Delegation and Decision Making

RNLVN UAP

•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!!!

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

Open minded Systematic Analytical Inquisitive Judicious Truth seeking Confident in reasoning

A. AuthoritarianB. SystematicC. Laissez-faireD. Ambitious

B. Systematic

Rationale: critical thinking dispositions include a systematic & flexible approach.

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?

Data gathering

Analysis

Establishing Goals/Outcomes/Strategies

Implement chosen alternatives

Evaluate Outcomes

Resources

Listing Pros and cons

Algorithms

Clinical pathways

Thinking hats

Critical or Clinical Pathways

Does the group have sufficient knowledge?

Is there enough time?

Is the group mature enough?◦ Conflict◦ Individual differences

Will management support the group?

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

Beneficence: do or bring about good (similar to nonmaleficence – do no harm)

Autonomy: each individual makes personal decisions

Justice: obligation to be fair to all people, non-discrimatory. Pt. should be informed of wrongs.

Fidelity: carry out the agreement and responsibilities one has undertaken: faithful to the clients- opposite of patient abandonment

Veracity: to tell the truth…

Supporting ethical decision making by patient and families

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…

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 isempowered to make that decision

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

1987 - NCSBN became concerned about ability of nurse’s to delegate

1990-1995 – conceptual papers written.

Defined delegation: Transferring to a competent

individual the authority to perform a selected nursing task in a selected situation. The nurse retains accountability for this delegation.

You must delegate if you want to deliver quality care to all of your patients in a timely manner

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?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 The Do's and Dont's of

Delegation

• 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

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 Direction/Communication

Right Person

Right Supervision/ Evaluation

1. Right task – Nurse Practice Act, Job Descriptions

2. Right circumstances – What are the circumstances of patient at this time?

3. Right Person- Who is competent to perform task?

4. Right Directions/Communication

5. Right Supervision/Evaluation

Evaluation

Feedback

There is no blanket delegation of tasks

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?

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?

RULES AND REGULATIONS related to PROFESSIONAL NURSE EDUCATION,

LICENSURE AND PRACTICE

Delegation Resource

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

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.

(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…

.◦ (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 TasksDiscretionary 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

(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 (

◦ (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

(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

◦

1. The Medication Aide can do all the following except:

◦ 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 re-order the medications

C. Have the patient re-order the medications

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

(b) If the above not met…must communicate this fact to the licensee who delegated the task

BON of Texas

RN’s cannot “give-away” 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

• 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 the lab now as the patient’s p02 is 84.”

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 tasksActivities of daily living (ADLs)Health maintenance tasksNursing tasks

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

Six criteria◦ Ability of client ◦ Support systems◦ Tasks◦ Client’s knowledge base◦ Traditional and non-traditional methods for

communication◦ Frequency of Assessment

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

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

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

Rule 225.10- includes◦ ADL’s and HMA’s◦ Maintenance of indwelling tubes (foley, trach)◦ Maintenance O2, scheduled inhalation

treatments

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

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?

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

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.

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

7 / 4 / 2 0 0 6 2 8

K e y P o i n t s

• R N A s s e s s m e n t• R e a s o n a b l e a n d P r u d e n t R N• A s k c a n t h e t a s k b e d e l e g a t e d• N o N u r s i n g J u d g m e n t• I d e n t i f y U A P• V e r i f y C o m p e t e n c y• S u p e r v i s i o n• R N A c c o u n t a b l e• C l e a r C o m m u n i c a t i o n• C a r e f u l F o l l o w - u p / e v a l u a t i o n• R i g h t C i r c u m s t a n c e

The End!

Review your Nurse Practice Act; and Apply the 5 rights of Delegation (task, circumstance, person, direction/communication, supervision/evaluation)

Delegation Gone Wild