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Delegation

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  • 1. Mosby items and derived items copyright © 2002 by Mosby, Inc. Effective Delegation and Supervision Insert Chapter 18 opening illustration
  • 2. Mosby items and derived items copyright © 2002 by Mosby, Inc. Key Concepts • Staffing patterns in the current health care system • Principles of delegation and supervision • Safe delegation practices • Delegation vs. assignment
  • 3. Mosby items and derived items copyright © 2002 by Mosby, Inc. Effective Delegation and Supervision • Accomplish patient care safely • Effectively use a variety of skilled and nonskilled workers • Provide essential skills for the RN in any practice role or setting
  • 4. Mosby items and derived items copyright © 2002 by Mosby, Inc. Issues Affecting Staffing Patterns • Balanced Budget Act of 1997 • Managed care • Prospective payment system • Nursing shortage
  • 5. Mosby items and derived items copyright © 2002 by Mosby, Inc. Changes in Staffing Patterns • Decline in the number and utilization of RNs • Increased utilization of unlicensed assistive personnel (UAP) • Overlapping of care providers’ roles
  • 6. Mosby items and derived items copyright © 2002 by Mosby, Inc. Economic Necessity • Place for competent, appropriately supervised UAPs and licensed practical nurses/licensed vocational nurses (LPNs/LVNs ) in patient care • RNs’ confidence with delegation and supervision skills is essential
  • 7. Mosby items and derived items copyright © 2002 by Mosby, Inc. Delegation • Management strategy to accomplish cost- effective health care • Transfer of responsibility and authority for the performance of an activity • RN remains accountable for outcomes • Two-way process between RN and delegatee
  • 8. Mosby items and derived items copyright © 2002 by Mosby, Inc. RN Delegator Responsibilities • The act of delegation • Supervising the performance of the delegated task • Assessment and follow-up evaluation • Any intervention or corrective actions required to ensure safe and effective care
  • 9. Mosby items and derived items copyright © 2002 by Mosby, Inc. Delegatee Responsibilities • Monitoring his or her own actions • Accepting delegation within the parameters of training and education • Communicating appropriate information to delegator • Completing the task
  • 10. Mosby items and derived items copyright © 2002 by Mosby, Inc. What Can Be Delegated? • No definitive list • Varies: – From state to state – From organization to organization – From situation to situation • Assessment, evaluation, and nursing judgment cannot be delegated
  • 11. Mosby items and derived items copyright © 2002 by Mosby, Inc. Delegation Guidance • State nursing practice acts • Patient needs • Job descriptions • Competencies of employees • Policies and procedures • Clinical situation • Professional standards of nursing practice
  • 12. Mosby items and derived items copyright © 2002 by Mosby, Inc. State Nursing Practice Acts • Provide guidance for legal delegation • Criteria may be presented in various parts of the act • State Board of Nursing can offer guidance • Know legal scope of practice for LPN/LVN • UAP practice generally governed by the health care organization
  • 13. Mosby items and derived items copyright © 2002 by Mosby, Inc. Patient Needs • RN must perform patient assessment • Stable patients generally mean a safer delegation opportunity • Tasks that can be delegated may be intertwined with a nursing responsibility
  • 14. Mosby items and derived items copyright © 2002 by Mosby, Inc. Job Descriptions • Detail tasks and responsibilities required as a condition of employment • Comply with state laws and organization’s standards of care • Training should be related to the job description • Legal requirements supersede organizational policies
  • 15. Mosby items and derived items copyright © 2002 by Mosby, Inc. Competencies • Confirm the staff member’s specific knowledge and skills • Written competency documentation required by regulatory and accrediting agencies • RN should be knowledgeable of staff members’ competencies
  • 16. Mosby items and derived items copyright © 2002 by Mosby, Inc. Organizational Policies and Procedures • Designate specific skill level and supervision requirements for tasks • Designate general standards of care such as infection control
  • 17. Mosby items and derived items copyright © 2002 by Mosby, Inc. Clinical Situation • Time to perform the task • Familiarity with characteristics of the population • Complexity of the task • Resources to perform the task • Adequate supervision available
  • 18. Mosby items and derived items copyright © 2002 by Mosby, Inc. Professional Standards of Nursing Practice • Agreed-upon levels of nursing practice competence determined by American Nurses Association (ANA) and specialty nursing organizations
  • 19. Mosby items and derived items copyright © 2002 by Mosby, Inc. ANA’s Delegation Standard • When delegating, the RN will consider: – Assessment of the patient condition – Capabilities of the nursing and assistive staff – Complexity of the task to be delegated – Amount of clinical supervision needed – Staff workload
  • 20. Mosby items and derived items copyright © 2002 by Mosby, Inc. ANA’s Delegation Standard— cont’d • What can be delegated: – Feeding, drinking, positioning, ambulating, grooming, toileting, dressing, and socializing – Collecting, reporting, and documenting data related to these activities – Maintaining a clean, safe, and efficient environment – Housekeeping, transporting, and record keeping – Stocking and maintaining supplies
