Professional- 1

Professional Roles and Values Case Study

Mary Kinsey

Professor Nelson

NVT2

Western Governors University

February 2012

Professional- 2

In this case study many issues present concerns such as the lack of cultural care competence, the

patients’ diagnosis of developmentally disabled, and under delegation by the family nurse

practitioner (FNP). The FNP does not seem to have a solid understanding of the patients’

culture. To provide competent care the FNP needs to understand Ms. R’s cultural values, beliefs,

behaviors, and intellectual level of understanding. The FNP verbalized frustration with the

Latino patient who did not seek regular or preventive health care, missed appointments, and was

always late.

I believe that Ms. W’s lack of knowledge regarding Latino culture hindered the care she

provided to the patient. A key factor to be considered is the fact that Latino/Hispanic cultures

consider the area between the waist and knees to be extremely private and only discussed with a

few select individuals. Usually that would be the mother of the patient however in this case that

relationship is not intact. Latinos place a lot of importance on demonstrating “respecto” (respect)

in interactions with others they see in a position of authority such as healthcare providers. They

are quiet and hesitant to ask questions regarding their care and treatments because they believe it

is disrespectful.

American healthcare providers are time and task-oriented, whereas Latinos focus more on

personal relationships. Many Latinos have a relaxed attitude regarding time and do not place

much value on being on time to appointments, which is a socially accepted behavior in their

culture. Latinos place value on physical gestures such as shaking hands, pat on the back, placing

a hand on the arm to show caring and warmth by the provider. Latinos expect healthcare

providers to be pleasant and polite and when a providers appears frustrated, upset, short, or

business like to them they are unhappy with the care they received. This can result in

noncompliance with the treatment plan and follow-up care. (Peterson-Iyer; K, Betanxourt, J.)

Professional- 3

The FNP should understand that individuals with developmental disabilities experience chronic

conditions that may be either mental and/or physical in nature, and have problems with language

and learning. With this knowledge the FNP should be aware that the way they communicate with

a patient with a developmental disability is different and make appropriate modifications based

on the individual’s specific limitations. The following suggestions would help when talking with

someone with an intellectual disability: make eye contact; use simple, clear explanations or

questions that can be answered with yes/no; use a respectful calm tone; be patient, allow enough

time for the individual to process the information presented before they respond; have the patient

summarize the information using presented in their own words; and remember respect, touch and

kindness places the patient at ease, happy with the care, and more compliant.

The FNP verbalized frustration regarding the patient’s non-compliance with the medication

ordered for her UTI and presenting again with symptoms of a urinary tract infection. It is

important that healthcare providers understand the possible risks of pyelonephritis, preterm birth,

low birth weight, and increased perinatal mortality to the patient and fetus associated with

recurrent or untreated urinary tract infections in pregnancy. However, for this patient the FNP

needed to stress in terms the patient could understand the importance of having a urinary tract

infection during pregnancy and the correlation with premature labor with the initiation of

treatment. Even though the patient was given instruction to call the office with any concerns

regarding the treatment the FNP should have gone a step further and informed the patient that

other medications were available to her if she had any trouble with the one prescribed. The

patient does not need to understand the use of Class B medications during pregnancy such as

ampicillin, nitrofurantoin, and the cephalosporins, but should have understand that more than one

medication was available to help her get better.

Professional- 4

The nurse should explain on the patient’s level the importance of having an Rh negative blood

type, and how Rh incompatibility can affect future pregnancies by starting an immune response

in her body that could result in abnormalities and/or death of the next baby. The nurse should

have educated the patient on the importance of getting the Rhogam shot at 28 weeks to prevent

future complications.

As the supervisor of the clinic I could help the FNP recognize her role in better utilizing the

diverse workforce that is available in the clinic in the following ways. I would provide the FNP

with the resource book Health Care Teamwork: Interdisciplinary Practice and Teaching by Clark

and Drinka. Drinka describes the interdisciplinary health care team (IHCT) as a group of

individuals with different education and competencies who work as a team to solve patient

problems that are too complex to be solved by one provider. In order to provide efficient care

they share leadership and information and work as a group to solve identified problems. As a

unit they identify the goal(s) to be accomplished and work in collaboration with each other in

treating the patient. Each member of the team brings their areas of specialty and defined role(s)

to the group to provide the highest level of care.

As the supervisor it is my responsibility to know the regulations/laws and scope of practice for

all licensed personnel working in the clinic. I would provide the FNP with a written explanation

of each staff member’s qualifications and role responsibilities. Further education regarding each

staff members abilities could be presented in a conference format where each staff member could

be informed of the FNP’s patient situation and then each discipline could provide information to

the FNP on what they could offer using the knowledge of their specialty.

