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  1. 1. Chapter 9Delegation of Client Care<br />
  2. 2. Delegation of Client Care: Definition<br />The reassigning of responsibility for the performance of a job from one person to another<br /> (ANA, 1996)<br />
  3. 3. Concepts of Delegation<br />The responsibility of the task is transferred<br />Accountability remains with the delegator<br />Delegation may be direct or indirect<br />
  4. 4. Direct Delegation<br />Usually verbal direction<br />RN decides which staff member is capable of performing a specific task<br />
  5. 5. Indirect Delegation<br />Contained in an approved listing of tasks established by an institution<br />Permitted tasks may vary from institution to institution<br />
  6. 6. Assigning Tasks<br />The RN may assign a more skilled individual to perform a task<br />The RN may not assign an individual to perform an activity outside a job description or the scope of practice<br />
  7. 7. Delegation vs. Supervision<br />
  8. 8. Supervision<br />Supervision usually more direct than delegation<br />Requires directly overseeing the work or performance of others<br />Includes checking with individuals during the day<br />May entail delegation of tasks and activities<br />Nurse manager performs both<br />
  9. 9. The Nursing Process and Delegation<br />
  10. 10. Assessment<br />Assess client needs<br />Set client-specific goals<br />Match the personnel with the appropriate skills to care for the client<br />
  11. 11. Planning<br />Mentally identify who is best suited for the task or activity<br />Planning prevents later problems<br />
  12. 12. Implementation<br />Assign the appropriate personnel who have the level of expertise necessary to deliver the care or carry out the activities<br />
  13. 13. Evaluation<br />Oversee the care or activities<br />Determine if client care needs have been met<br />Allow for feedback<br />
  14. 14. Coordinating Assignments<br />
  15. 15. Methods to Help Organize Care <br />Critical pathways<br />Computerized information sheets<br />Personalized worksheets<br />Delegation tree<br />
  16. 16. Tips for Organizing Care<br />Plan time around activities that must be performed at a certain time<br />Perform high-priority activities first<br />Cluster activities that may be performed together<br />Consider your peak time when performing optional activities<br />
  17. 17. The Need for Delegation<br />
  18. 18. Changes in the Health Care Environment<br />Nursing shortage<br />Health care reform<br />Increased need for nursing services<br />Demographic trends<br />Use of unlicensed assistive personnel<br />
  19. 19. Unlicensed Assistive Personnel (UAPs)<br />Individuals trained to function in an assistive role to the nurse<br />Perform delegated tasks<br />Under direct supervision of the RN<br />May or may not be certified<br />
  20. 20. Delegation to UAPs<br />
  21. 21. Examples of Tasks<br />Vital signs<br />Skills learned through special training<br />Blood drawing<br />ECGs<br />Measuring intake and output<br />Non-nursing duties<br />
  22. 22. Safe Delegation<br />
  23. 23. Criteria for Safe Delegation<br />Potential for harm<br />Complexity of the task<br />Problem-solving and innovation necessary to complete the task or activity<br />
  24. 24. Considerations for Safe Delegation<br />Ability of the individual<br />Fairness of the task<br />
  25. 25. Guidelines for Delegation<br />https://www.ncsbn.org/delegation_grid_NEW.pdf<br />https://www.ncsbn.org/contcaregrid.pdf<br />https://www.ncsbn.org/Working_with_Others.pdf<br />
  26. 26. Task-Related Concerns<br />
  27. 27. Primary Concern<br />Does the individual assigned to the task have the ability to perform the task?<br />
  28. 28. Other Task-Related Concerns<br />Ability<br />Priorities<br />Efficiency<br />Appropriateness<br />
  29. 29. Relationship-Oriented Concerns<br />Fairness<br />Learning opportunities<br />Health<br />Compatibility<br />Preferences<br />
  30. 30. Summary of Expectations of Professionals<br />Respect of others<br />A reasonable workload<br />Appropriate wages<br />Determining his/her own priorities<br />Ask for what he/she wants<br />Accountability<br />Give and receive information as a professional<br />
  31. 31. Barriers to Delegation<br />
