Delegation and supervision

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Delegation and supervision

  1. 1. Effective Delegation and Supervision Delegation and Supervision in the Health Care System
  2. 2. Issues Affecting Staffing Patterns  Reduced reimbursement from Medicare, Medicaid, and private insurance companies  Prospective payment system  Growing uninsured population  Rapid advances in medical technology  Nursing shortage
  3. 3. Changes in Staffing Patterns  Decline in the number and utilization of registered nurses (RNs) and an increase in the employment of nursing assistive personnel (NAP)  Increased utilization of NAP forces the RN to delegate more nursing tasks.  Roles and responsibilities of care providers (RNs, licensed practical nurses/licensed vocational nurses [LPNs/LVNs], NAP) are significantly overlapping
  4. 4. Economic Necessity  Need competent, appropriately supervised NAP and LPNs/LVNs in patient care  RNs’ confidence with delegation and supervision skills is essential  RNs must understand legal responsibility related to delegation and supervision
  5. 5. Effective Delegation and Supervision What Is Delegation?
  6. 6. Definition  Transfer of responsibility for the performance of an activity from one individual to another while accountability for the outcome is retained  RN transfers responsibility and authority for the performance of an activity but remains accountable for overall nursing care  Management strategy used to ensure the accomplishment of cost-effective patient care
  7. 7. Two-Way Process  RN delegator is responsible for the following:  The act of delegation  Supervising the performance of the delegated task  Assessment and follow-up evaluation  Any intervention or corrective action that may be required to ensure safe and effective care
  8. 8. Two-Way Process  The delegatee (LPN/LVN, NAP) is accountable for the following:  His or her own actions  Accepting delegation within the parameters of his or her training and education  Communicating the appropriate information to the delegator  Completing the task
  9. 9. Effective Delegation and Supervision What Should and Should Not Be Delegated?
  10. 10. No Definitive List No definitive list of what can and cannot be delegated  Varies among states, organizations, and specific situations  Assessment, evaluation, and nursing judgment cannot be delegated.
  11. 11. No Definitive List  RNs will have to seek guidance and integrate information from  State Nursing Practice Acts  Patient needs  Job descriptions  Employee competency  Policies and procedures  Clinical situation  Professional standards of nursing practice
  12. 12. State Nursing Practice Acts State Nursing Practice Acts  Will provide guidance for legal delegation  Delegation criteria may not be clearly spelled out or may be presented in various parts of the Act  State board of nursing also may offer guidance  RN should understand the legal scope of practice for an LPN/LVN  Practice by NAP is generally governed by the health care organization’s standards
  13. 13. Patient Needs  RN is required to perform a patient assessment and to know the level of care required  Generally, the more stable the patient, the more likely delegation is to be safe  Many tasks that can be delegated may be intertwined with a nursing responsibility
  14. 14. Job Descriptions  Delineates the tasks, duties, and responsibilities required as a condition of employment  Generally comply with state laws and the health care organization’s standards of care  RN should be aware of the job training required to function as described in the job description  In all cases, legal requirements related to delegation supersede any organizational policy or job description
  15. 15. Competencies  Staff member must have the skills and knowledge necessary to perform a task before it is delegated  Competencies confirm that the individual has demonstrated specific knowledge and skills  Regulatory and accrediting agencies, such as The Joint Commission, require written documentation of staff competencies  RNs should be knowledgeable about the documented competencies of staff members whom they supervise
  16. 16. Competencies  Examples of competencies for an ambulatory care clinic:  Medication management  Telephone triage  Infection control  Glucose testing  Reporting abuse and neglect
  17. 17. Organizational Policies and Procedures  The specific skill and supervision requirements for various tasks are designated in written policies and procedures  Ensure that the delegatee is trained in and understands the organization’s general standards of care (e.g., infection control)
  18. 18. Clinical Situation  Does the NAP/LPN/LVN realistically have time to perform the task?  Is the staff member familiar with characteristics of the patient population?  How complex is the task?  Does the individual have the resources (supplies, equipment) to perform the task?  Is the RN able to provide an adequate level of supervision?