Professional- 5

As the supervisor I would educate the FNP as to when and how to delegate tasks to other

disciplines by providing the following information. When you are deciding whether or not to

delegate a task safely consider what the patients’ choices are. Is the patient stable? Are the

outcomes predictable? What is the scope of practice and competencies of the provider you are

delegating the task? Is there the possibility of harm to the patient? How often does the provider

perform the task delegated? Are there areas of concern during the completion of the task? Is the

task identified within the scope of employment guidelines? Is the task described appropriately

and supported in the clinics policy/procedure guidelines? Can the patient do the task themselves

or provide guidance to the provider how the task is performed? Additionally, the FNP would

understand that she/he would retain responsibility for supervision of the delegated task and if

they think the task is too complex, or requires a high level of supervision then the task should not

be delegated.

The supervisor/FNP is accountable for the delegation decision, the nursing process, supervision,

and evaluation of the nursing care. Therefore, they need to consider the following five rights

during the entire delegation process. First the right task which determines if the task to be

delegated is identified in the other providers job description and in the clinics policies/procedures

and standards of care. Second, the right circumstances which analyzes and identifies the nursing

needs of the patient based on the health assessment. The supervisor/nurse must create a list and

prioritize what the patient will need, available resources at the clinic, and determine if the

supplies are available that are needed to meet the patient’s needs. The supervisor/nurse need to

determine if the clinic has the identified staff and skill mix available to meet the patient’s needs.

Communicating the chain of authority and how information will be documented and shared with

team members and the patient are also responsibilities of the delegating person. The

Professional- 6

supervisor/nurse guides and delegates the delivery of care based on how complex the task being

delegated is and on the stability of the patient. Consideration is also given to the competency of

the available licensed staff and the amount of supervision required. Once the task has been

delegated the supervisor/nurse will assist, monitor, and evaluate both the staff performing the

task and how the patient is doing health wise. Third the right person, the supervisor/nurse bases

delegation decisions on multiple factors such as the clinics standards, state and federal

regulations and laws that identify what each licensed staff member may do based on their job

description. Additionally, the supervisor/nurse provides guidance and evaluates the competency

of the staff member the task was delegated to on a patient specific basis. Fourth the right

direction/communication: The supervisor must clearly state and define acceptable tasks to be

delegated, identify the qualifications and competencies of each staff member available. Identify

how the delegated task will be monitored and evaluated by providing a description of standards

of care, each staff members role descriptions and the clinics policies/procedures. The

supervisor/nurse communicates the task to be delegated on a specific patient. Identify the

information to be obtained and how and when the information is to be communicated to other

team members. Clearly define specific task(s) to each team member they are accountable for and

expected outcomes or possible problems that may occur and the fifth, and very crucial right of

supervision and evaluation. The supervisor and/or nurse provides indirect or direct supervision of

the task they delegated. The supervisor/nurse decision to delegate takes into consideration the

competencies and qualifications of the individual being delegated the task, whether the task(s) is

simple or complex, and how stable and predictable the patient’s health condition. It is the

responsibility of the supervisor and/or delegating nurse to provide clear directions and

expectations of how the task is to be completed and documented. To monitor the provider’s

Professional- 7

performance, provide assistance if needed, encourage and provide feedback. Upon completion

of the task the supervisor/nurse evaluates the entire delegation process which includes how the

patient is doing, what was done right, what was done wrong or could have been improved upon,

and the performance of the staff member the task was delegated. (ANA) &(NCSBN)

As the supervisor I would develop a staffing plan to help the FNP delegate the appropriate duties

to each member of the team based on the needs of this patient, and the available mix of staff

members. Recommendations would be clearly stated and written down to make sure that the

communication provided to all the health care team is correct.

For care to be patient specific the health care team must discuss the patient’s problem,

troubleshoot concerns, solutions, and alternatives, and agree on a treatment plan. The health care

team supervisor is responsible for coordinating the team members active in the plan of care,

supervise the delegated tasks, provide guidance and assistance, evaluate the effectiveness, and

make appropriate adjustments as needed.

The Licensed Vocational Nurse (LVN) who has been trained to conduct patient education on

labor and delivery, routine prenatal care, parenting, and infant care will be assigned the task of

providing education and the corresponding rationale regarding labs and tests to the patient during

her pregnancy. The patient will be told that a number of tests during her pregnancy will be

recommended that will tell everyone how she and her baby are doing, and identify any areas of

concern that could affect her or the baby’s health during the pregnancy. Education will be

provided regarding what type of tests will be requested during her first, second, and third

trimesters. Verbal and written documentation should be provided in the patient’s language and at

her educational level. The patient should be informed that during the first trimester they