  32. 32. Barriers<br />Experience<br />Licensure<br />Quality of care<br />Assigning work to others<br />
  33. 33. The Five Rights of Delegation<br />Right task<br />Right circumstances<br />Right person<br />Right direction/communication<br />Right supervision/evaluation<br />
  34. 34. Conclusion<br />
  35. 35. Points to Consider<br />Delegation is not new<br />The role is essential for good working relationships<br />Organizational skills are a prerequisite for delegation<br />Understanding client needs is essential for appropriate delegation<br />
  36. 36. The RN Needs to Understand<br />The State Nurse Practice Act<br />The capabilities of each staff member<br />The tasks that may be delegated<br />The concept of accountability in delegation<br />
  37. 37. Chapter 10Quality and Safety<br />
  38. 38. History and Overview<br /><ul><li>Historical trends and issues
  39. 39. The Institute of Medicine and the Committee on the Quality of Health Care in America</li></li></ul><li>Trends and Issues<br />Economic<br />Societal demographics and diversity<br />Regulation and legislation<br />Technology<br />Health care delivery and practice<br />Environmental and globalization<br />
  40. 40. Statement of Quality of Care<br />The IOM concluded that<br />Quality can be defined and measured <br />Quality problems are serious and extensive <br />Current approaches to quality improvement are inadequate<br />There is an urgent need for rapid change<br />
  41. 41. Focus Areas of To Err is Human<br />The IOM recommended (Box 10-3)<br />Enhance knowledge and leadership regarding safety<br />Identify and learn from errors<br />Set performance standards and expectations for safety<br />Implement safety systems within health care organizations<br />
  42. 42. Crossing the Quality Chasm Conclusions<br />The gaps between actual care and high-quality care could be attributed to key inter-related areas in the health care system<br />The growing complexity of science and technology<br />An increase in chronic conditions<br />A poorly organized delivery system of care and constraints on exploiting the revolution in information technology <br />
  43. 43. Ten Rules to Govern Health Care Reform for the 21st Century<br />Care is based on a continuous healing relationship<br />Care is provided based on patient needs and values<br />Patient is source of control of care<br />Knowledge is shared and free-flowing<br />Decisions are evidence-based<br />
  44. 44. Ten Rules to Govern Health Care Reform for the 21st Century (cont’d)<br />Safety as a system property<br />Transparency is necessary; secrecy is harmful<br />Anticipate patient needs<br />Waste is continually decreased<br />Cooperation between health care providers<br />
  45. 45. Quality in the Health Care System<br /><ul><li> Quality improvement
  46. 46. Using CQI to monitor and evaluate quality of care
  47. 47. Quality improvement at the organizational and unit levels
  48. 48. Aspects of health care to evaluate
  49. 49. Risk management</li></li></ul><li>Quality<br />The Institute of Medicine (IOM) defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current and professional knowledge” <br />(IOM, 2001, p. 232)<br />
  50. 50. Six Aims for Improving Quality in Health Care<br />Health care should be<br />Safe<br />Effective<br />Patient-centered<br />Timely<br />Efficient<br />Equitable<br />
  51. 51. QI vs. CQI<br />QI<br />Began with Florence Nightingale<br />Structured organizational process<br />Included evidence-based methods for gathering data and achieving goals<br />CQI<br />Purpose<br />Identify, collect data, analyze, evaluate, change<br />Responsibility<br />
  52. 52. Evaluation of Health Care<br />Structure <br />Process<br />Outcomes<br />
  53. 53. Risk Management <br />Service occurrence<br />Serious error<br />Sentinel event <br />
  54. 54. The Economic Climate in the Health Care System<br /><ul><li> Economic perspective
  55. 55. Regulation and competition
  56. 56. Nursing labor market </li></li></ul><li>Factors Influencing Economic Climate<br />Economic<br />Regulation<br />Competition<br />Nursing labor market<br />
  57. 57. Safety in the U.S. Health Care System<br /><ul><li>Types of errors
  58. 58. Error identification and reporting
  59. 59. Developing a culture of safety