  19. 19. Professional Standards of Nursing Practice Professional standards of nursing practice  Agreed-upon levels of nursing practice as determined by the American Nurses Association (ANA) and specialty nursing organizations  ANA’s standard states that in delegation, the RN will consider the following:  Assessment of the patient condition  Capabilities of the nursing and assistive staff  Complexity of the task to be delegated  Amount of clinical oversight (supervision) the RN will be able to provide  Staff workload
  20. 20. Professional Standards of Nursing Practice  ANA has delineated activities that can be delegated by the nurse  Functions that are technical and assistive in nature and can be taught (e.g., feeding, ambulating a stable patient)  Activities that provide amenities to the patient (e.g., making beds, cleaning the environment)
  21. 21. Professional Standards of Nursing Practice  ANA has delineated activities that the RN cannot delegate:  Initial nursing assessment and any subsequent assessment that requires nursing knowledge, judgment, and skill  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. 22. Effective Delegation and Supervision Developing Safe Delegation Practices
  23. 23. Establish a Foundation of Knowledge Establish a foundation of knowledge  Know delegation criteria delineated in the state’s Nursing Practice Act  http://www.state.tn.us/sos/rules/1000/1000-01.pdf  Know specific skill requirements designated in written policies, procedures, and standards of care  Know delegatee’s scope of practice, competencies, and job description  Know professional standards for nursing practice and specific recommendations on delegation
  24. 24. Know the Patient  Assess the patient before delegation  What is the potential for change in the patient’s condition as a result of the delegated task?  Can the patient’s safety be maintained with delegated care?
  25. 25. Know the Staff Member  Does the staff member have the skills and knowledge necessary to perform the task?  Does the staff member perform the task on a routine basis?  Be involved in training programs and the development of job descriptions for NAP and LPNs/LVNs
  26. 26. Know the Task to Be Delegated  RN delegator must be competent and skilled in performing the task  Task must be in the RN’s scope of practice  Routine, standardized tasks are the safest to delegate  Complex tasks or activities that convey high risk for patient complications or unpredictable outcomes must be carefully considered
  27. 27. Explain Task and Outcomes  Failure to effectively communicate may result in unsatisfactory performance, errors, or patient harm  Clearly explain the task, what must be done, and the expected outcomes  Demonstration and return demonstration may be required
  28. 28. Expect Responsible Action  Delegatee becomes responsible for his or her own actions  RN should supervise appropriately  RN should not intervene unless assistance is requested, or an unsafe situation is recognized
  29. 29. Assess and Supervise Job Performance Assess and supervise job performance:  Make frequent rounds, observe, and communicate  Provide the appropriate level of supervision  Be available for questions or unexpected problems  Supervise in a positive and supportive manner  Intervene immediately if the task is not being performed safely and appropriately  Never ignore poor performance—Document and report  Use mistakes as learning opportunities
  30. 30. Provide for Positive Outcomes  Ongoing communication and support are vital  Necessary resources to perform the tasks should be available
  31. 31. Evaluate and Follow Up Evaluate and follow up:  Always evaluate the delegated action by reassessing the patient  Evaluate the staff member’s performance  Follow up with any interventions that may be required  Review and document the skills that were learned
  32. 32. Characteristics of High-Risk Delegation  Delegated task can be performed only by the RN according to law, organizational policies, or professional standards of nursing practice  Delegated task could involve substantial risk or harm to a patient  RN knowingly delegates a task to an individual who does not have appropriate training  RN fails to provide adequate supervision  RN does not evaluate the delegated action by reassessing the patient
  33. 33. Delegation and the Nursing Process  Components of the delegation process become familiar when compared with the nursing process  Assess the patient and plan the care, then identify tasks that someone else can perform  Implement the plan of care, and assign and supervise task performance  Evaluate the delegatee’s performance, planned outcomes, and client response
  34. 34. “Five Rights of Delegation”  Right task: Delegated tasks must conform to established guidelines  Right circumstances: Delegated tasks do not require independent nursing judgment  Right person: One who is qualified and competent  Right direction and communication: Clear explanation about the task and outcomes and when the delegatee should report back to the RN  Right supervision and evaluation: Feedback to assess and improve the process; evaluate patient outcomes
  35. 35. Effective Delegation and Supervision Supervision
  36. 36. Definition  The active process of directing, guiding, and influencing the outcome of a worker’s performance  On-site supervision—The nurse is physically present or is immediately available while the activity is being performed  Off-site supervision—The nurse has the ability to provide direction through various means of written and verbal communication
  37. 37. Definition  Distinction between on-site and off-site supervision has become unclear with the use of telecommunications technologies  ANA has established operational guidelines for supervision related to telecommunication technologies  Who is in control of the activity?  How should controls be instituted?
