client’s/CRA’s level of participation
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Rule 225.10- includes
◦ ADL’s and HMA’s
◦ Maintenance of indwelling tubes (foley, trach)
◦ Maintenance O2, scheduled inhalation treatments
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Oral or via g-tube
Sublingual
Topical
Eye, ear, nose drops and sprays
Vaginal or rectal suppositories
Only injectable insulin (No other injectables)
No IV meds or fluids
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Does calculation
Injectable medications (except insulin)
Medications via a non-permanent tube
Verbal and telephone orders
Initial dose
The responsibility of the total nursing care of
the patient rests on the RN’s shoulders
http://www.lopez1.com/lopez/clinical.cases/092699.htm
Discuss situations in which the RN might
incorrectly delegate.
You are the charge nurse on a pediatric unit.
You have 16 patients. Staffing is yourself,
one UAP and one LVN who routinely work
on this unit, and an ER nurse who has been
pulled to your unit for the shift. This is the
first time he has worked on your unit. What
criteria would you use to make
assignments?
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Start with a positive attitude.
Clarify availability- especially if UAP with many
RN’s
Give clear directions in a respectful manner.
Include reportable parameters.
Be fair about undesirable activities.
Indicate priorities
Give and receive feedback
Most,
but not all, limit LPN scope of practice to:
–collects, validates, organizes, and reports data,
–contributes to assessment (not initial
assessment)
–selects standardized plan of care based on
nursing diagnoses
–contributes to identification of priorities, goals,
and nursing activities
–implements teaching plans
–evaluates client responses & revises plan of care.
–See link to compare LVN-RN Scope of Practice
(print)
•Administering infusions of:
•blood/blood products
•total parenteral nutrition
•chemotherapeutic or antineoplastic agents;
•Administration of IV therapy to neonates.
•Administration of some IV push medications.
•Mixing IV medications.
You are caring for a patient with esophageal cancer. Which task
could be delegated to the nursing assistant?
1. Assist the patient with oral hygiene
2. Observe the patient’s response to feedings
3. Facilitate expressions of grief
4. Initiate daily weights
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In caring for a patient with neutropenia, what tasks
can be delegated to the nursing assistant? (Choose
all that apply)
1. Take vital signs every 4 hours.
2. Report temperature elevation >100.4 F
3. Assess for sore throat, cough or burning with
urination.
4. Gather the supplies to prepare the room for
protective isolation.
5. Report superinfections, such as candidiasis.
6. Practice good handwashing technique.
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Which actions should you delegate to the nursing
assistant for the client with diabetic ketoacidosis?
1.Check finger stick glucose every hour.
2. Record intake and output every hour
3. Check vital signs every 15 minutes
4. Assess for indicators of fluid imbalance
Taking accuchecks require additional training and
is not automatically delegated without asking
questions
Key Points
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RN Assessment
Reasonable and Prudent RN
Ask can the task be delegated
No Nursing Judgment
Identify UAP
Verify Competency
Supervision
RN Accountable
Clear Communication
Careful Follow-up/evaluation
Right Circumstance
7/4/2006
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The End!
Review your Nurse Practice Act; and Apply the 5 rights of
Delegation (task, circumstance, person,
direction/communication, supervision/evaluation)
Delegation Gone Wild