  60. 60. Organizations, agencies, and initiatives supporting quality and safety in the health-care system </li></li></ul><li>Types of Errors<br />Diagnostic<br />Treatment<br />Preventive<br />Other<br />
  61. 61. Types of Events<br />Near miss<br />Adverse event<br />Accident<br />
  62. 62. Culture of Safety <br />Roles of leadership, individuals, and teams<br />Event reporting systems<br />Methods<br />Organizations, agencies, and initiatives <br />
  63. 63. Health Care System Reform<br />Role of nursing in system reform<br />The ANA’s Agenda <br />Influence of Nursing<br />
  64. 64. Role of Nursing in Health Care Reform<br />American Nurse’s Association<br />Nursing’s agenda for health care reform<br />ANA’s health care agenda<br />You<br />Become informed<br />Plan<br />Take action!<br />
  65. 65. Chapter 15<br />Nursing Yesterday and Today<br />
  66. 66. Nursing’s Public Image<br />25 years ago, society perceived nurses in gender-linked, task-oriented terms<br />Popular media have improved somewhat in the portrayal of nursing’s image<br />
  67. 67. Nursing Defined<br />1859: Nightingale<br />1950: Henderson<br />1963: Rogers<br />2002: American Nurses Association<br />
  68. 68. Nursing Leaders<br />Florence Nightingale<br />Lillian Wald<br />Margaret Sanger<br />Mildred Montag<br />Mary Elizabeth Mahoney<br />Virginia Henderson<br />
  69. 69. Florence Nightingale<br />
  70. 70. Florence Nightingale<br />Considered the founder of modern nursing<br />Innovative thinker<br />Acted as a change agent<br />
  71. 71. Background<br />Born in Florence, Italy, in 1820<br />Father saw to her education<br />Always showed an interest in the welfare of those less fortunate <br />Insisted on going to Kaiserworth to become trained as a nurse<br />
  72. 72. Crimean War<br />Nightingale was commissioned to go to the Crimea to investigate the conditions and make improvements<br />She found a disaster<br />
  73. 73. Changes in Care<br />Nightingale and nurses cleaned up environment<br />Delivered nursing care<br />Wrote letters to families<br />
  74. 74. The Nightingale School<br />This was an independent educational institution<br />Her book, Notes on Nursing: What it is and what it is not, set the fundamental principles of nursing<br />
  75. 75. Health-Care Reform<br />Nightingale kept statistical records<br />These records convinced the British to make reforms<br />Her work marked the beginning of modern military nursing<br />Her work led to hospital reform<br />
  76. 76. Limitations?<br />Did not support the germ theory<br />Did not believe in a central registry for nurses<br />
  77. 77. Lillian Wald<br />
  78. 78. Background<br />Born in Ohio<br />Attended the New York Hospital School of Nursing<br />Thought she wanted to continue in medical school and entered Women’s Medical College in New York<br />
  79. 79. The Visiting Nurses<br />Wald and Brewster established a settlement house in New York’s Lower East Side<br />They built an independent nursing practice<br />Eventually, they developed a respected reputation among hospitals and physicians<br />
  80. 80. The Henry Street Settlement House<br />Established 2 years later<br />Grew into a well-organized social service system<br />Multiple services were available<br />
  81. 81. Other Accomplishments<br />Developed school health nursing<br />Organized the Children’s Bureau<br />Nursing Service Division of the Metropolitan Life Insurance Company<br />
  82. 82. Margaret Sanger<br />
  83. 83. Background<br />Born in Corning, New York<br />Attended the White Plains Hospital School of Nursing<br />Worked at the Manhattan Eye and Ear Hospital<br />Married and became a homemaker<br />
  84. 84. Advocate and Social Reformer<br />Sanger was concerned about the working conditions of people who lived in poverty<br />A major strike in Lawrence, Massachusetts, influenced her life<br />She intervened on behalf of the children<br />
  85. 85. Sanger the Public Health Nurse<br />Sanger was assigned to maternity cases on the Lower East Side<br />While caring for a young mother who had attempted to self-abort, Sanger began to see a need for education in family planning<br />
  86. 86. Reform<br />Sanger worked toward making contraceptive information available to women<br />She opened the first birth control clinic in the United States<br />When Sanger was arrested, she walked to the courthouse, refusing to ride<br />