Professional- 8

following labs/tests will be done: a CBC, urinalysis with micro, urine culture and sensitivity,

blood type, Coombs test, Hepatitis B screen, Rapid Plasma Reagin (RPR) , Rubella titer, PAP

smear, cervical cultures for chlamydia and gonorrhea, and HIV testing. During her second

trimester she will have an alpha-fetoprotein test to screen for spinal bifida at 15–19 weeks; a

sonogram at 16–19 weeks to screen for fetal anomalies; and a CBC and 50g glucola test at 25–28

weeks to screen for gestational diabetes and anemia. In the third trimester another CBCwill be

obtained, and at 32–36 weeks cervical cultures for chlamydia, gonorrhea, and group B

streptococcus will be done. (OB Focus)

The nutritionist as part of the interdisciplinary team can contribute to health promotion and

illness prevention on behalf of the patient, and provide education regarding diet and impact on

unborn child. Explain that ketonuria usually indicates dehydration and/or anorexia and could

affect how the baby’s brain develops. Provide education regarding recommended treatment of

1500 to 2000 ml’s of intravenous fluids such as Lactated Ringers until the her urine is negative

for ketones. In addition, the nutritionist could create a patient specific diet and address specific

nutrition-related illnesses with the patient. As part of the team she/he would communicate

relevant nutritional information to other health care providers regarding the patients’ health.

The social worker would be delegated the task of investigating any cultural values, traditions,

history, family issues, or beliefs that are contributing to the patients non-compliance in her health

care regime. The social worker would identify cultural beliefs and traditions that may prevent the

patient from discussing certain topics with the FNP. She/he could recommend the best way to

communicate information to the patient regarding sexual or private matters such as urinary tract

infections or labor and delivery. (Transcultural Nursing)

Professional- 9

The role of the social worker on an interdisciplinary team includes identifying the strengths and

weaknesses of the patient, clearly explain goals of the treatment plan with the patient, identify

barriers to medical compliance and assist others on the team in the management of the patient.

The social worker could evaluate if the patients developmental disability is related to her

presenting health care issues. The social workers assessment takes into consideration how well

the patient is functioning physically (functional abilities), psychologically (affect, mood, attitude,

personality characteristics, cognitive functioning), socially (vocation, social roles, support

system, education, and financial status), culturally (values, beliefs regarding the causes of illness

and medical treatments, communication), environmentally (living conditions) and spiritually

(beliefs about people's roles and responsibilities, diet, and acceptable medical treatments). The

goal of the social worker is to help the patient achieve the highest level of emotional and social

functioning possible. The nurse with a BSN in community health has the knowledge of what

community resources are available and can make the appropriate referrals. The community

health nurse possesses valuable knowledge regarding available community resources, the skills

in coordinating the needs of the patient with resources, and can function as an advocate for the

patient. The nurse understands financial issues in regards to state, federal, and county programs.

Community health programs focus around six elements of nursing practice; five are relevant to

this case study: promotion of healthy living, prevention of health problems, and treatment of

disorders, evaluation and research. The community health nurse must function in multiple roles

such as care provider, educator, advocate, manager, collaborator, leader, and researcher. In this

case the nurse should be utilized to determine with the patient what resources the patient and

infant will need and make the appropriate contacts and referrals prior to the delivery of the

infant.

Professional- 10

As the supervisor/nurse responsible for the patients care I would contact the obstetrician on call

and inform him/her of all areas of concern regarding the patients care, and seek their medical

advice regarding referring the patient to another facility. Because the physician is available only

for deliveries and emergencies and is responsible for multiple rural communities within a 100-

mile radius of the clinic my concern would be access to care immediately should something

happen. Since the patient is 30 weeks and missed several important labs and tests I believe

careful monitoring and immediate access to care is vital.

There are risks associated with every pregnancy and having a chronic condition(s) increases the

risks of problems to the patient and fetus. Therefore the patient should be monitored closely so

immediate intervention can occur. This patient has recurrent urinary tract infections, Rh

incompatibility, and poor prenatal care and treatment compliance all of which place her in a high

risk category. Therefore, it is important that the healthcare team consult with a physician using

the identified consultation standards, and/or refer the patient to another health care professional.

(Lehigh). The following information will help the FNP and other health care providers determine

when to refer the patient for outside consultation rather than delegating within.

Consistent with the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001), the

nurse must practice within the law and not delegate to others tasks that are not within their

practice acts or job descriptions. If a nurse does not feel she/he has the qualifications to safely

perform a task being delegated to them they have the responsibility to refuse the task and refer

the task to others qualified to complete the task in the best interest of the patient.

Supervision is the process of delegating, guiding and affecting the outcome of another providers

completion of a task and can be either direct or indirect. (Matthews, J., 2010)

Professional- 11

A nursing supervisor is still accountable for the delegation process even when they do not have

control of the delegated task based on the nurse practice act guidelines and standards of practice

identified by the board of nursing. They are expected and held accountable to understand the

state and federal regulations regarding acceptable practice and delegation based on staff

qualifications. In addition the supervisor is held accountable for delegation by making sure the

clinic has appropriate resources and the correct mix of staff required for the delegation process.