  38. 38. Components of Supervision  Initial direction: instructions provided when the task is first delegated  Periodic inspection: the decision the RN makes regarding frequency of monitoring the delegatee’s performance
  39. 39. Levels of Supervision  Unsupervised  One RN works with another RN in a collegial relationship  Neither RN is in the position of supervising the other
  40. 40. Levels of Supervision  Initial direction/periodic inspection  RN is supervising a licensed or unlicensed caregiver  Knows the individual’s training and competencies  Has developed a working relationship with the individual
  41. 41. Levels of Supervision  Continuous supervision  RN has determined that the delegatee will need very frequent to continual support and assistance  Continuous supervision is required when  The working relationship is new  The task is very complex  The delegatee is inexperienced or has not demonstrated an acceptable level of competence
  42. 42. Effective Delegation and Supervision Assigning versus Delegating
  43. 43. Definition of Assignment  Distribution of work that each staff member is responsible for during a given work period  Designates activities consistent with job position and description, legal scope of practice, and educational background  The staff member assumes responsibility and is accountable for completing the assignment.
  44. 44. Assignment Considerations  Assigning groups of clients to various care providers, including NAP and LPNs/LVNs is not appropriate  NAP assignments would include functions and tasks  LPNs/LVNs may be assigned specific clients for which to perform care, but RNs remain responsible for all nursing practice activities
  45. 45. Assignment Considerations  The RN is responsible for assignments made to nursing personnel and should consider the following:  Patient’s physiologic status and complexity of care  Infection control or cross-contamination issues  Level of supervision required  Staff development opportunities such as assigning a less experienced nurse to a more complex patient with an increased level of supervision
  46. 46. Utilizing the Interdisciplinary Health CareTeam  Interdisciplinary team members will be valuable in meeting patient care needs  RNs should know scope of practice and training background of team members
  47. 47. Utilizing the Interdisciplinary Health CareTeam  RN should know how the work is delegated or assigned to interdisciplinary team members  Interdisciplinary team members may report to the RN, who is responsible for assigning and delegating patient care tasks  Interdisciplinary team members may report to supervisors in their individual disciplines and may work in a collaborative manner with the RN to provide patient care
  48. 48. Effective Delegation and Supervision Building Delegation and Supervision Skills
  49. 49. Novice Nurses’ Barriers to Effective Delegation  Fear of being disliked, losing control, taking risks, making mistakes  Lack of confidence  Lack of knowledge
  50. 50. Communicate Effectively  Know exactly what needs to be done and what outcomes are expected  Maintain self-control and confidence  Listen carefully to the delegatee’s response  Ask for feedback by using open-ended, nonthreatening statements if the delegation action elicits a negative response
  51. 51. Create an Environment of Trust and Cooperation Maintain a nonthreatening and nonjudgmental attitude—Problems will be reported more quickly Avoid blaming and criticizing when mistakes occur—Look for root causes such as inadequate training or too heavy workload Encourage staff members to report and discuss problems
  52. 52. Create an Environment of Teaching and Learning  Remember that inadequate training is a common cause for poor performance in the work setting  Identify staff learning needs and provide educational programs aimed at building skills and competencies  Be willing to teach and demonstrate how to perform a task rather than merely telling how it should be done
  53. 53. Promote Patient Satisfaction  Clients need and want to know their caregivers’ qualifications  The RN is responsible for describing the health care team to the client
  54. 54. Provide Feedback and Follow Up  Delegation process is not complete until the RN reassesses the patient and adjusts the plan of care as indicated  Provide honest feedback to the delegatee about his or her performance  Praise good performance  Address poor job performance  Stop inappropriate, unsafe, or incompetent performance immediately; document and report to the nurse manager or supervisor  Request additional training or other appropriate action to ensure that patient safety is protected

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