  87. 87. Creation of Planned Parenthood<br />Sanger established Planned Parenthood<br />Today this organization offers birth control information and family planning counseling<br />
  88. 88. The Feminist<br />Sanger can be considered an early feminist<br />She was independent and assertive at a time when it was not considered politically correct for a woman to be outspoken<br />She used her nursing background to promote political change<br />
  89. 89. Mary Elizabeth Mahoney<br />
  90. 90. Background<br />She was born free on May 7, 1845, in Dorchester, Massachusetts<br />She showed an interest in nursing during her adolescence<br />She worked for 15 years at the New England Hospital for Women and Children<br />She was hired as a cook, held a janitor’s position, and spent time as a washerwoman and an unofficial nurse's assistant<br />
  91. 91. Education<br />At the age of 33, she applied to the hospital’s nursing program and was accepted as a student<br />16 months later, Mary and four white students completed the rigorous course<br />She ended her nursing career as director of an orphanage in Long Island, New York<br />
  92. 92. Contributions to Nursing<br />Recognized the need for nurses to work together to advance the status of black nurses within the profession <br />Co-founded the National Association of Colored Graduate Nurses (NACGN)<br />
  93. 93. Mildred Montag<br />
  94. 94. Background<br />Proposed two levels of nursing <br />Described what she referred to as the “technical nurse” <br />Developed the curriculum for associate degree nursing programs<br />
  95. 95. Contributions to Nursing<br />ADN is the primary model for basic RN education<br />Associate degree nursing (ADN) education has exerted a profound impact on nursing education<br />
  96. 96. Contributions to Nursing (cont’d) <br /> Montag’s major achievement was to shift nursing education from service-based facilities to institutions of higher learning.<br />
  97. 97. Virginia Henderson<br />
  98. 98. Background<br />Born in 1897 in Kansas City, Missouri<br />Attended the U.S. Army School of Nursing<br />Continued her career in public health<br />
  99. 99. Nurse Educator<br />Attended Columbia Teacher’s College<br />Joined the faculty<br />In 1953, joined the Yale School of Nursing Faculty, where she remained for 40 years<br />
  100. 100. Contributions to Nursing<br />She published the four-volume Nursing Studies Index<br />She pioneered the work that is considered the essence of modern nursing<br />Her most important writing was The Principles and Practice of Nursing<br />
  101. 101. Contributions (cont’d)<br />Henderson actively participated in nursing organizations<br />Sigma Theta Tau International Nurses Honor Society named its library in honor of her contributions<br />
  102. 102. Henderson’s Legacy<br />Recognized as the “first lady of nursing”<br />Many colleagues refer to her as the “20th-century Florence Nightingale”<br />She represents the essence and the spirit of nursing to all of us<br />
  103. 103. Men in Nursing<br />
  104. 104. Early History<br />Early Egyptian priests practiced nursing<br />The first nursing school started in India in 250 BC, and only men were considered “pure enough” to be nurses<br />Nursing was practiced by men during the Byzantine Empire<br />
  105. 105. The 19th Century<br />Male and female slaves served as nurses<br />During the Civil War, the Confederate army used men as nurses, whereas the Union army used women<br />In 1863 the Alexian Brothers opened the first hospital in this country and educated men as nurses<br />
  106. 106. The 20th Century<br />The ANA first admitted nurses to its membership in 1930<br />Men were not allowed to serve as nurses in the military until the conclusion of the Korean War<br />Today the number of men in nursing is increasing, resuming their historical role as caregivers<br />
  107. 107. Professional Organizations<br />
  108. 108. The ANA<br />
  109. 109. American Nurses Association (ANA)<br />Works for improvement of health standards<br />Promotes availability of health care services<br />Fosters high standards for nursing<br />
  110. 110. ANA’s Social Policy Statement<br />The social context of nursing practice<br />The nature and scope of nursing practice<br />Specialization in nursing practice<br />Regulation of nursing practice<br />The ethics of nursing practice reviewed by the House of Delegates<br />