This includes having appropriate documentation of competencies for all staff members that

provide patient care accessible to the individual delegating nursing tasks.

According to the Indiana Board of Nursing; section 5 (a) a clinical nurse specialist provides and

assists other health care providers with patient care, helps meet health goals, and consults and

collaborates with other providers in complex patient situations. In section 1 (848 IAC 2-1-3)

under competent practice of nurse practitioners it states that a “nurse practitioner shall perform as

an independent and interdependent member of the health team” (p 82). Collaboration, consulting,

referral, managing the plan of care, and guiding patients and other team providers, is defined in

IC 25-23-1-19.4 by the board. Understanding one’s own knowledge and experience limitations

and when it is appropriate to consult/refer patients to other health care is identified by Indiana

code 25-23-1, as well as tasks that can be delegated and the fact that the supervisor/nurse

delegating still remains professionally accountability for the delegated task. According to rule 3,

848 IAC 4-3-1a competent supervisor/clinical nurse specialist provides indirect nursing care,

helps plan, guide, direct, and evaluate other staff members in the provision of patient care. As a

supervisor they serve as a consultant and resource person for the care providers directly involved

with the patient care. Supervisors play an important role in organizing resources, establishing

Professional- 12

expectations of patient care and outcomes, defining roles of the team members within the

organization, and enabling the team process.

It is important for a nursing supervisor to develop skills associated with the authority of

delegation because supervisors are held accountable to the organization, state and federal

organizations, providers, and patients for all delegated care provided. The supervisor assumes

multiple responsibilities which include the ability to identify and prioritize duties and then

delegate the right task to the appropriate staff member. The supervisor plans, guides, organizes,

and delegates patient care to the different staff disciplines based on the supervisor’s knowledge

of the different staff members practice act, experience, comfort level, state and governmental

regulations and organizational policy/procedures. Organizations hold the supervisor accountable

for safe and competent care, which meets regulatory requirements, is cost effective, and meets

the organizations policies/procedures. Supervisors play an important role in gathering resources,

defining patient care and outcomes, and defining the roles of the different team members. The

supervisor is responsible to make sure that the task(s) delegated are performed safely and

effectively, and result in good patient outcomes. A nursing supervisor must collaborate with all

members of the team to clearly identify what task(s) need to be done and determine which staff

member(s) has the qualifications to complete the task, is willing to accept the assignment, and

feels competent to complete the task. Some providers may believe the task delegated to them

could result in harm to the patient because they have not performed it before (or on a limited

basis) even if the task falls within their scope of practice. Patient safety remains at the forefront

of all delegation decisions therefore the supervisor needs to assign the task to another health care

provider.

Professional- 13

References

American Nurses Association (ANA) and the National Council of State Boards of Nursing

(NCSBN). Joint Statement on Delegation. http://www.tnaonline.org/Media/pdf/nursing-

delegation-guides.pdf

Betancourt; Joseph R .Cultural Competence in Health Care: Emerging Frameworks and Practical

Approaches;

http://www.commonwealthfund.org/usr_doc/betancourt_culturalcompetence_576.pdf

Drinka, Theresa J and Clark, Phillip G. (2000). p 47 Health Care Teamwork: Interdisciplinary

Practice & Teaching. Westport, CT: Greenwood Publishing Group.

Lehigh Valley Health Network. Guidelines for Consultations.

http://medicalstaff.lvh.org/c_images/pdf/Consultation_Guidelines.pdf

Matthews, J., (May 31, 2010) "When Does Delegating Make You a Supervisor?" OJIN: The

Online Journal of Issues in Nursing Vol. 15, No. 2, Manuscript 3

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/

TableofContents/Vol152010/No2May2010/Delegating-and-Supervisors.html

National Association of Social Workers. Social Work Speaks: NASW Policy Statements (2000b)

and the NASW Code of Ethics (2000a), which charges social workers with the ethical

responsibility to be culturally competent. (NASW, 2000b, p. 61). www.socialworkers.org.

NASW Standards for Cultural Competence in Social Work Practice. National Association of

Social Workers. http://www.socialworkers.org/practice/standards/NASWCulturalStandards.pdf

OB Focus. http://www.obfocus.com/prenatal/firstpreg.htm

Professional- 14

Peterson-Iyer; Karen. Culturally Competent Care for Latino Patients: Introduction;

http://www.scu.edu/ethics/practicing/focusareas/medical/culturally-competent-are/hispanic.html

Transcultural Nursing http://www.culturediversity.org/hisp.htm