  • 21. Mosby items and derived items copyright © 2002 by Mosby, Inc. ANA’s Delegation Standard— cont’d • What cannot be delegated: – Initial nursing assessment – Determination of nursing diagnoses – Establishment of nursing care goals – Development of nursing plan of care – Evaluation of patient’s progress – Health counseling or teaching – Activities that require specialized nursing knowledge, skill, or judgment
  • 22. Mosby items and derived items copyright © 2002 by Mosby, Inc. Safe Delegation Practices • Establish a foundation of knowledge • Assess patient before delegation • Know delegatee’s knowledge and skill level • Know the task to be delegated • Comply with skill requirements in written policies and procedures
  • 23. Mosby items and derived items copyright © 2002 by Mosby, Inc. Safe Delegation Practices— cont’d • Explain task and outcomes • Expect responsible action • Assess and supervise job performance • Provide for positive outcomes • Evaluate and follow-up
  • 24. Mosby items and derived items copyright © 2002 by Mosby, Inc. Safe Delegation Practices— cont’d • Know specific standards of nursing practice • Be involved in LPN/LVN and UAP training programs • Help develop LPN/LVN and UAP job descriptions • Always evaluate the delegated action • Never ignore poor performance
  • 25. Mosby items and derived items copyright © 2002 by Mosby, Inc. High-Risk Delegation • Task should be performed only by an RN • Task could involve substantial risk for the patient • Delegatee has not had the necessary training • RN fails to provide adequate supervision • RN fails to evaluate the delegated action
  • 26. Mosby items and derived items copyright © 2002 by Mosby, Inc. Delegation and the Nursing Process • Assess the patient and plan the care • Identify tasks that someone else can perform • Implement the plan of care • Assign and supervise task performance • Evaluate performance and client response
  • 27. Mosby items and derived items copyright © 2002 by Mosby, Inc. Five Rights of Delegation • Right task • Right circumstances • Right person • Right direction and communication • Right supervision and evaluation
  • 28. Mosby items and derived items copyright © 2002 by Mosby, Inc. Supervision • Active process of directing, guiding, and influencing a worker’s performance • On-site supervision – Physically present or immediately available • Off-site supervision – Available through written and verbal communication – Increased use of telecommunications technology is raising supervision questions
  • 29. Mosby items and derived items copyright © 2002 by Mosby, Inc. Components of Supervision • Initial direction • Periodic inspection • Levels of supervision – Unsupervised – Initial direction and periodic inspection – Continuous
  • 30. Mosby items and derived items copyright © 2002 by Mosby, Inc. Supervising • Make frequent rounds, observe, and communicate • Provide the appropriate level of supervision • Be available for questions/unexpected problems • Supervise in a positive, supportive manner
  • 31. Mosby items and derived items copyright © 2002 by Mosby, Inc. Supervising—cont’d • Intervene immediately if the task is not being performed safely and appropriately • Never ignore poor performance—document and report • Use mistakes as learning opportunities
  • 32. Mosby items and derived items copyright © 2002 by Mosby, Inc. Assigning vs. Delegating • Assignment – Transfer of responsibility and accountability is downward or lateral – Activities designated are consistent with job position and qualifications – Staff member assumes responsibility and is accountable
  • 33. Mosby items and derived items copyright © 2002 by Mosby, Inc. Assignment Considerations • UAP assignments are functions and tasks, not patients or groups of patients • LPN/LVN may be assigned specific clients for whom to perform care • RN remains responsible for nursing practice activities
  • 34. Mosby items and derived items copyright © 2002 by Mosby, Inc. Assignment Considerations— cont’d • Patient’s psychologic status • Patient’s physiologic status • Complexity of care • Infection control or cross-contamination • Level of supervision required • Staff development opportunities
  • 35. Mosby items and derived items copyright © 2002 by Mosby, Inc. The Transdisciplinary Team • Teams valuable in meeting patient care needs • Team members should know scope of practice and training of other team members • Team members may report to the RN • Team members may report to supervisors in their individual disciplines and work collaboratively with the RN
  • 36. Mosby items and derived items copyright © 2002 by Mosby, Inc. Barriers to Effective Delegation • Fear of being disliked • Fear of losing control • Fear of taking risks • Fear of making mistakes • Lack of confidence • Lack of knowledge
  • 37. Mosby items and derived items copyright © 2002 by Mosby, Inc. Effective Delegation and Supervision Skills • Communicate effectively • Create an environment of trust and cooperation • Create an environment of teaching and learning • Promote patient satisfaction • Provide feedback and follow-up
  • 38. Mosby items and derived items copyright © 2002 by Mosby, Inc. Appropriate Feedback • Provide honest feedback about performance • Praise good performance • Address poor performance – Immediately stop inappropriate, unsafe, or incompetent performance – Document and report – Request additional training or other action