Nursing Delegation and Prioritization Nursing 3 Lab Spring

Nursing Delegation and Prioritization Nursing 3 - Lab Spring 2020

Objectives Upon completion of this chapter, the reader should be able to: 1. Review the history of delegation. 2. Define delegation, accountability, responsibility, authority, and assignment making. 3. Identify responsibilities the health team members can perform. 4. List the five delegation rights. 5. Identify three potential delegation barriers. 6. List six cultural phenomena that affect transcultural delegation.

Historical Perspective of Delegation in nursing has been emphasized and deemphasized at different periods in history. Delegation has not always been emphasized in nursing education. Current staffing practices require a greater amount of delegation from the nurse.

What is Delegation? NCSBN defines delegation: “Transferring to a competent individual the authority to perform a selected nursing task in a selected situation” The act of delegation carries with it the LEGAL expectation that the nurse will supervise the delegate. The nurse retains accountability for the delegation Key Terms: ØCompetent ØSelected task ØSelected situations

Accountability and Responsibility Accountability means that the nurse is legally liable for her actions and is answerable for the overall nursing care of her patients. Responsibility involves reliability, dependability, and the obligation to accomplish work. Responsibility also includes each person’s obligation to perform at an acceptable level. Authority occurs when a person who has been given the right to delegate, based on the state Nurse Practice Act, also has the official power from an agency to delegate.

Safeguarding the Public Safety • State Boards of Nursing are responsible for Nurse Practice Acts, Scopes of Practice, and clear regulations for delegation. • A licensed nurse has ultimate responsibility & accountability for management and provision of patient care. http: //www. op. nysed. gov/prof/nurse/article 139. htm

Delegation is an essential nursing skill

Assignment versus Delegation 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

Supervision Provision of guidance by a qualified nurse for the accomplishment of a nursing task or activity with initial direction of the task or activity and periodic inspection of the actual act of accomplishing the task or activity. (National Council) Mosby items and derived items © 2005 by Mosby, Inc.

Supervision ØSupervision usually more direct than delegation ØRequires directly overseeing the work of others ØIncludes checking with individuals during the day ØMay entail delegation of tasks and activities Ø Nurse manager performs both

Responsibilities of Health Team Members ØCare should be used in delegating or accepting responsibility for any action that: Ø May carry the potential for harm Ø May be highly complex or require advanced skill Ø May require a high level of problem-solving skill Ø Has a greater than average degree of unpredictability Ø Requires a complex level of patient interaction

Functions of the Professional Nurse ØThe registered nurse is responsible and accountable for the provision of nursing care. ØThe registered nurse is always responsible for patient assessment, diagnosis, care planning, and evaluation. ØThe registered nurse remains responsible for the patient outcome. ØNurses must be alert and avoid misuse of UAPs and LPN/LVNs.

UAP Functions ØUAPs can deliver supportive care. They are expected to document and report information related to such activities. ØUAPs cannot practice nursing or provide total patient care. They cannot be delegated to assess or evaluate responses to treatment. ØThe RN has an increased scope of liability when delegation takes place to a UAP.

UAP Functions The ANA states that since the RN is accountable for the delegation of nursing care activities, the RN must consider the following in determining the appropriate use of a UAP: Ø An assessment of patient condition Ø The capabilities of the UAP Ø The complexity of the nursing task Ø The amount of supervision the RN will be able to provide Ø The available staff assigned to accomplish the unit workload

Problems with delegating and UAPS ØThere are 65 job titles for UAP ØThere is no universal training ØThere is no universal hiring ØLack of consistent job descriptions between different settings in same facility

Licensed Personnel Functions ØLPN/LVNs are able to perform duties and functions that UAPs are not allowed to do ØLPN/LVNs are held to a higher standard of care and are responsible for their actions. ØThe RN is still primarily responsible for overall patient assessment, planning, and evaluation of the quality of care delegated.

Licensed Personnel Functions Common LPN/LVN duties include: Ø Ø Ø Teaching from a standard care plan Reinforcing teaching Updating initial assessments Removal of sutures In some states, starting and or maintaining intravenous lines, after receiving additional education

Activities Outside LPN Scope of Practice Ø Administering infusions of blood/blood products; Ø Administering infusions of total parenteral nutrition; Ø Administering infusions of chemotherapeutic or antineoplastic agents; Ø Administration of IV therapy to neonates. Ø Administration of IV push medications. Ø Mixing IV medications. Ø Initiation of TPN in peripheral lines. Ø Ongoing administration of TPN in central lines.