  111. 111. American Nurses Association (ANA)<br />Stimulates and promotes the professional development of nurses<br />Advances nurses’ economic and general welfare<br />
  112. 112. The NLN<br />
  113. 113. National League for Nursing(NLN)<br />Membership is open to other health professionals and interested consumers, not just nurses<br />Participates in test services, research, and publication <br />Lobbies actively for nursing issues<br />Currently working with ANA and other nursing organizations on health care reform <br />
  114. 114. National League for Nursing Accreditation Commission<br />Accredits colleges and schools of nursing<br />
  115. 115. The NOADN<br />
  116. 116. National Organization for Associate Degree Nursing (NOADN)<br />Associate degree nursing programs prepare the largest number of new graduates for RN licensure <br />Began in 1986<br />
  117. 117. Role of NOADN<br />Strong educational programs <br />Dynamic education of students in a variety of settings <br />Emphasis on lifelong learning <br />Continued articulation with colleges and universities<br />
  118. 118. Other Organizations<br />
  119. 119. American Academy of Nursing<br />Leaders in nursing practice, education, administration, and research<br />Mission to advance health policy and practice<br />
  120. 120. National Institute for Nursing Research<br />Federal Agency<br />Supports and conducts basic and applied research<br />Supports research training<br />
  121. 121. Specialty Organizations<br />Nurses may join specialty organizations<br />Provide nurses with information regarding standards of practice and evidence-based practice within specialty areas<br />
  122. 122. Nursing Today<br />
  123. 123. Health Care System Changes<br />Historical perspective<br />Managed care<br />Insurance<br />
  124. 124. Current Concerns<br />Fragmentation<br />Uninsured<br />High and rising costs <br />Quality<br />
  125. 125. Issues<br />Preventing patient care errors, including medication errors<br />Emphasis on outcomes<br />Changing competencies<br />Improved infection control<br />Inadequate staffing increases patient mortality<br />Aging nursing workforce<br />
  126. 126. Changing Competencies<br />Critical thinking skills<br />Understanding of systems<br />Care management<br />
  127. 127. Changing Competencies (cont’d)<br />Team-building and communication skills<br />Negotiating, collaborating, conflict management skills<br />Cultural competency<br />
  128. 128. Changing Competencies (cont’d)<br />Flexibility<br />Technological competence<br />Business skills<br />
  129. 129. Communicating Nursing’s Role<br />
  130. 130. TriCouncil<br />ANA, NLN, AACN, AONE<br />Designed a campaign to communicate the contributions of nurses<br />
  131. 131. Three Areas<br />Nurses as resource people<br />Nurses as health-care coordinators<br />Nurses as expert practitioners<br />
  132. 132. Using Nursing Influence<br />Carry your license<br />Use your special training and experience<br />Become a double agent<br />Network with and empower colleagues<br />
  133. 133. Using Nursing Influence (cont’d)<br />Eliminate “the enemy within”<br />Focus on operations<br />Organize as a supportive group<br />
  134. 134. Conclusion<br />
  135. 135. In the Future<br />More holistic, patient-centered care<br />Seamless transitions from hospital to extended care to home<br />Eliminate health disparities<br />Universal health care insurance<br />Equalizing emphasis on prevention, acute care, long-term care, mental health<br />Healthier environment<br />Global health concerns<br />
  136. 136. Conclusion<br />Nursing has a rich and exciting history<br />Nursing is cyclical<br />Nursing is diverse<br />Nursing deals with individuals, their health, and their environments<br />To meet the needs of the future, nurses need to become involved in theory development and research<br />
  137. 137. Conclusion<br />Nurses need to take the lead in movement toward a clearer identity and role delineation of the profession <br />To achieve nursing goals, the value of nursing and acceptance of its professional status must be recognized<br />

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