RN-LPN-UAP Ø LPNs may not delegate Ø RN’s do not delegate to LPNs Ø RN’s make assignments to LPN’s Ø RN’s delegate to unlicensed personnel

General Criteria for Delegation RN must make an assessment of the clients nursing care needs…. prior to…. delegating and determine that a nursing task must be one that a: 1. Reasonable and prudent RN would find is within the scope of sound nursing judgment 5 rights! 2. Can be properly and safely performed by the UAP…not jeopardizing client’s welfare 3. Requires no professional judgment !!! 4. Adequate identification by individual training, education and/certification, experience/ permit etc.

General Criteria for Delegation Ø RN shall either instruct the UAP in the delegated task or verify UAP’s competency Ø RN must adequately supervise Ø If the delegation continues over time, the RN must periodically evaluate the delegation of tasks

Five Rights of Delegation ØThe right task ØThe right circumstance ØThe right person ØThe right direction and communication ØThe right supervision and evaluation

5 Rights of Delegation (NCSBN) 1. Right task – Nurse Practice Act, Job Descriptions, Is assessment, ETC. involved? Should be routine in nature 2. Right circumstances – What are the circumstances of patient at this time? • Has assessment been done? Is patient stable, or unstable? What is potential for harm? Does task require problem solving/decision-making? Level of technology? Is teaching required? Exactly what is needed at this time?

5 Rights of Delegation (NCSBN) 3. Right Person – Who is competent to perform task? Job description? Training? Scope of practice? Ind. Strengths and weaknesses 4. Right Directions/Communication/Information Clear, Concise, Complete Who, what, when, where, why, how? Include parameters and timeframes Help them prioritize 5. Right Supervision/Evaluation Supervision is the active process of directing, guiding and influencing the outcome Initial direction Periodic inspection Follow-up/feedback and appropriate action Evaluation of patient outcomes and the person

**Red Flags of Delegation Refusal to accept delegation Incomplete directions Failure to confirm expectations Failure to communicate

Delegation of Tasks Green Light Tasks- Most Commonly Delegated…. Ø Non-invasive and non-sterile treatments Ø The collecting, reporting, and documentation of data (but not interpreting it) including… Ø signs, height, weight, I&O, glucose monitoring; environmental situations; client or family comments …. Relating to client’s care Ø Ambulation, positioning, and turning Ø Transportation of patient in the facility

Delegation of Tasks More Green Light Tasks …. Ø personal hygiene and elimination, including vaginal irrigations, sitz baths and cleansing enemas Ø feeding- cutting up of food or placing of meal trays Ø socialization activities Ø ADLs Ø reinforcement of health teaching planned and/or provided by the RN

Delegation of Tasks-Discretionary Delegation Tasks…Yellow Light Tasks Nursing tasks not usually within the scope of sound professional to delegate… Ø sterile procedure …a wound or an anatomical site which potentially can become infected Ø non-sterile procedure , such as dressing or cleansing penetrating wounds and deep burns Ø care of broken skin other than minor abrasions or cuts generally classified as requiring only first aid treatment

Nursing Tasks Prohibited from Delegation-Red Light Tasks!! Ø physical, psychological and social assessment which require professional nursing judgment, intervention, referral, or followup Ø formulation of the NCP and evaluation of the client’s response to the care rendered Ø specific tasks involved in the implementation of the NCP which require professionals nursing judgment or intervention

Delegation of Tasks con’t-- Red Light Tasks (c Ø The responsibility and accountability for client health teaching and health counseling which promotes client education and involves the client’s significant others… Ø Remember the UAP can only reinforce health teaching! Ø Administration of medication, except by medication aides as permitted under state law

Stop and Reflect The nurse asks a C. N. A. , who didn’t hear shift change report to take a patient’s B/P. The C. N. A. measures the BP in the left arm which has a arteriovenous shunt. Which “right” of delegation did the nurse violate? Right time, right person, right information, or right task.

The responsibility of the total nursing care of the patient rests on the RN’s shoulders

You might ask- What is my liability and how does delegation affect my license? RN’s are not automatically held liable for all acts of negligence on the part of those they supervise, but they can be if they were negligent in their supervision UAP’s carry some accountability of their own. http: //www. lopez 1. com/lopez/clinical. cases/092699. htm

Reflection How do you give feedback?

Trust one another- confidently expect fulfillment of patient’s and each other’s needs Respect for all roles/tasks and their importance Admiration- express approval/pride verbally and nonverbally Define/describe roles clearly (job descriptions). Expectations must be upheld for all roles.

What words or phrases come to mind when we hear the word prioritization?

How the “experts” define prioritization: Clinical Definition “Deciding which needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent. ” What should I do first? ? What should I do if I only have time to do one thing?

Factors that influence prioritization ØExperience & expertise of individual nurse ØPatient acuity ØNurse-patient relationship ØUnit organization ØModels of care ØIndividual priority-setting strategies

Who should you see first? ? Mr. C. , 68 -year-old with unstable angina who needs teaching for Cardiac Cath, scheduled this morning. Ms. J. , a 45 -year-old woman experiencing chest pain scheduled for a graded exercise test later today. Mr. R. , a 75 -year-old with a 2 -day-old left-sided stroke. Mr. L. , a 59 -year-old man with mild shortness of breath and chronic emphysema.

Strategy for Prioritizing CURE Critical needs Urgent needs Routine Responsibilities Extras

Priority Setting 1 st priority—immediate threat to survival or safety (ABCs) such as airway compromise, choking, shock, hemorrhage, cardiac arrest, major head injury, unconscious, unresponsive, seizure 2 nd priority—request for immediate help 3 rd priority—needs that require regular monitoring even if pt has not asked for help 4 th priority—needs for future Mosby items and derived items © 2005 by Mosby, Inc.

Priority Setting cont’d ØA patient in acute distress has priority. ØIf two are in acute distress then go by ABC system or delegate one to a competent person. ØIf client has several requests, consider basic needs first. ØIf you have a group of patients, use priority system Mosby items and derived items © 2005 by Mosby, Inc.

Stop and Think Nurses set priorities fast when they “first look” at patients. i. e. “walking rounds” Get in the habit of observing the following: Ø Overall appearance Ø Breathing Ø Circulation Ø Drainage Mosby items and derived items © 2005 by Mosby, Inc.

After hearing shift report which patient will you see first? 1. A 20 year old with possible acute myelogenous leukemia who has just arrived on the medical unit. 2. A 38 year old with aplastic anemia who needs teaching about decreasing infection prior to discharge. 3. A 40 year old with lymphedema who requests help to put on compression stockings before getting out of bed. 4. A 60 year old with non-Hodgkin’s lymphoma who is refusing the ordered chemotherapy regimen.

Test your Understanding of Delegation General Criteria 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

Test your Understanding Which of the following tasks should be delegated to a nurse assistant? a. Initial assessment b. Discharge assessment c. Glucose POC testing d. Medication Administration e. Emptying a foley As a RN you have an eager nursing student working as a CNA on your team. A NG tube needs to be inserted. The CNA (AKA…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 CNA you cannot insert an NG tube D. Sure, go ahead, but I will chart that it was done

Questions 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.

Question The charge nurse assigned the care of a client with acute renal failure and hypernatremia to you a newly graduated RN. Which actions can you delegate to the nursing assistant? 1. Provide oral care every 3 -4 hours. 2. Monitor for indications of dehydration. 3. Administer. 45 NS by IV. 4. Assess daily weights for trends.

Question Which actions should you delegate to the nursing assistant for the client with diabetic ketoacidosis? 1. Check fingerstick glucose every hour. 2. Record intake and output every hour 3. Check vital signs every 15 miinutes 4. Assess for indicators of fluid imbalance

Answer a couple of challenging questions! 1. A nurse delegates a glucose fingerstick to UAP who records a result of 40, but fails to notify the RN of the finding. Legal accountability or the delayed intervention would be with the • a. RN • b. unit manager • c. UAP • 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? • a. “This is stat!” • b. “Take this specimen to the lab immediately. We need the results now. ” • c. “Please do this as soon as possible!” • d. “I need this in lab now as the patient’s p 02 is 84. ”

References Power. Point presentation: Patricia Kelly-Heidenthal Power. Point presentation by: Linda Holyoak, RN, CMSRN Power. Point presentation By Nancy Jenkins, RN, MSN/Carolyn Morse Jacobs RN, MSN, ONC